MIDTERM EVALUATION
AIDS PREVENTION AND CONTROL PROJECT (APAC)
Submitted by:
The Synergy Project
TvT Associates, Inc.
Gerard R. Bowers
K.C. Malhotra, Ph.D.
Eliot T. Putnam, Jr.
Rajani R. Ved, M.D.
Submitted to:
The United States Agency for International Development/India
Under Contract No. HRN-C-00-99-00005-00
May 2000
The Midterm Evaluation: AIDS Prevention and Control Project (APAC) was made possible through
support provided by the United States Agency for International Development (USAID)/India
under the terms of Contract Number HRN-C-00-99-0005-00.
The opinions expressed herein are those of the authors and do not
necessarily reflect the views of USAID.
Additional copies of this report may be obtained by writing to:
1101 Vermont Avenue, NW Suite 900
Washington, DC 20005
(202) 842-2939
(202) 842-7646 (Fax)
or via e-mail at tvt@tvtassoc.com.
ACKNOWLEDGMENTS
The midterm AIDS Prevention and Control Project (APAC) evaluation team is grateful to
USAID and APAC colleagues and other partners for having made this assignment a most
positive experience. It helped, of course, that the project being assessed has been
remarkably successful. Evaluating an initiative that is serving as a dynamic model and
laboratory for new approaches to preventive health care is clearly more gratifying than
looking at one which has no positive lessons to teach the world. But beyond that, the
work was made stimulating and enjoyable by the people and offices who supported the
team at every juncture.
The team is also grateful for the comprehensive assistance given us, from the moment the
assignment was first conceived, by Saha AmaraSingham, Caroline Curtis, Lena
Thompson, Mona Feldman, and the staff of TvT Associates in Washington, D.C., who
were unfailingly responsive to all of our needs. The team is also most appreciative of the
generous help and guidance provided by the USAID Mission in New Delhi, especially
Dora Warren, Victor Barbiero, Anitha Ravishankar, and Sathi Anand. Their careful
scheduling and attention to detail, not to mention their probing questions, helped the team
make the most of its time in New Delhi.
Finally, the team wants wholeheartedly to thank the APAC staff members for their warm
welcome to Chennai. They tirelessly answered all questions and arranged a rich and
varied exposure to the people, institutions and nongovernmental organizations that are the
essence of APAC, as well as to those whose lives it is improving. The staff is rightly
proud of what it has accomplished and is committed to achieving even greater impact in
the years ahead.
ACRONYMS AND FOREIGN TERMS
AIDS Acquired immune deficiency syndrome
AMP Allopathic (Western medicine trained) medical practitioners
ANM Auxiliary nurse midwives
APAC AIDS Prevention and Control Project
ARM Association for Rural Mass Media
BCC Behavior change communication
BSS Behavioral Surveillance Survey
CED Centre for Entrepreneur Development
CETC Continuing education training center
CHW Community health worker
CLIP Clinic-based intervention project (APAC intervention)
CSW Commercial sex worker
DFID Department for International Development (United Kingdom)
ESRM Experience sharing and review meeting
FFW Female factory worker
FHI Family Health International
FP Family planning
GOI Government of India
HIV Human immunodeficiency virus
HLL Hindustan Latex, Ltd.
HPN Health, Population and Nutrition Office (USAID)
HTA Hindustan Thompson Associates, Ltd.
ICWO Indian Community Welfare Organization
IEC Information, education and communication
JKAL J. K. Ansell, Ltd.
MCH Maternal and child health
MFW Male factory worker
MMHRC Meenakshi Mission Hospital and Research Centre
NACO National AIDS Control Organization
NGO Nongovernmental organization
NIS National Institute of Sales
OR Operations research
PATH Prevention Along the Highways (APAC intervention)
PMC Project management committee
PVOH II Private Voluntary Organizations in Health (2nd project)
RIMP Registered Indian medical practitioner
SRC State Resource Centre
STD Sexually transmitted disease
STI Sexually transmitted infection
TH Truck drivers and helpers
TNSACS Tamil Nadu State AIDS Control Society
UNAIDS Joint United Nations Programme on HIV/AIDS
USAID United States Agency for International Development
VCT Voluntary counseling and testing center
VHS Voluntary Health Services
WIP Women in Prostitution (APAC intervention)
CONTENTS
EXECUTIVE SUMMARY ................................................................................................. i
I. INTRODUCTION.................................................................................................... 1
The APAC Project ..................................................................................................... 1
Purpose of this Evaluation ......................................................................................... 1
Methodology.............................................................................................................. 2
II. BACKGROUND AND CURRENT ENVIRONMENT........................................ 3
Donor Support............................................................................................................ 3
III. THE USAID RESPONSE: THE APAC PROJECT............................................. 4
Rationale .................................................................................................................... 4
Project Structure......................................................................................................... 4
Pre-Launch Phase (1992-95): Creating a Framework for Success........................... 5
IV. KEY FINDINGS AND RECOMMENDATIONS................................................. 7
Overall Impact ........................................................................................................... 7
BSS Data.............................................................................................................. 7
NGO Monthly Reports......................................................................................... 8
Performance: Project Components ............................................................................ 8
Promotion and Distribution of Condoms............................................................. 8
STD Management ................................................................................................11
NGO Capacity Building.......................................................................................15
Research...............................................................................................................18
Information, Education and Communication (IEC)/Behavior Change................18
Project Implementation..............................................................................................20
The Funding of APAC.........................................................................................20
The Management of APAC .................................................................................21
Partnerships..........................................................................................................23
V. PROJECT SUSTAINABILITY..............................................................................25
VI. NEW DIRECTIONS................................................................................................27
New Initiatives...........................................................................................................27
Estimated Cost of New Initiatives .............................................................................30
VII. ISSUES......................................................................................................................31
Projected Allocations and Expenditures....................................................................31
The APAC Model: Implications for AVERT and World Bank, Phase II..................31
STD Drugs.................................................................................................................32
ANNEXES
A: Scope of Work
B: Persons Contacted
C: Map of NGO Support in Tamil Nadu
D: BSS Data
E: APAC Project Data
F: Particulars of Condoms Distributed in Tamil Nadu
G: Operational Research Topics for STI Management
i
EXECUTIVE SUMMARY
In the early stages of an acquired immune deficiency syndrome (AIDS) epidemic, the
greatest impact on the spread of the disease is achieved by focusing prevention activities
on groups at high risk of becoming infected with human immunodeficiency virus (HIV).
In Tamil Nadu, these groups include commercial sex workers and their clients, truck
drivers and other transportation workers, slum dwellers, and sexually transmitted disease
(STD) patients. The AIDS Prevention and Control (APAC) project concentrates its
activities on these core transmitters of HIV, specifically by introducing and reinforcing
preventive behavior, by promoting the sale and use of condoms, and by enhancing STD
services and counseling.
When the project was designed in 1991–92, it included several features which were novel
at the time in India. These included a thematic approach that targeted interventions on
high-risk population groups, selection of one state (Tamil Nadu) as a project site, and a
decision to implement the activity through Indian nongovernmental organizations
(NGOs). Partners in the government of India (GOI) and Tamil Nadu state government
had several reservations about this approach, even while the United States Agency for
International Development (USAID) remained confident in the correctness of its strategy.
The successful resolution of these differences took 26 months—valuable time which was
lost to the HIV-prevention effort, but which was very useful to the further refinement of
the project design and to the achievement of the parties’ consensus around the key
principals advocated by USAID. The project was formally launched in February 1995,
following the signing of a tripartite agreement between USAID, the GOI National AIDS
Control Organization (NACO), and the implementing organization, Voluntary Health
Services (VHS) of Chennai, Tamil Nadu.
The project is being managed by an APAC project office within VHS and is implemented
through approximately 40, mostly urban, NGOs and technical support organizations in
the state.
The midterm evaluation team reviewed the project to
ß determine its overall impact in promoting behavior change among the target
population groups;
ß assess the project’s specific performance in furthering each of its key
objectives: increase condom availability and use, improve the accessibility
and quality of STD services, and improve the capacity of the NGOs
participating in the project; and,
ß assess the effectiveness of the project’s implementation arrangements; and,
ß identify lessons and areas for future activity on the part of USAID, NACO and
VHS/APAC.
ii
OVERALL IMPACT
The project is succeeding in meeting its objectives. In fact, it has already achieved most
of the benchmarks identified in the tripartite agreement. Two data sets were examined to
assess the project’s overall impact. These included data from three waves (1996–97–98)
of the HIV-Risk Behavioral Surveillance Survey (BSS) in Tamil Nadu, and data selected
from the monthly reports submitted by participating NGOs. The data are consistent and
show that not only is meaningful behavior change under way in the state, but that much
of that change can be attributed directly to the APAC project. Key behavior changes
taking place among target population groups include an increase in condom use, an
increase in STD treatment-seeking behavior, and decreases in sexual contacts with
nonregular partners.
SPECIFIC PERFORMANCE
Condom Sales
Commercial sales of condoms in Tamil Nadu have more than doubled since 1995, from
12.6 million pieces that year to 27.9 million pieces in 1999. More recently, the rate of
increase in commercial sales has plateaued, achieving a modest 4 percent increase during
the 1998–99 period. Factors appear to include a decline in the vigor of the project’s
cooperative effort with Indian condom manufacturer J.K. Ansell to market condoms
through additional, nontraditional outlets; some weaknesses in condom promotion for
NGO staff and marketing training for potential retailers; and, the continued availability of
a plentiful supply of free condoms in Tamil Nadu. APAC activities to date have been
very effective in making the topic of condoms less sensitive in Tamil Nadu and in
introducing the notion of condom use into the popular vocabulary in the project area.
STD Management
APAC has developed a comprehensive STD care strategy which focuses on raising
demand for STD care and creating a large pool of providers trained in quality STD case
management to meet the increased demand. Project data show that increasing numbers of
patients are being referred for STD care and are receiving treatment from medical
practitioners associated with and/or trained by the project. APAC–supported NGOs have
established strong referral networks with public and private sector treatment facilities.
Some elements of the training and follow-up strategy need refinement; APAC needs to
ensure that operations research projects carried out under the project focus on research
issues, and that they not be managed as intervention projects.
NGO Capacity Building
APAC provides a comprehensive package of technical, organizational and evaluative
support for its participating NGOs. The management and staff of virtually every NGO
contacted by the evaluation team pointed to this intensive, nurturing relationship with
APAC as singularly important to improvement of the NGOs’ competence—both in HIV
prevention and in their overall effectiveness as community-based service organizations.
iii
PROJECT IMPLEMENTATION
Management of the APAC project is sound, operating on a basic philosophy which
minimizes unsustainable expenses. The key to its success is its excellent staff, assembled
through a rigorous and open recruitment process, which has meshed skills and experience
gleaned from both public and private sectors into a total commitment to APAC’s mission.
The partnership between VHS and the Tamil Nadu State AIDS Control Society
(TNSACS) has been mutually supportive, emphasizing complementarity of roles within
the overall context of the state STD/HIV/AIDS agenda. On a national level, NACO
acknowledges APAC’s importance and has used the APAC model as a reference point
for targeted interventions in India. Its failure, however, to facilitate an uninterrupted flow
of funds to the project has been a source of deep concern. Finally, the APAC partnership
with USAID/India has been one of the project’s strengths. The Mission negotiated
vigorously with the GOI over key elements of the APAC tripartite agreement. It then
invested much time and energy in helping the project develop its systems and launch its
activities, a process which, while difficult at times, is generally acknowledged (especially
by APAC) to have been critical to its successes. USAID will have to maintain this
activist posture relative to NACO if it is to develop a durable solution to the project’s
financial problems.
FUTURE DIRECTIONS
APAC is positioned to extend its successful performance to additional parts of Tamil
Nadu (by engaging additional NGO partners), to reach out to population groups not
covered by the current activity (e.g., industrial workers), to add services (e.g.,
community-based care) not presently included in the project, and to improve its STD
diagnosis and treatment capacity through an STD reference laboratory. The APAC
project should be extended to March 2005—and project funding increased—to create the
temporal and financial means for these new elements.
1
I. INTRODUCTION
AIDS PREVENTION AND CONTROL (APAC) PROJECT DATA
Project Approved: September 1992
Project Begun (Tripartite Agreement Signed): February 1995
Project Ends: March 2002
(US $ millions)
Total Project Funding: 10 
Amount Obligated: 6.42
Amount Committed: 4.735
Accrued Expenditures: 3.514
THE APAC PROJECT
The AIDS Prevention and Control (APAC) Project is intended to prevent and control the
spread of acquired immune deficiency syndrome (AIDS) in the state of Tamil Nadu by
supporting the efforts of nongovernmental organizations (NGOs) to undertake human
immunodeficiency virus (HIV)–prevention activities among high-risk groups. The
project was designed to focus on interventions demonstrated as having the greatest
impact on preventing the transmission of HIV, such as increased condom use and the
treatment of sexually transmitted diseases (STDs). The APAC project is implemented by
Voluntary Health Services (VHS), a nongovernmental hospital and community health
service organization located in the state capital, Chennai.
The United States Agency for International Development (USAID)/India and the
government of India (GOI) executed a bilateral agreement for the APAC project in
August 1992. Project activities did not begin, however, until February 1995, when the
parties agreed to key implementation arrangements proposed under the project.
PURPOSE OF THIS EVALUATION
When it was designed, the APAC implementation model was unique in India. It was the
first wholly private sector approach to address HIV prevention in Tamil Nadu, and it was
the first HIV-prevention activity to focus on specific population groups especially
vulnerable to HIV infection. USAID/India seeks to ascertain whether the hypotheses and
assumptions made during the project design process are still valid, to determine whether
the project is achieving its objectives, and to identify lessons which the project might
offer for application elsewhere in India.
Although taking place relatively late in APAC’s planned seven-year (1995–2002) project,
this evaluation is technically a midterm assessment, the findings and recommendations of
which may be used to improve project performance over the remaining period of project
activity.
2
METHODOLOGY
The APAC assessment team was composed of four persons, including an evaluation
specialist/team leader, an NGO specialist, a program management specialist, and an STD
specialist. Team members reviewed APAC documents, reports, studies and research
papers prior to the beginning of the evaluation and throughout the assessment process.
(See annex A.) They interviewed personnel from USAID/Washington, USAID/India,
representatives of the Indian government in New Delhi and in Tamil Nadu,
representatives of other donor organizations, APAC staff, NGOs affiliated with the
APAC project, and officers of private firms and contractors retained by VHS/APAC to
provide support services for the project. (See annex B.) Following initial work in New
Delhi, the team undertook fieldwork for two weeks in and around Chennai and Madurai.
The team returned to New Delhi for report preparation and presentation of key findings
and recommendations to USAID and to the GOI National AIDS Control Organization
(NACO). The assessment was carried out during the period January 24–February 19,
2000.
To keep this report succinct, much of the descriptive content that might ordinarily be
included in a midterm evaluation is not included. The report was prepared for a relatively
small readership, comprised of persons who are already familiar with the APAC project.
The report’s findings and recommendations, moreover, are generally limited to matters of
direct concern to project managers at USAID, NACO and VHS/APAC. The APAC
project is a highly innovative and successful initiative which has important lessons for
other HIV–prevention efforts in India. As noted in the report, the APAC experience
should be more fully documented—preferably by Indian experts—and disseminated to a
broad audience, in India and throughout the world.
3
II. BACKGROUND AND CURRENT ENVIRONMENT
India’s HIV/AIDS epidemic is well into its second decade. The epidemic is still strongly
driven by heterosexual transmission, and the initial concentration among high-risk groups
is being followed by rising prevalence in the general population. Although HIV
prevalence is low in a majority of states, the overall number of infections is high.
Estimates of HIV infection at the national level are about 3.5 million cases.
Implementing effective prevention, control, and care programs while tracking the
epidemic are major challenges.
The period from 1986 to 1997 marked a passage from denial of the threat of HIV to
sporadic efforts at HIV prevention spread unevenly across the country. The focus was on
creating high levels of awareness, infrastructure strengthening and blood safety. The
National AIDS Control Organization (NACO) was established in 1992. Now, with
committed leadership from NACO and support from bilateral and multilateral donors,
India has shaped a national response that encompasses government and civil society and
is characterized by decentralized program management at the state level. The major
components of the national program are targeted interventions among high-risk groups,
prevention of HIV transmission in the general population, models of low-cost care,
strengthening institutional capacity, and intersectoral collaboration.
In Tamil Nadu, a responsive state government took action in early 1993 to initiate
HIV/AIDS prevention, focusing mainly on mass media campaigns and support to NGOs
to create awareness through street plays and interpersonal communication. In addition,
programs for blood safety were implemented. There was little systematic effort at
targeting high-risk groups, among whom HIV prevalence was steadily climbing. Despite
all these efforts, a community-based prevalence study conducted by APAC in 1997
showed that the overall prevalence of HIV in the community was about 1.8. The
prevalence among women was 2.0. The study in Tamil Nadu also showed an STD
prevalence of 9.7. These data substantiate the fact that STDs and HIV are no longer
restricted to core groups but are moving rapidly into the general population, and that the
former facilitates transmission of the latter.
DONOR SUPPORT
The World Bank, the Department for International Development (DFID) and USAID are
the principal donors providing support for HIV/AIDS in Tamil Nadu. While the World
Bank’s Phase II project is implemented through the Tamil Nadu State AIDS Control
Society (TNSACS), which is focused largely on the public sector, USAID’s APAC
project is wholly within the private sector. Apart from these two donors, DFID supports
a few trucker interventions as part of its Healthy Highways project.
4
III. THE USAID RESPONSE: THE APAC PROJECT
RATIONALE
The APAC project was designed at a time (1991–92) when the World Bank and GOI
were attempting to launch Phase I of a World Bank loan that was focused primarily on
the control of STDs and assurance of a safe blood supply. However, as USAID
conducted its own research preparatory to the design of a USAID–assisted HIV–
prevention project, it became clear that heterosexual transmission of HIV was by far the
most important factor in the spread of the virus in India, accounting for approximately 90
percent of the cases in the country. The evidence available from other countries’
experiences further demonstrated that in the early stages of an AIDS epidemic, the
greatest impact on the spread of the disease could be achieved by focusing prevention
activities on groups at high risk of becoming infected with HIV. In Tamil Nadu, these
groups were subsequently determined to include commercial sex workers (CSWs) and
their clients, STI patients, and persons with multiple sex partners, such as truck drivers
and other workers in the transportation industry. USAID consequently decided to pursue
a project approach that would reduce the transmission of HIV by promoting behavior
change among high-risk population groups.
In addition, three other factors influenced USAID/India’s thinking about the project’s
overall design. The first was a belief that government agencies were ill equipped to carry
out programs addressing sexual behavior. Second, the Mission had concluded from its
experience with the Private Voluntary Organizations in Health (PVOH)–II project that
NGOs were often unable to receive funds in a timely manner when those funds were
transited or disbursed by GOI institutions. Third, USAID determined that financial,
management and operational constraints limited the feasible project area to one state.1
 On
the basis of these considerations, USAID decided to develop an NGO–based project,
focused on the promotion of behavior change among high-risk population groups in one
state, with a project structure which allowed for greater flexibility in managing and
disbursing project funds. The project would be developed in close consultation with the
GOI, specifically NACO, to ensure its consistency with India’s national HIV/AIDS–
prevention strategy.
PROJECT STRUCTURE
The project that emerged from the foregoing conceptual framework had the following
features:
 
1 Tamil Nadu was selected as the project site by USAID and the GOI following a review process and in
accordance with selection criteria which, for brevity’s sake, will not be discussed in this report.
5
Goal
To reduce sexual transmission of HIV in Tamil Nadu.
Purpose
To introduce and reinforce HIV-preventive behavior in high-risk populations. APAC was
designed to accomplish this by enabling NGOs to educate target populations, promote and sell
condoms, and enhance STD services and counseling. The project also included provision for
research needed to ensure effective implementation and monitoring of the project.
Outputs
Several outputs were established for the project, including, most notably,
ß Increased awareness of HIV/STD preventive measures and increased condom use
among high-risk populations, due to NGO activities that reach 3 million people over
the life of the project;
ß A network of at least 100 NGOs actively involved in AIDS prevention activities;
ß A 15 percent increase in total condom sales in Tamil Nadu;
ß Sustained condom distribution in at least 55,000 retail outlets;
ß Development of an STD clinical management and counseling module and at least
500 people trained in STD clinical management and counseling; and,
ß Fifteen behavioral and operations research studies completed and results
disseminated to policy makers and program managers.
Strategic Approach
To take advantage of the window of opportunity now open in India—that is, the critical few
years during which transmission of the virus might be stopped within the population of core
transmitters, thereby minimizing a spread into the general population.
The project was to be implemented by an NGO that would in turn manage a program of
subgrants, technical assistance and oversight for approximately 100 indigenous NGOs in
Tamil Nadu.
PRE-LAUNCH PHASE (1992–95): CREATING A FRAMEWORK FOR SUCCESS
The project design summarized above was new—even novel—in India at the time, and
was not immediately perceived by Indian counterparts as an appropriate response to the
country’s HIV challenge. Innovative features, which both the central and state
governments had reservations about, included
ß the first-ever notion of a bilateral, donor-supported activity directed at the
state, rather than national level;
ß the use of thematic interventions concentrated on high-risk groups;
6
ß implementation of the project through a network of Indian NGOs; and,
ß USAID’s insistence on a simplified funding mechanism for the project.
GOI counterparts objected to the diminished role of the central government in the review
and disposition of project resources. Tamil state officials had reservations regarding the
project’s focus on high-risk groups (as opposed to the general population), and on a
limited, mostly urban project area (as opposed to being a statewide activity).
Despite these objections, USAID held firm—for 26 months—to the project’s defining
characteristics, until the central and Tamil Nadu state governments agreed in 1995 to let
the activity go forward essentially as designed. To be sure, this breakthrough was due in
large measure to USAID’s strength of conviction in its project design. But it also came
about only after technical and strategic thinking at both levels of the Indian government
had evolved, narrowing the conceptual distance between the parties’ views of the
project’s potential usefulness. Indeed, by the time the project was officially launched in
early 1995, both central- and state-level governments had assumed constructive
partnership roles in relation to the new activity.
Valuable time was certainly lost during this protracted negotiation phase—time which
could have been used to begin an urgently needed activity. Despite the lapse, there were
positive outcomes. Basic understandings and project refinements that the various parties
worked out during those 26 months have subsequently proven to be singularly important
to the success of the APAC project. Some—including the use of an NGO umbrella
organization to manage the project and the project’s emphasis on NGO capacity
building—have been crucial to APAC’s good performance and credibility in Tamil Nadu.
Of special significance during this period was the agreement of all parties to the principle
that the project should function within a strategic framework established by the GOI
and Tamil Nadu state government, but without the encumbrances generally
associated with government-funded programs. This understanding, while not stated
explicitly in the tripartite agreement of 1995, was the defining principle of that agreement
and a sine qua non of the project. Events over the past year—most notably the funding
crisis and an increased intensity of NACO oversight of the project—lead to the
conclusion that this basic understanding is being eroded, to the extent that the future
success of the project may be compromised. (See discussion in section IV below.)
7
IV. KEY FINDINGS AND RECOMMENDATIONS
OVERALL IMPACT
Finding
The APAC Project is succeeding.
The APAC project is by design a relatively compact activity in terms of its geographic
and population coverage. The 48 predominately urban clusters covered by the project
compose about 20 percent of Tamil Nadu’s 60 million inhabitants. Of the 12 million
people in that project area, high-risk population groups targeted by APAC total
approximately 1,000,000 persons (commercial sex workers, STD patients, transport
workers, and high-risk groups living in slum areas). APAC reaches these people through
the outreach programs of 35 NGOs, each of which focuses on one or more high-risk
groups within its cluster area (see the map in annex C).
The evaluation team attempted to assess the results to date of the APAC project by
examining two different data sets: data from the longitudinal Behavioral Surveillance
Survey (BSS) for Tamil Nadu, and selected data from monthly reports that participating
NGOs submit to APAC for routine monitoring purposes. (Other data sources were also
reviewed, along with the findings of APAC–supported research, to assess the
performance of the project’s various components. These component-specific findings are
discussed in separate sections of this report).
BSS Data
The BSS was never intended to serve as a direct measure of APAC performance; rather,
it was designed to track trends over time in the sexual behavior of the vulnerable
population groups targeted by the project. It should be noted that no other organization
has been or is undertaking comprehensive thematic interventions in the APAC project
area (DFID is supporting only modest truckers’ interventions), such that BSS data can in
fact be viewed as a fairly reliable indicator of the APAC project’s performance per se.
Those data (BSS Waves 1 through 3) have been reported elsewhere and will not be
repeated or analyzed in this report, except to note that they show significant and sustained
changes over time in the sexual behavior of the high-risk groups targeted by the project
(annex D).
Interestingly, the most dramatic behavior changes reported by the BSS have occurred
among the two groups most regularly reached by APAC–supported NGOs—commercial
sex workers and truckers—while desired behavior change is markedly less among two
target groups (male and female factory workers) not regularly served by the project
(except for industrial workers reached via the slum-based projects). These differences
support the argument that most of the behavior change occurring among commercial sex
workers (CSWs), truckers and slum-based workers can be attributed primarily to
APAC-supported interventions.
8
NGO Monthly Reports
Notwithstanding this presumed linkage between APAC’s performance and BSS data,
other data sources were examined to corroborate the changes reflected in the BSS. It was
noted that each of the 35 participating NGOs submitted process data on a monthly basis
to APAC. Most of the information in these reports is used by APAC for monitoring
purposes and to facilitate feedback to the NGOs regarding their performance.
Information reported includes numbers of counseling sessions held, training sessions
conducted, and advocacy meetings held. From these process data, the assessment team
selected four data sets, which when viewed over time, could serve as generally reliable
indicators of the project’s progress toward achieving its behavior change objectives.
Importantly, since these data are specific to APAC–supported NGOs, they can provide a
more accurate estimate of the direct effects of the project.
The selected indicators included condom distribution, number of STD referrals, and
number of STD cases treated (as reported by health care providers collaborating with the
project). These data are shown in annex E. Despite several dips and peaks in the
monthly numbers, all of the indicators show a consistent rising trend during the two-year
(1998–99) period covered by the reports. They clearly suggest that the APAC project is
achieving the changes for which it was designed.
PERFORMANCE: PROJECT COMPONENTS
Promotion and Distribution of Condoms
Outputs
Planned: 1. Total condom sales in Tamil Nadu increased by 15 percent per year.
2. Sustained condom distribution in at least 55,000 retail outlets and in 80
percent of NGOs that are involved in AIDS prevention.
Achieved: 1. Commercial sales of condoms in Tamil Nadu (statewide) have increased
from 12.6 million pieces per year in 1995 to 27.9 million pieces (estimated)
in 1999. Sales increased by 23 percent in 1995–96, 56 percent in 1996–97,
13 percent in 1997–98, and 4 percent in 1998–99. (See Findings below for
an explanation of the reduced rate of increase.)
2. Condom retail outlets increased from 17,600 in 1996 (actual number of
outlets where condoms were available) to 35,400 in 1999. (Source:
Operations Research Group Retail Audit Report, 1999)
The condom is the only effective means available (aside from abstinence) to prevent the
transmission of HIV. The success of the APAC project therefore rests in large measure
on its ability to increase the condom-using practices of the project’s target population
groups. APAC tries to effect these changes via a two-pronged approach, including a
generic condom promotion campaign designed by Hindustan Thompson Associates in
9
close collaboration with APAC and a series of initiatives intended to increase the
availability of and preference for condoms. Major activities under the latter component
include an initiative managed by J.K. Ansell Ltd. (JKAL) to increase the number of
commercial outlets for condoms, a retailer training program implemented by the National
Institute of Sales (NIS), and a training program, conducted by the Centre for
Entrepreneur Development (CED) in Madurai, to improve the condom social marketing
skills of NGO staff. APAC also supports, with technical assistance from Family Health
International (FHI), the periodic testing of condom quality.
FINDING
The project has produced significant increases in commercial sales of condoms. Those
sales figures are beginning to plateau, however. Apparent reasons include inadequate
commercial sector interest in expanding total condom sales, especially in peri-urban
and rural areas, the need for more training of NGO staff in the social marketing of
condoms, inadequate training for nontraditional vendors, and the broad availability of
free condoms.
Private Sector Collaboration
Sales of fully priced (commercial) condoms in Tamil Nadu have increased significantly
since 1995 (see annex F). The biggest jump in sales, however, occurred during 1996–97,
when both JKAL and Hindustan Latex, Ltd. (HLL), participated in a pilot condom
marketing effort—an expanded version of which is currently being implemented by
JKAL alone under a three-year (1998–2001) contract with APAC. Since that one-year
sales increase of 56 percent, the rate of increase in commercial sales has been modest and
was almost flat (4 percent) in 1999. APAC’s view is that the earlier increase (1996–97)
owed much to the competition at the time between JKAL and HLL, implying that the
former is becoming complacent in its current efforts. JKAL believes that its cooperation
with APAC is advancing the firm’s corporate interests, as evidenced by its commitment
to finance 60 percent of the cost of the marketing program. JKAL acknowledges,
however, that its primary interest in the activity is to increase its market share in southern
India—an objective which may or may not contribute to an increase in the total demand
for condoms.
Social Marketing Training
APAC believes (correctly in the view of the evaluation team) that the long-term
sustainability of HIV–prevention efforts in Tamil Nadu requires a sustained increase in
the use of condoms purchased from commercial sources. Thus, in addition to the
JKAL–managed initiative to expand the number of commercial outlets for condoms,
APAC is encouraging its participating NGOs to adopt a vigorous social marketing
approach to condom promotion. In this instance, social marketing does not refer to
activities (e.g., the Nirodh program) that involve the sale of condoms at subsidized prices.
Rather, it means that APAC urges NGO peer counselors and other NGO outreach
personnel to convince their clients to purchase condoms at retail outlets. The CED social
marketing training program in Madurai was established specifically to reinforce the
promotional skills of NGO staff. Assessment team observation of the course—as well as
interviews with faculty, participants, and APAC consultants—found that the training is
10
thorough, well-conceived, and valued by its participants. However, virtually no follow-on
training was taking place back at the participants’ home NGOs, and many had little direct
contact with frontline peer educators. Without such follow up, the potential value of the
training is being diminished.
NIS Training
The National Institute of Sales in Chennai was contracted by APAC to motivate and train
nontraditional retailers to market condoms. NIS trained 2,125 retailers during its first
year of activity (1998–99) and will train an additional 2,700 retailers under a one-year
contract extension currently being negotiated with APAC. Follow-up surveys of the first
graduates found that only 10.8 percent of them decided to stock condoms after having
attended the 1-week training program. Another 28 percent stated that they would
consider stocking condoms if a reliable wholesale source were available. Yet despite this
very low success rate among its trainees, NIS has done nothing to revise its curriculum
for the next round of training.
Free Condoms
Almost 50 percent of the condoms distributed each year in Tamil Nadu are free. The
total number, moreover, is rising annually—mirroring the rate of increase in commercial
sales—even to the extent of echoing the commercial sector’s recent plateau effect.
Indeed, with the exception of 1997, distribution of free condoms has exceeded sales of
fully priced condoms every year since 1995. (Supply and marketing problems have
reduced the Nirodh program to an insignificant role in Tamil Nadu.) Even the NGOs
affiliated with APAC are themselves distributing an ever-increasing number of free
condoms, despite APAC’s strong promotion of the retail sector as the source of choice.
There is, of course, a positive aspect to these trends: overall condom use is increasing,
and as pointed out previously, the APAC project is no doubt responsible for much of this
increase. The negative effect of free distribution is that it continues to slow a commercial
response to clients’ needs and ultimately undercuts prospects for long-term sustainability
of an NGO–based HIV–prevention program.
Finally, it should be recalled that APAC’s coverage in Tamil Nadu is relatively modest—
probably reaching no more than 5 percent of the state’s population with intervention
programs. The recommendation offered below suggests ways to increase commercial
sales of condoms within the current scope of the APAC project. To significantly
expand those sales, however, will require an expansion of the project to additional
geographic areas and/or target groups.
Recommendations: APAC should increase condom sales in its project areas by
ß identifying a second condom manufacturer/distributor (e.g., TTK) to
participate in a condom marketing initiative;
ß strengthening the NGO social marketing training program by
11
· limiting participation in CED training programs to NGO staff who are
directly involved in condom promotion and who are likely to conduct
second-generation training of colleagues in their respective NGOs,
· revising the CED curriculum to include training in the skills that NGO
trainees will need to conduct this follow-on training, and
· instructing APAC consultants to monitor/reinforce the NGOs’ social
marketing efforts; and,
ß Extensively reworking the NIS curriculum—based on the findings of the
trainee follow-up survey—to focus on training content found to be most
successful in enlisting additional (nontraditional) vendors for condoms.
In addition, USAID and APAC should create new markets for condom sales by extending
the project to additional NGOs and to additional target groups (i.e., industrial workers),
as discussed in section VI, New Directions.
STD Management
Outputs
Planned: 1. STD case management and counseling module developed.
2. Five hundred individuals trained in STD clinical management and counseling.
Achieved: 1. Five STD care modules developed for pharmacists, registered indigenous
medical practitioners, auxiliary nurse midwives, allopathic medical
practitioners, and community health workers.
2. Over 3,536 health care personnel trained in STD management and counseling.
The objective of APAC’s STD strategy is to increase access to STD services and to
improve the quality of STD care for high-risk groups. Key interventions are to
ß provide NGO grants for behavior change communication focused on CSWs,
truckers and related stakeholders in the sex industry, tourists and women in
prostitution in tourist towns, and individuals at high-risk living in urban slum
areas;
ß build the capacity of five continuing education and training centers (CETCs)
to train a range of health care providers2
 in quality STD case management,
 
2
 These include allopathic (Western medicine trained) medical practitioners (AMPs), registered Indian
medical practitioners (RIMPs, which also includes practitioners with no formal training in any of the Indian
systems of medicine), pharmacists, auxiliary nurse midwives (ANMs), and community health workers
(CHWs). Only the AMPs are trained in the syndromic approach; the rest are expected to refer patients with
symptoms of STD, but provide information on condom use and partner notification.
12
comprising syndromic approach, partner notification, counseling, condom
promotion, and follow up;
ß conduct operations research studies of models for delivering STD care
through community-level projects (i.e., through integrated maternal and child
health/family planning [MCH/FP] interventions); and,
ß set up model clinics to demonstrate a comprehensive approach to STD care in
a hospital setting (clinic-based intervention projects, or CLIPs).
In addition, behavioral and biomedical research is conducted both at baseline and at
periodic intervals to track progress and inform modifications in project strategies. The
project agreement includes two additional components: ongoing surveillance for common
clinical presentations and drug resistance patterns, and increasing access to rapid
laboratory tests for STD diagnosis. However, these have not been incorporated into
APAC’s present STD strategy, as training of providers and behavior change
communications were considered higher priority.
FINDING
APAC has developed a comprehensive model of STD care for high-risk groups that
combines the use of innovative behavior change strategies to raise the demand for
quality STD services with a training program for providers to meet this demand.
APAC has developed and is implementing a comprehensive model to improve STD case
management. Its key components include an intensive communication effort through
mass media, interpersonal communication, and peer education; training of providers in
areas where APAC–supported NGOs promote quality STD care; and, an aggressive
condom promotion strategy. Routine monitoring data show an increasing trend in the
number of patients referred for treatment and those that actually seek care for STDs. In
addition, BSS Wave 3 data show that reported treatment-seeking behavior for STDs in
truckers is about 80 percent (up from 64 percent in Wave 1, 1996).
FINDING
APAC-supported NGOs have built referral linkages for STD care with appropriate
providers.
APAC NGOs have taken the initiative to build and nurture referral linkages with
providers in their area to ensure that target populations are able to obtain high-quality
STD care. Currently, a collaborative spirit of partnership exists between NGOs and local
governments in the implementation of STD/HIV/AIDS programs, and NGOs have used
the opportunity to ensure services for their target populations. CSWs who can afford the
services of private providers are referred to those trained by APAC. Others are linked to
public sector providers, who have been trained by TNSACS in STD case management.
In addition, NGOs have recruited and trained counselors who are then located in
government hospitals which lack counseling services.
Recommendation: APAC should capitalize on the prevailing environment of
collaboration to actively work with TNSACS to ensure that a uniform training procedure
13
for STD case management is adopted and APAC's comprehensive strategy is
incorporated into the public sector system.
FINDING
APAC support has built capacity in five institutions around the state to serve as
training centers for STD case management and to reach out to community-based
organizations. Certain elements of the training strategy need strengthening.
APAC initiated the training of providers in STD case management through CETCs in
July 1997. Training targets were based on the capacity of the training institutions, and
participants were selected randomly from each CETC catchment area. Since February
1999, CETCs and NGOs have collaborated more systematically in identifying for training
those providers located in the areas served by APAC NGOs. This change in focus has
enabled CETCs to train providers who are actually accessed by the target groups for STD
case management.
RIMPs and pharmacists are expected to refer patients with symptoms of STD to AMPs.
The CETCs and NGOs provide lists of trained providers to facilitate this referral.
CETCs use participatory training processes that are generally appreciated by the trainees.
However, the response of AMPs who attended the training has not been enthusiastic.
Feedback from providers suggests that, to hold their attention, training time be shortened
from the present two half-days and that the technical content include more information on
recent advances in STD/HIV/AIDS diagnosis and management. In addition, RIMPs and
pharmacists would like information on medical treatment of patients with STDs. They
are not content with only being trained to counsel and refer patients.
A recent evaluation shows that about 60 percent of AMPs were using the syndromic
approach to treat STDs. About 30 percent of RIMPs and 66 percent of pharmacists (who
are expected to refer cases) were prescribing drugs for STDs. Moreover, pharmacists did
not appear to be aware of the right dosages and duration for the drugs they prescribed.
The prescription of antimicrobial drugs without the correct application of the syndromic
approach could fuel already existing drug resistance problems.
The quality of follow up of trained providers is also an issue. One CETC has been able
to follow up about 75 percent of providers they have trained, while the others have
followed up about half of all trainees. The CETCs use social workers for follow-up
visits, a problem with AMPs who do not perceive them as peers. In addition, the
structured questionnaires used for follow up do not enable CETCs to identify gaps in
learning and restructure training content. Annual alumni meetings for providers do not
attract a high proportion of trainees.
The ratio of male to female providers trained is about 3:1. Considering that about 50
percent of STDs are asymptomatic in women, and that women prefer to be examined by
female providers, the lack of trained female providers could seriously hamper women’s
access to high-quality services.
14
Recommendation: APAC should review the strategy for training providers, using the
findings from the CETC evaluation report and feedback from the evaluation of the
targeted intervention projects. Major targets should be to
ß set realistic targets for each category of provider;
ß select appropriate strategies to capture the interest of each category of
provider;
ß conduct follow up on trained providers with appropriate personnel,
supplemented by technical update mailings;
ß update training modules in accordance with current findings and technical
advances relating to the diagnosis and management of STDs;
ß emphasize problems of drug resistance in training modules for RIMPs and
pharmacists to discourage inappropriate drug prescription;
ß recruit and train female doctors to make them sensitive to the prevalence and
appropriate management of symptomatic and asymptomatic STDs in women;
and,
ß train NGO staff members working with CSWs to alert them to the necessity of
periodic screening (internal examinations) for STDs, even in the absence of
symptoms.
FINDING
Without substantial technical support, operational research (OR) projects on
integrating STD services with community-based MCH services and CLIPs could
potentially evolve into conventional intervention projects, and lose the OR focus.
Maternal and Child Health/Family Planning (MCH/FP) Projects
Seva Nilayam has been successful in obtaining community support for discussion of
STDs and raising awareness about condom use and has been well supported by APAC in
collecting and reporting data on a periodic basis. Regarding management of STDs, some
issues persist. At the present time, most women with complaints of discharge are being
treated using only the syndromic approach, increasing the possibility of incorrect
diagnosis of STDs, overtreatment, and the erroneous assumption of high-risk behavior
among monogamous women and/or their husbands. Risk assessment criteria have not
been developed as yet. Although laboratories are usually equipped to conduct basic
laboratory investigations, the data suggest that not all women are screened for STDs.
One of the risk behavior correlates identified in the STD community prevalence study is
medical termination of pregnancy, which is widely practiced in Tamil Nadu. The OR
project should include the implications of this finding in community education.
15
CLIPs
Two CLIPs serve as referral centers for APAC NGOs implementing targeted
interventions. The third is a stand-alone center, in a general hospital setting. The
caseload is small, mainly because patients prefer the anonymity of a private clinic despite
the lack of laboratory investigations, counselors, and condom distribution/promotion.
More effort is needed to market STD clinics among private providers, government
dispensaries, and subcenters to increase referrals. CLIPs should be able to offer an
evaluative approach for women which includes a bimanual examination, a speculum
examination, and microscopy of vaginal and cervical secretions and culture, in addition to
counseling, condom promotion, and partner notification. Demonstration clinics should
serve to link the approach to STD care with better understanding of microbial etiology
and rational choice of antimicrobials.
Recommendation: Operations research projects (see annex G) should supplement the
syndromic approach in MCH/FP clinics by simple laboratory tests and risk assessment
protocols. In addition, APAC should provide technical support to OR projects in order
to ensure that all research questions are effectively addressed through interventions.
APAC should consider CLIPs as partners in validating current syndromic approach
protocols by linking them with an APAC–supported central reference laboratory.
NGO Capacity Building
Outputs
Planned: A network of at least 100 NGOs actively involved in AIDS prevention activities.
Achieved: 1. One-year grants executed with 40 NGOs (small grants for single programs or
to pilot projects).
2. Three-year grants executed with 35 NGOs.
At the core of the APAC project is the development of the capacity of NGOs in Tamil
Nadu to reduce the incidence of STDs and AIDS through targeted interventions with
groups at high risk of infection. These include commercial sex workers, truck drivers,
tourists, slum residents, and persons suffering from STDs. Starting with a rigorous and
selective grant-making process, APAC develops close working partnerships with its
NGOs, which range from voluntary organizations and educational institutions to
charitable societies and trusts, providing them with the training, technical assistance, and
other inputs required for their success.
Since the project’s inception, APAC has developed long-term (minimum three years)
working relationships with 35 NGOs. It has awarded 47 three-year grants to these NGOs
and other institutions: 31 in the “medium” category, defined as being between 3 and 21
lakhs, and 16 “large” grants of over 21 lakhs. Grants were awarded to NGOs and training
institutions in targeted urban areas throughout Tamil Nadu. In addition, 109 “small”
grants (under 3 lakhs) were awarded to NGOs and others for a wide range of activities in
16
support of the interventions, including OR projects, AIDS awareness and prevention
campaigns, and World AIDS Day celebrations.
The Capacity-Building Process
FINDING
APAC has succeeded in building the technical and management capacity of its partner
NGOs, in the process developing their confidence and self-esteem as significant
contributors to a critical mission. It has done so by instituting rigorous and transparent
NGO selection and grant application procedures, by providing high-quality training in
all intervention categories, and by ensuring ongoing technical and moral support for
the duration of grant activities. The “APAC NGO model” has set an important
standard for productive partnerships with private sector institutions.
APAC’s intensive approach to developing and supporting targeted interventions in the
private sector has a number of distinguishing features:
ß Carefully designed criteria for NGO partner selection, including presentation
of a good concept paper, legal NGO status, effective interactions with other
NGOs and government, an adequate administrative structure on which to
build, and at least three years experience in the field;
ß A detailed and demanding NGO grant application process, which assesses not
only proposal quality but the applicant’s track record with health-related
activities, with an emphasis on STD and AIDS prevention and community
outreach work;
ß Assistance to NGO partners in strengthening their management and
accounting systems, project monitoring capabilities, and use of information,
education and communication (IEC) materials, which it makes available in
quantity; and,
ß Designation of 2 of the 43 consultants with whom APAC has ongoing
contractual relationships to provide each NGO with ongoing technical
assistance over the life of a grant, through a schedule of quarterly visits and
other contacts, as needed.
The APAC project’s commitment to capacity building is especially evident in the range
of training opportunities it provides for various levels of NGO personnel and for others
who play related roles in promoting STD/AIDS awareness and prevention. Based on an
assessment of the skills required to reach high-risk groups with information, services and
counseling, it offers training at five continuing education training centers (CETCs) and
other sites to NGO managers, health personnel, counselors, social workers, and
volunteers. Depending on the audience, training is provided in areas ranging from social
marketing to STD/HIV/AIDS counseling to syndromic management of STDs. Training of
trainers is provided in peer education and street theater. Barbers, pharmacists and
community health workers have all benefited from APAC training initiatives. The project
has also published a wide range of training modules and materials, which it updates on a
regular basis.
17
To date, over 14,000 people have received training in connection with the APAC project,
at a strikingly modest average cost of less than 900 rupees (US $22 per trainee).
Training provided under APAC is further reinforced by a number of monitoring and
technical assistance mechanisms. These include participatory site visits; regular
experience sharing and review meetings (ESRM) for NGO representatives, keyed to
particular thematic interventions (Women in Prostitution [WIP] projects, Prevention
Along the Highways [PATH] projects); cluster meetings, which bring together NGOs in
particular geographic areas for exchange of experiences and ideas; and, specially
arranged visits between projects and/or NGOs for exposure to individual success stories
and new ideas and models.
Networking
FINDING
APAC has succeeded in establishing excellent, supportive networks among its NGOs at
thematic and cluster levels. As they have matured, APAC NGOs have also developed
effective working relationships with nonproject NGOs and with the public sector.
Networking is accomplished at the following three levels, and contributes substantially to
capacity building among the participating NGOs.
1. Networking among APAC–supported NGOs is one of the principal goals of
the ESRMs, organized every 6 months for NGOs working in a particular
thematic area (e.g., WIP, PATH). ESRMs are typically attended by NGO
project staff, consultants, and APAC technical and financial management
staff. Performance of each project is reviewed and problems and ideas for
their solution are exchanged and discussed. Minutes are kept for continuing
reference. NGO representatives contacted during this midterm evaluation
were unstinting in their praise of these meetings as aids to their work and a
boost to their morale.
2. Networking among APAC NGOs in each of the eight geographic clusters into
which they are divided is achieved by bringing together individuals and NGOs
involved across all thematic interventions in that cluster. These meetings are
also convened on a 6-month basis and serve as a valuable opportunity for
participants to be exposed to and learn from the full range of APAC
STD/HIV/AIDS-prevention activities.
3. Finally, most NGOs establish working relationships with other, non–APAC
NGOs, private health care practitioners, retailers, community leaders, and
public sector entities active in their areas. In fact, many receive funding from
other sources as well as APAC. While they universally rate APAC’s approach
to NGO capacity building above all others, they also benefit from resources
such as training programs offered by TNSACS and from being able to refer
clients to practitioners in the area.
18
Research
Outputs
Planned: Fifteen behavioral and operations research studies completed and the findings
disseminated to policy makers and program managers.
Achieved: Seventeen research studies conducted; results disseminated.
FINDING
APAC’s research agenda is carefully crafted. About 17 formative and evaluative
biomedical and behavioral research studies have been carried out so far. APAC has
also systematically documented and disseminated the results of these studies. Data
from APAC–supported research studies are valued within NACO and the state
government.
The design of the condom promotion program and the behavior change communications
strategy were based on formative research studies, conducted much before the strategies
were conceptualized. The BSS measures trends in sexual behavior over time. BSS data
reflect the impact of APAC’s interventions and also capture changes in other areas. The
health facility survey was the basis of the training program for health care providers in
STD case management. The STD-prevalence study is one of the few community-based
studies of its kind in India.
In terms of the future, an urgent indepth analysis of data is needed to establish, for
example, the correlation between symptoms and microbiologic etiology, especially in
women, and to study influencing factors, such as higher prevalence in women with a
history of a medical termination of pregnancy. In addition, the data should be introduced
into the public domain to enable access to researchers and planners from other parts of
India to design and implement similar studies.
APAC has contracted with commercial research firms to implement the research studies,
but maintains stringent quality control over data collection, analysis, and report writing.
Information, Education and Communication (IEC)/Behavior Change
FINDING
APAC’s Communications Program provides its partner NGOs with creative technical
assistance and a broad spectrum of tools with which to reach their target populations.
Its approach effectively complements the communications initiatives of other
organizations. Where it is in need of some strengthening is in the area of training and
follow up of counselors, so as to maximize the potential of one-to-one interactions in
changing high-risk behaviors.
By all accounts, as illustrated elsewhere in this report, significant amounts of behavior
change, in the direction of increased awareness of STDs and AIDS and their prevention,
have occurred in Tamil Nadu among high-risk groups as the direct result of APAC
project interventions. Contributing to this result have been APAC’s innovative
communications strategies. These include developing a range of print materials providing
19
information, much of it refreshingly frank and explicit, on AIDS, STDs, and their
prevention. Flyers, posters, stickers, handouts, booklets, and an APAC newsletter are all
available in quantity to all NGOs and other project collaborators and are widely
distributed. Their strength lies in the number and variety of the messages they transmit,
constituting a cafeteria approach to information dissemination and ensuring that there
will be an appropriate and effective message for all audiences.
As with much of its work, rather than building up its staff beyond sustainable levels,
APAC relies on a private contractor for technical input in the development of its
communications strategies, as well as for all materials production. Hindustan Thompson
Associates, Ltd. (HTA), is sufficiently impressed with APAC’s professionalism and
pleased with the working relationship to have recently renewed its contract despite the
fact that, for reasons described below, payment for services has often been delayed. In
addition to print materials, HTA has also produced two spots for television broadcast,
each in long and short versions targeted at adolescents and young married couples. These
were less focused on high-risk groups than the print materials; this area could be left to
TNSACS, which has a significant commitment to disseminating awareness and
prevention messages in electronic media. Otherwise, contrary to suggestions that APAC’s
IEC initiatives might duplicate other agencies, they filled an important niche,
complementing rather than competing with the efforts of others.
A particularly innovative element in APAC’s IEC/behavior change communication
(BCC) inventory is the development and production of street dramas by community
groups in slums and rural areas. APAC contracts with the quasi-governmental State
Resource Center (SRC) in Chennai to train writers and producers, who then train
community groups to make dramatic presentations, often quite graphic, of the impact of
STDs and AIDS on Indian lives. Follow-up surveys conducted by the players themselves
indicate that this is a particularly effective way to transmit messages to audiences that, by
virtue of being illiterate or lacking access to other media, would otherwise not receive
them.
One area in need of strengthening is behavior change counseling. Sensitive, focused, one￾to-one counseling can be one of the most effective, if not the most effective, means of
convincing individuals to change their behavior. The information being transmitted by
NGO counselors to their clients is somewhat stilted, reflective of knowledge of the facts
and consequences of high-risk behaviors, but inflexible in responding to individualized
concerns. This observation was confirmed by others with whom the assessment team
spoke and is not surprising, given the skill needed to provide advice and comfort in such
a sensitive area. Nonetheless, it points to inadequacies in the training being provided by
the counseling training center (CTC) at Christian Medical College/Vellore, and the need
for secondary training and careful follow up.
Recommendation: Review existing counseling training curricula for areas needing
improvement. Develop detailed refresher training and follow-up protocols with which to
monitor and strengthen skills of counselors once they are in the field. Also, consider
requiring APAC staff and consultants to receive basic counseling training.
20
PROJECT IMPLEMENTATION
The actual implementation of the APAC project was assessed from three perspectives.
The first had to do with its funding under the bilateral agreement signed in 1992 between
USAID and the government of India, and the shortcomings of a system of funds
disbursement which has been, at best, unpredictable. The second assesses the quality and
effectiveness of the management of the project by VHS/APAC. The third looks at the
partnerships at state, national and donor levels that have been the most instrumental to the
functioning of the project.
The Funding of APAC
FINDING
Interruptions and inconsistency in the flow of funds to APAC have severely affected its
operations, risking loss of momentum and demoralization of NGO partners when the
project is at its most productive. At the heart of the problem is inadequate
implementation of the revolving fund called for in the January 1995 tripartite
agreement signed between the government of India, USAID and Voluntary Health
Services, the purpose of which was to ensure continuity in financial support that would
be critical to such an innovative undertaking.
Notwithstanding the remarkable success of APAC interventions to date, and the
genuinely high regard in which the project is held by the NGOs it supports and the
institutions and contractors with whom it collaborates, there is on all sides an underlying
unease about its, and their, ability to continue. The reason is that for the better part of a
year, funding flows from NACO to APAC have been, at best, inconsistent. From
November 1999, until the time of this evaluation, there had been no disbursements at all.
The result is that training sessions have had to be cancelled, consultant visits curtailed,
monitoring activities postponed, and new grants and contracts put on indefinite hold. The
intensity and quality of support that are so integral to the project’s impact are in jeopardy.
Many NGOs have been severely affected by APAC’s inability to meet its financial
commitments to them. While unabashedly proud of what they have accomplished, and
willing to carry on voluntarily in the hope that the situation will improve, they cannot do
so indefinitely. Some NGO staff in whose training and nurturing the project invested
have already been lost. In general, NGOs understand that the problem is not of APAC’s
doing, and remain committed to its approach. If financial uncertainties persist, however,
NGO loyalty and survivability will be tested.
At the core of the matter is the fact that the APAC revolving fund concept, agreed to in
1995 by all parties, has not been effectively implemented. Since VHS/APAC, as an
umbrella NGO, would serve as the engine through which the capacity of a large number
of smaller NGOs to engage in STD/AIDS prevention initiatives was developed, it had to
be in a position to provide financial resources to those NGOs. Hence, the unique
agreement, developed after long negotiation between NACO, VHS and USAID, to
establish a replenishable, revolving fund from which APAC could support training, start￾up, and monitoring activities of its NGOs, many of them small and financially weak.
21
Annual revolving fund limits for each project year, from 1995 to 2001, were specified in
the APAC project tripartite agreement document. The fund was to be replenishable up to
these limits, on a quarterly basis, on presentation of appropriate statements. However, this
system was never fully implemented. Especially in the last year, reimbursement of APAC
by NACO has been beset with delays and partial payments. The result is that uncertainty
has for some time been the dominant feature in APAC’s financial picture.
A number of explanations are offered for this situation. In its early years, APAC’s
financial commitments were lower than projected, which is not surprising, given its
newness and complexity. As a result, NACO may not have adequately budgeted for
increasing budgetary requirements, and was subsequently unable to rapidly readjust when
the project gained momentum and expenditures increased. Also, in the project’s early
years, VHS management made an investment of APAC project funds in an unauthorized
bank account in Tamil Nadu. Although the funds were fully reimbursed and systems were
installed to preclude similar episodes in the future, lingering doubts about APAC
financial management may have influenced NACO’s disbursement decisions. Finally, the
APAC project management committee (PMC), normally scheduled to meet every quarter,
had not been convened since September 1999. As the principal project interface with the
GOI (membership includes NACO, TNSACS, USAID. and VHS), the PMC, if it had met
on schedule, might at least have been able to help ease cash flow problems.
Whatever the reasons, what is certain is that the system by which APAC funding is
projected and disbursed needs to be rationalized, through full implementation of the
revolving fund designed for the purpose. The project has accomplished much despite
funding uncertainties and deserves to have that burden removed. USAID leadership and
persistence in working with the government and VHS to hammer out the original APAC
model and support system was exemplary. No less is required at this important juncture
in helping all parties understand each other’s needs and remove impediments to a
productive partnership.
Recommendation: USAID, in consultation with APAC/VHS, should clarify and reaffirm
with NACO the terms of the APAC project tripartite agreement, especially regarding the
functioning of the revolving fund, which was established by the agreement “to facilitate
rapid and effective project implementation.” It should do so with the goal of permanently
removing impediments to project operations resulting from funding uncertainties.
The Management of APAC
FINDING
APAC project management is sound. The flexibility and efficiency of the
administration of its main office and personnel in Chennai are evident as well in the
guidance and support that it gives to NGOs in developing their capacity to design and
implement STD/AIDS education and prevention activities for high-risk populations.
Staff recruitment and grant application procedures developed by APAC have set a high
standard for its NGOs, as well as for other projects.
There is little to criticize in APAC’s management of its central office. At this point in its
life, it has resolved problems resulting from administrative growth and modest staff
22
turnover. This is notably the case in financial management, now in very capable hands
with detailed and effective systems in place. Overall, APAC is operated by a committed,
adaptable team with a commendable degree of frugality. APAC offices are comfortable
but spartan. Administrative policies keep unsustainable expenses to a minimum. There
are, for example, no APAC vehicles, and travel expense allowances for staff and
consultants are kept at the basic level. At the same time, APAC/VHS has worked
diligently to provide the project with the best guarantee of successæa talented and hard￾working staff.
From the start, and with USAID’s urging and guidance, APAC/VHS designed an open,
rigorous staff recruitment process, one that invited applications from qualified individuals
in both the public and private sectors. The result is a staff that combines entrepreneurial
skills of private business, technical and idealistic attributes of nonprofit organizations and
professions, and political and administrative skills gleaned from government service. The
mix permits a holistic approach to program planning, monitoring and evaluation, and a
capacity for change as circumstances dictate.
Merging public and private sector perspectives in a new initiative dealing with complex
issues was not always easy. In the words of one staff member, “it took us almost a year
for us to trust each other, and there was a lot of frustration,” but now “APAC is a family
affair.” The project was also wise in its selection of senior staff. In its first director,
APAC benefited from the leadership of a skilled government technical expert, who was
able to give full rein to his team’s creative skills while maintaining cordial,
nonconfrontational, public sector relationships. His replacement has the interpersonal
skills and substantive experience (including his role as the first APAC NGO coordinator)
to continue the growth process at both a staff and program level.
This is especially true if he can correct one weakness perceived by the evaluators in staff
management. This was the lack of systematic communication between APAC technical
and management units of the details of program priorities and activities. With no
regularly scheduled staff meetings, and because they are so busy, senior staff members
are often insufficiently aware of each other’s current activities. A second weak spot lies
in inadequacies observed in the follow up of individuals who participate in the various
training programs offered by APAC-supported CETCs. Follow up does occur, but to
date has not been used to the maximum to refresh trainees’ retention of material and
identify additional training needs. (This point, with an accompanying recommendation, is
addressed elsewhere in this report.)
In general, however, sound management practices at the top have led to sound technical
assistance to NGOs in developing their interventions. As noted in an earlier section of
this report, there was wide appreciation among project NGOs for the intensive,
responsive support rendered by APAC staff and consultants. NGOs find that APAC’s
grant application process, while detailed and demanding, makes them better stewards of
their grants when awarded. They are grateful for “APAC’s systematic way of doing
things,” and for the regular opportunities for exchange through staff monitoring,
consultant visits, and ESRMs. In contrast, with the projects of most other donors, they
find that “there is not much training and very little follow up.”
23
Recommendations: Senior management should institute a system of regular staff
meetings, at least on a monthly basis, preferably biweekly. The purpose would be to
improve intraoffice communication, especially with respect to the sharing of technical
and programmatic priorities and activities.
Given its proven success and wide endorsement, the APAC NGO model of project
implementation, built around targeted, thematic approaches and intensive support for
NGO capacity building, needs to be documented. As a whole and in its individual parts,
the model has much to teach STD/HIV/AIDS awareness and prevention initiatives, in
India and elsewhere in the world.
Partnerships
FINDING
Partnerships at state, national, and donor levels have been instrumental in the
launching and successful maturation of the APAC project. Each partner has played
an important role in ensuring the comprehensiveness of the APAC approach.
Meanwhile, the partnership that most embodies APAC’s unique contribution to
STD/AIDS prevention is that between itself and the NGOs whose capacities it seeks to
build. As reflected elsewhere in this report, that relationship has much to teach the
world.
With the exception of the unauthorized financial transaction noted above, APAC’s
partnership with VHS has been harmonious and productive. Indeed, because of its
success, the approach of creating an umbrella NGO within an existing institution with an
established presence in the community is being adopted for STD/HIV/AIDS prevention
projects in Maharashtra and elsewhere. By all reports, VHS has been a cordial and
benevolent host to the project, giving it full freedom to pursue its objectives while not
hesitating to express itself on matters of policy and donor involvement when needed;
hence, for example, the VHS secretary’s strong appeal to USAID/India in December for
help in resolving with NACO the debilitating issue of APAC funding interruptions,
described above.
On balance, the partnership with USAID has also been positive. First and foremost, the
Mission from the beginning committed itself totally to negotiating a strong, workable
project collaboration with NACO. It refused to obligate funds until an acceptable
tripartite agreement was signed, almost two and a half years after the September 1992
signing of the original bilateral agreement, which gave birth to the APAC initiative. It is
hoped (see above) that USAID/India can bring the same level of involvement to
reaffirming terms for which it originally fought so hard.
At an operational level, criticism was reported to the assessment team from some
respondents that the Mission, especially in the early stages of the project, had been guilty
of “micromanaging.” Indeed, from the APAC staff perspective, USAID was more
involved than they would have liked at the time. It became “painful to us” and prompted
a request to the Mission director that APAC be given more room to maneuver.
Ultimately, however, the staff has concluded, as has the evaluation team, that this level of
early USAID involvement was valuable, even essential. Given the newness of the project,
24
not to mention the sensitivity of its mission, there was much at stake for all concerned.
USAID’s involvement in monitoring staff recruitment, NGO selection, and proposal
solicitation, among other functions, was instrumental in helping APAC develop the
systematic, comprehensive approach to project implementation for which it is now
praised. A more laissez-faire approach on the part of the Mission might have resulted in a
significantly lower return on its investment.
APAC’s relationship with TNSACS has been cordial and mutually supportive,
emphasizing complementarity of roles. TNSACS operates statewide, makes more NGO
grants of generally shorter duration than APAC, and at the central level focuses on blood
safety and broad STD/HIV/AIDS awareness raising and prevention communication
strategies. APAC’s involvement at points of intervention is far more intense, its IEC/BCC
activity focused on high-risk groups with more explicit messages than TNSACS is able to
disseminate. The team did not agree with those who suggested that APAC’s
communications activities duplicate those of TNSACS, except perhaps in videotape
production (see above). In general, there is room for both.
There is good communication between staffs, who often benefit from each others’
training offerings. APAC’s evaluation and research specialist has provided technical
assistance on research models to TNSACS and there is regular exchange of information
on NGO grants, especially where NGOs are receiving support from both sources. The
one critical observation of TNSACS is that in its most recent annual report, which
purports to provide an overview of the battle against STDs, HIV and AIDS in Tamil
Nadu, no mention is made of APAC.
APAC’s partnership with NACO has, for the most part, been mutually supportive. APAC
staff has supported NACO in training programs and in the development of the Phase II
program. However, NACO’s difficulty in systematically replenishing a revolving fund
for project disbursements, as mandated in the tripartite agreement, is a hindrance to
current operations and a worry for the future. NACO has a huge role to play in
coordinating the battle against AIDS in India. It must oversee numerous donor
agreements, led by the $191 million Phase II loan from the World Bank, and has
determined it will do so without increasing staff. APAC may be the most innovative,
effective AIDS prevention activity in the country, but it may also be the smallest player
in financial terms; hence, there is a need to confer with NACO without delay, to remove
complications from the project funding process and, in so doing, make the most of the
APAC/NACO partnership.
Finally, it should be noted that FHI’s support to APAC has been timely and appreciated.
Especially in the project’s first two to three years, FHI’s responsiveness and technical
assistance in systems development was, by staff account, of great value. That its role now
is perceptibly smaller (although FHI remains available as needed) speaks well for the
APAC capacity that it helped build. The BSS model, created with FHI’s technical
leadership, has proven to be a unique tool for assessing project impact. (Indeed, the BSS
has been adopted by NACO as the primary device for monitoring STD/HIV/AIDS
prevention activities countrywide.) The fourth wave sentinel survey, now underway in
nine target urban areas in Tamil Nadu, is testimony to the continuing importance of
FHI’s contribution to APAC’s mission.
25
V. PROJECT SUSTAINABILITY
One of the more obvious lessons to emerge from the APAC project is that it does not
take large sums of money to effect meaningful change in HIV prevention. Far more
important are a carefully designed and well-executed project, frugality in project
administration, and reliance on existing institutions that share a common commitment to
the project’s objectives.
APAC’s NGO capacity-building efforts have contributed substantively to the
strengthening of a large number of increasingly experienced NGOs and to the
development of the skills of the personnel who work in and for these organizations.
Assuming (realistically) that donor fatigue in the field of HIV prevention is not likely to
set in soon, the human and organizational resources being developed by APAC will
be in place and ready to perform well under a variety of donor-funded initiatives in
the future.
Beyond the immediate parties to the project, the APAC project concept has demonstrated
a degree of sustainability unusual for any development activity: virtually every major
HIV-prevention program now under way or being designed in India incorporates
the core features of the APAC project. These include a focus on vulnerable population
groups, adoption of a public-private partnership model of program implementation at the
state level, reliance on Indian NGOs as change agents in the campaign against HIV, and a
consensus around the notion that state-level programs require considerable autonomy and
flexibility in order to succeed under varying conditions at the local level. If APAC ended
today, most of its key elements would survive within the framework of these other
programs.
Notwithstanding APAC’s success—or perhaps because of it—the question arises as to
how long the APAC intervention model will be needed in Tamil Nadu. That modelæwith
its attendant costs for materials development, staff training, and intense project
management—is designed to reach and convince high-risk population groups to change
their sexual behavior. By one scenario, the type of interventions now employed by APAC
could eventually become counterproductive—that is, once most clients in the target
population groups adopt the behavior changes promoted by the project, subsequent
interventions become more annoying than helpful and produce increasingly fewer
increments in behavior change per rupee expended. It is tempting to forecast, for
example, the eventual conversion of the current “crusade” model of the project into a
lower-cost, less staff-intensive “maintenance” model (conceding the unfortunate
comparisons to the malaria eradication experience).
Finally, the longest term test of the durability of APAC’s efforts will be the extent to
which its genuinely novel ideas are taken up by the larger health and community welfare
sector in India. APAC has shown, for example, that a relatively modest project can
achieve something previously considered beyond the capacity of most primary health
care systems—that highly mobile segments of the community (truckers, migrant
CSWs, STD patients) can be reached with primary health care information and
26
services on a sustained basis. APAC has made a powerful demonstration of an idea
which, if broadly adopted by the country’s primary health care and community outreach
systems, might obviate the need for future “APACs.”
27
VI. NEW DIRECTIONS
NEW INITIATIVES
A number of options, changes and/or new initiatives have been identified that warrant
favorable consideration by USAID, NACO, and APAC.
1. Extend the project: By one measure, APAC has already achieved the major outputs
called for under the tripartite agreement. Much remains to be done, however, as
neither the project nor other HIV-prevention activities in Tamil Nadu have yet
reached and convinced a “critical mass” of high-risk persons to permanently change
their sexual behavior. Moreover, APAC’s readiness to expand its coverage (i.e., by
engaging additional competent NGOs and by launching new initiatives—see below)
is constrained by life-of-project considerations which bar any new activity from
having a duration of more than two years. It is strongly recommended that the parties
extend the project by three years, to March 2005. APAC would use that additional
time to further improve and consolidate its current program, to expand its coverage
(as described below), and to help ensure long-term sustainability of the program after
2004.
2. Increase the number of participating NGOs: One of the keys to APAC’s success
has been its careful attention to the caliber and competence of the NGOs that
participate in the project. The importance of this factor was demonstrated early in the
project, when APAC’s eagerness to sign up NGO partners in the manner of TNSACS
(for one-year grants) led to the involvement of some overly fragile and ultimately
nonperforming NGOs. The lesson was learned, however—such that APAC now
estimates that, in addition to the 35 NGOs currently working on the project, only 25
or so additional NGOs in Tamil Nadu would meet APAC’s strict standards for
participation in the project. (Some observers estimate that up to 1,000 nominal NGOs
may exist in the state.) APAC would “graduate” some of the current 35 NGOs as it
initiated new subgrants with the new NGOs.
3. Develop “nodal” NGOs: Even if APAC were given the additional time mentioned
above, they would be hard pressed to support many additional NGOs in the labor￾intensive, hands-on manner which accounts for so much of APAC’s success to date.
In addition, regional differences and logistic constraints argue for some measure of
devolution of APAC tasks to other, especially strong, NGOs in the state. At least
initially, such tasks would fall short of subgrant approvals and financial oversight, but
would include provision of technical assistance, staff training and follow up, and
project monitoring. The key to this process would be the engagement of regional
NGOs that have close links to their communities, which are already perceived by
smaller NGOs to be effective, and which have the skills and experience which the
smaller NGOs need to succeed. Over time, these “nodal” NGOs could assume the
character of—in the words of APAC staff supportive of the idea—“mini-APAC’s”—
which might attract their own financial support to continue interventions on regional
bases after the end of the APAC project.
28
4. Establish an STD reference laboratory: Ongoing surveillance of STDs and
antimicrobial resistance and validation of syndromic approach protocols need back￾up support of a high-quality, STD reference laboratory which providers in both public
and private sector can access. Tamil Nadu has several research laboratories, one of
which can be strengthened to serve as such a reference laboratory. The Christian
Medical College in Vellore and the Postgraduate Institute of Biomedical Sciences, for
example, are organizations which have the requisite capacity and which are also
linked to APAC. One of the most challenging aspects of establishing such a center is
to develop its referral networks in the private and public sector which reach into the
periphery to obtain the data for surveillance.
5. Launch a small number of new thematic interventions: VHS/APAC identified
several initiatives which they propose (not all with the same priority) for inclusion in
the project. Based on the evaluation team’s discussions with APAC staff and
observation of project activities, the following recommendations regarding these
prospective activities (many of which are already familiar to USAID) are provided:
ß HIV Information and Documentation Center at VHS: VHS proposes to
open such a center within the institution itself. While the idea of having more
ready access to information in Chennai is appealing, given other information
dissemination plans already under way as part of APAC, this is not seen as a
necessary investment, and it could detract from other activities.
Recommendation: Do not approve the Center.
ß STD “model clinic” at the VHS hospital/expansion of CLIPs: APAC
proposes to set up a model STD clinic at VHS. There is little clarity in the
concept of what such a clinic could accomplish beyond the function of the
current CLIP projects. (Moreover, the tripartite agreement does not allow
APAC to support any project interventions at VHS). APAC also proposes to
increase the number of CLIPs, three of which have been established as
demonstration STD clinics. The lessons from these three clinics need to be
studied before APAC establishes any more models.
Recommendation: APAC should not fund any demonstration STD
clinics.
ß Voluntary counseling and testing centers (VCTs): Awareness levels
regarding HIV/AIDS, including its etiology, are very high in Tamil Nadu.
This has resulted in several centers offering HIV testing without pre- and
postcounseling or confidentialityækey elements of testing protocols for
HIV/AIDS. In response to this high demand for voluntary testing, APAC
proposes to identify two private sector laboratories, each in major towns in
APAC’S priority regions. The laboratory technicians would be trained in pre￾and posttest counseling and in strengthening the quality of interpretation and
reporting. Centers would also serve as testing facilities for APAC-supported
NGOs. While there is a great need to set up high-quality, voluntary counseling
and testing centers, the design of this proposal needs serious modifications.
Major issues include the following:
29
· distinction between the roles of a laboratory technician and
counselors,
· need for follow-up and refresher training of counselors and
laboratory technicians,
· incentives for the laboratory to participate in such schemes, and
· sustainability of the VCTs.
Lessons learned from such VCTs (which have the potential of being
financially viable) can be disseminated to stimulate the private sector/private
hospitals to set up such centers.
Recommendation: APAC should support four demonstration VCTs after
revision of the current concept.
ß Extend the project to Pondicherry: APAC staff point to the cultural and
linguistic similarities between Tamil Nadu and Pondicherry and acknowledge
that much of the project’s work could be extended to the latter with a
minimum number of changes in operational methods, materials, and behavior
change strategies. The evaluation team has concluded, however—with the
concurrence of APAC staffæthat extending the project into Pondicherry
would be burdensome and disruptive to the APAC project. At the least it
would require the engagement of another state health authority, another AIDS
control society, and the probable inclusion of Pondicherry personnel on the
project’s executive committee. While such an extension would clearly reach
out to additional high-risk populations, the added administrative burden might
compromise APAC’s ability to succeed in Tamil Nadu.
Recommendation: Do not extend the project to Pondicherry.
ß Extend the project to border areas: This would introduce the same
complications described above and for relatively marginal gains in project
coverage. APAC agreed, however, that it should communicate closely with
program managers in Andra Pradesh and Kerala to make them sensitive to the
location and needs of migrant communities in those states. Special mention
was made of APAC’s responsibility to alert Andra Pradesh personnel to the
needs of 16 specific communities in that state which provide over 50 percent
of the CSWs working in tourist areas in Tamil Nadu.
Recommendation: Do not extend the project to border areas.
ß Home/community-based care and support: APAC proposes to identify four
of their current grantees (based on need and competence) and provide them
with grants to implement community-based care and support programs. This
initiative would draw on experience gained by similar projects in Tamil Nadu
and abroad. The projects will focus on building community support for
persons living with HIV/AIDS, for identification of opportunistic infections,
30
establishing referral linkages for hospital care and counseling support for
affected individuals and their families.
Recommendation: APAC should support four existing organizations that
have the community outreach and competence to set up care and support
projects.
ß Industrial workers intervention: USAID and APAC have already concurred
in principle to the inclusion of this initiative in the APAC project, but it was
deferred because of the limited time (two years) remaining in the project.
Recommendation: Launch the Industrial Workers Initiative once the
time extension discussed above has been approved.
ESTIMATED COST OF NEW INITIATIVES
(All recommendation assume approval of a project extension to March 2005.)
Total
Activity Project Cost
($000)
Involve up to 25 more NGOs 1,000
Enlist four “Nodal” NGOs 200
STD Reference Laboratory 1,000
Four VCTs 40
Home/community-based care 300
Industrial Workers 375
Additional APAC staff (2) 80
TOTAL 2,995
31
VII. ISSUES
PROJECTED ALLOCATIONS AND EXPENDITURES
APAC expenditures are currently averaging approximately $375,000 per quarter, or $1.4
million per year. In the absence of any new activities or cost elements, the project’s
current allocations ($2.9 million) would cover costs for about 24 months.
Start-up costs for most of the new initiatives shown above would be relatively low over
the next 12 months, probably amounting to less than $300,000 through calendar year
2000. New cost elements would include recruitment of two additional staff, the launch of
some initial interventions with industrial workers, and initiation of work to establish an
STD reference laboratory.3
By early 2001, APAC would be rapidly enlisting additional NGOs in the project while
“graduating” others and it would begin to implement most of the other initiatives
discussed above. Annual costs would likely increase to $1.8 million per year in 2001—
during which time some of APAC’s current NGO programs would be renewed, new
NGOs would be brought into the project, and the STD reference laboratory would be
fully operational.
Project costs would likely rise to approximately $2.5 million per year by 2002, and
remain at that level through the end of the project. During this period, all of the new
NGOs, plus some of the existing NGOs and the nodal/regional NGOs, would be fully
engaged in the project. Total project costs for the period March 2000-March 2005 would
be approximately $11.1 million, of which about $6.5 million is currently available to the
project.
THE APAC MODEL: IMPLICATIONS FOR AVERT AND WORLD BANK,
PHASE II
As discussed previously in this report, the USAID-supported AVERT project in
Maharashtra state and the countrywide World Bank Phase II loan both incorporate many
of the design and operational features of the APAC project. Managers of those other
activities should take note, however, that the APAC model utilizes several features that
are, so far, unique to the project, and have not yet been replicated in the two larger
activities. The most noteworthy of these special features is the intense, hands-on support
and nurturing relationship which APAC maintains with its affiliated NGOs. To a
considerable extent, APAC’s success has been a result of its willingness to invest the
time and resources that these NGOs need to succeed.
 
3
 USAID might want to consider supporting the establishment of the STD reference laboratory as a discrete
assistance activity, i.e., outside the framework of the APAC project.
32
USAID managers responsible for the AVERT project may be able to promote a similar
ethos within that activity’s project management unit. If that orientation does not emerge
in the project management unit, the AVERT project may not be able to produce results
commensurate with APAC’s.
The Phase II program will face similar concerns—perhaps exacerbated by a World Bank
working style which does not (indeed cannot) devote the kind of donor oversight and
managerial input which has characterized USAID’s support for APAC.
APAC has also demonstrated, in the course of its recent funding crisis, that it is
especially vulnerable to lapses in communications with NACO and that it can be
seriously compromised if funding falters due to such problems. NACO is about to take on
a hitherto unparalleled challenge in managing the more than $300 million Phase II
program and plans to do so without recruiting any additional staff. USAID should be
attentive to ensure that the comparatively low-profile activity in Tamil Nadu does not fall
below the field of vision of NACO managers.
STD DRUGS
Drug availability is an essential component of STD case management. Treating a patient
at first encounter is a fundamental premise of syndromic management. However, in
APAC-supported trucker projects, where target groups are counseled on condom use,
treatment seeking for STDs and other preventive behaviors, no facilities exist for STD
case management, including drug prescription. NGOs rely on patient referrals to trained
providers in towns and cities, which may or may not be located at easy access points
from the highway. Since truckers are a mobile population, it is practically impossible to
ascertain if they have actually sought care from a trained medical provider. NGOs and
APAC have suggested the possibility of setting up STD clinics at NGO intervention
points along the highway. They have also requested that these clinics be stocked with
STD drugs.
Recommendation: NGOs should explore the possibility of identifying providers who are
located near intervention points and involve them (through sensitivity and other training)
to provide high-quality STD services. These can then serve as referral centers.
ANNEXES
A: Scope of Work
B: Persons Contacted
C: Map of NGO Support in Tamil Nadu
D: BSS Data
E: APAC Project Data
F: Particulars of Condoms Distributed in Tamil Nadu
G: Operational Research Topics for STI Management
ANNEX A
SCOPE OF WORK
(from USAID/India)
AIDS PREVENTION AND CONTROL PROJECT
(APAC)
MID-TERM EVALUATION
JANUARY 24 TO FEBRUARY 19, 2000
DELIVERY ORDER STATEMENT OF WORK
BACKGROUND:
USAID/India plans to conduct the first evaluation of its bilateral AIDS Prevention and
Control (APAC) Project. It contributes to the result of “Reduced Transmission of
HIV/AIDS and Related Infectious Diseases in Tamil Nadu” under the Strategic
Objective “ Reduced Transmission and Mitigated Impact of Infectious Diseases.” The
state of Tamil Nadu had been chosen for the interventions because it was one of the three
states in the country demonstrating a rapid increase in HIV infection among high-risk
groups. The activity was designed to change behavioral norms through selective
interventions that have been identified as the most effective in reorienting populations to
practice HIV preventive behavior. The planners of the activity intended that APAC
project should target high-risk populations, including prostitutes and their clients, and
STD patients. Grants to NGOs were envisaged to educate target populations, to promote
and sell condoms, and to enhance STD services and counseling.
The bilateral agreement for APAC was signed on 8/30/92. However implementation
began on 2/01/95 when the Government of India (GOI) agreed to key implementation
arrangements proposed under the activity. The Agreement forged a tripartite
arrangement between the GOI, USAID and a local NGO, Voluntary Health Services
(VHS) (which was identified to implement the activity in Tamil Nadu). The activity is
scheduled for completion in March 2002.
The implementation arrangements under APAC project specify that USAID will provide
local currency, through the Ministry of Finance to the National AIDS Control
Organization (NACO), a Government organization under the Ministry of Health and
Family Welfare. NACO in turn will establish a revolving fund with VHS for
implementing all the components of the activity. VHS was identified because it was
known as a reputable and large NGO in Tamil Nadu and had/has the backing of the local
medical fraternity. To implement the activity, VHS established an APAC unit, consisting
of a Director and other professionals who oversee activities in condom promotion and
sales, IEC, research, STD treatment, NGO grants, and finance.
The APAC implementation model is unique to the state because it was the first wholly
private sector approach to address the problems of AIDS in Tamil Nadu. The Tamil
Nadu government has set up the Tamil Nadu State AIDS Control Society (TNSACS) to
facilitate the implementation of the program in the state.
The principal interventions envisaged under the APAC project are: 1) Increase demand
and access to condoms; 2) Promote behavior change to reduce sexual partners and high￾risk sexual behavior; and, 3) Improve STD services. High-risk groups are targeted. In
Tamil Nadu, these groups include prostitutes, their clients, truckers and helpers and other
people with multiple sex partners who reside in urban and peri-urban areas.
The activity has four elements. The first element is administration. This element
supports the administrative costs incurred by VHS in implementing the activity. The
second element is an NGO Grants activity. To date VHS has provided 104 Grants (small,
medium and large grants up to ~$300,000). The third element is NGO Support and
Development. Under this element activities include communication for behavioral
change, STD services delivery and condom promotion. The fourth element is research.
Priority areas include condom access and availability, the quality of condoms
manufactured in India, and, a survey of STD care in health facilities. The authorized
LOP level is $ 10 million. As of September 30, 1999 the Mission has obligated $ 6.420
million. The total commitments under the activity are $4.693 million and the
expenditures are $3.086 million.
Technical progress is measured by three indicators namely: 1) cumulative number of
APAC grants for AIDS prevention in Tamil Nadu; 2) percentage of individuals belonging
to specified high-risk groups who report condom use in most recent sexual encounters
with a non-regular partner; and, 3) percentage of population with symptomatic Sexually
Transmitted Diseases (STDs) seeking care from qualified medical practitioners in Tamil
Nadu. The data available so far indicate that the targets have been achieved.
The purpose of this evaluation is to better understand the contributions under APAC,
ascertain whether conditions for sustainability and replicability related to USAID
assistance exist, reexamine the validity of the hypotheses and assumptions taken when
the activity was initially designed, determine whether the needs of intended customers are
being served, and distill “lessons learned” which may be useful for the GOI and for
USAID in other programs.
OBJECTIVE OF EVALUATION
To evaluate the APAC activity and make recommendations to USAID/India regarding
the effectiveness, efficiency, impact, and sustainability and replicability of the activities.
To provide insights in to the future directions for the Project and options for expansion
(or curtailment) of USAID-HIV activities in Tamil Nadu.
 STATEMENT OF WORK
The contractor shall conduct an evaluation and submit a report, which provides clear and
concise findings, conclusions and recommendations. The evaluation report shall also
provide a statement of lessons learned and future directions that may emerge from the
exercise.
The key aspects of the Project to be addressed are listed below:
1. Approach:
The APAC interventions focus on promoting behavior change to reduce the frequency of
different sexual partners and other high-risk sexual behaviors. In addition, the project
aims at promoting the use of condoms and improving the quality of STD services. The
principal approaches under APAC’s activities have been to involve local non￾governmental organizations, to focus resources on high risk groups in the state of Tamil
Nadu, to study knowledge, attitudes and behaviors of the target populations, and, to
reinforce messages through a variety of communication approaches including mass
media, folk media, interpersonal communication and counseling to bring about behavior
change.
Questions that should be addressed are:
ÿ Are the interventions effectively applying the above strategies?
ÿ Does the approach need to be revised or reinforced?
ÿ How effective has the project been at integrating its components into health care
systems at various levels?
ÿ Is there any duplication of effort made in interventions between the Tamil Nadu
State AIDS Control Society and APAC project?
ÿ Is there room for expansion or has the area been saturated?
Primary Responsibility – Team Leader
2. Capacity Building/Partnership Development/Sustainability:
The project is partnering with several organizations to accomplish the objectives of the
project. To date 104 NGO grants have been provided and 21 contracts for
communication and research have been supported. Inherent in the strategy is
strengthening the capacity of various organizations, to effect behavioral change among
high-risk groups in Tamil Nadu.
The Team should consider:
ÿ What have been the efforts so far to create effective partnerships and what needs
to be done to further these effects?
ÿ Is capacity building taking place? What further efforts need to be taken?
ÿ Are the effects of the project sustainable? If not, what further efforts are needed?
Primary Responsibility – NGO Expert
3. Implementation:
APAC was designed to support a nodal agency that will implement all the components of
the project in Tamil Nadu. However, the workplans etc. are approved by a broader
Project Management Committee (PMC) which meets quarterly in Tamil Nadu. The PMC
consists of representatives from USAID, Government of Tamil Nadu, Tamil Nadu State
AIDS Control Society (TNSACS), and the National AIDS Control Organization. The
fund flow for the activities is from USAID to the GOI’s Ministry of Finance to NACO,
which in turn will pass it on directly to VHS.
Issues to consider include:
ÿ Is implementation on track and achieving satisfactory progress towards its stated
objectives?
ÿ How effective have the partners been in implementing APAC (USAID, NACO,
VHS and TNSACS)?
ÿ Are the effects of the project being produced at an acceptable cost?
ÿ Is the input level adequate or too high/low for the intended outputs? Has the
absorptive capacity of implementers been reached?
ÿ What has been the impact of Technical Assistance provided by local technical
support organization and Family Health International (FHI) under APAC?
ÿ How effective is the relationships between VHS and partner NGOs – does the
monitoring of both the technical and financial aspects need strengthening?
ÿ Are the technical and fiscal monitoring capabilities of APAC/VHS satisfactory?
Primary Responsibility – Program Management Expert / STD Expert
4. Attribution:
ÿ Is the host country (which includes central/state governments, public sector and
private sector) and/or other donors providing support in any of the APAC activity
areas?
ÿ If yes, what is the nature of their intervention and what is the amount of the
resources involved?
ÿ Does the project significantly influence the direction of the host country and/or
other donor resources; i.e. did the USAID activities help to leverage funds? If
yes, how did the project accomplish this?
ÿ Are interventions under the project leading to replication of similar activities by
the host country and/or other donors, i.e. did it have a demonstration effect?
ÿ Based on these do the indicators accurately reflect the manageable interest of the
project?
Primary Responsibility – Team Leader / NGO Expert
5. Host Country Contribution:
Evaluators are requested to report on the adequacy and reliability of the HCC as well as
NGO contribution required from subrecipients.
Primary Responsibility – NGO Expert
6. Future Direction:
Based on the progress to date the Team is requested make recommendations regarding
the initiation of new activities in the project. Such new activities could be: 1) expansion
of APAC into other geographic areas such as Pondichery or border areas of Tamil Nadu
in the neighboring states of Andhra Pradesh and Karnataka, 2) national level impact
studies which impact on Tamil Nadu, 3) pilot activities such as care of the HIV patients
especially children etc.
Primary Responsibility – Team Leader and Team Members
METHODOLOGY
In order to examine the above issues, the following methodology should be considered:
1. Review of documents such as project paper, project agreement, project
amendments, project implementation letters, tripartite agreement, Result
Review and Resources Request (R4) etc.;
2. Meetings and discussions with concerned officers at USAID, NACO, VHS,
other donors;
3. Review of monitoring and evaluation reports;
4. Site visits to project-funded areas by APAC and other agencies;
5. Interaction with target groups;
6. Other information such as case studies, observational and anecdotal data may
also be used as appropriate.
REPORTS
The contractor will submit an evaluation report, preferably under 20 pages, in accordance
with the requirements specified below. Three days prior to departure from New Delhi the
consultants will submit a draft report to USAID/India for review and discussion. They
will also debrief VHS and NACO on the conclusions and recommendations. The team
leader will ensure that all reasonable comments on the draft report are incorporated into
the final draft report. The final report will be due 30 days after leaving Delhi.
The format for evaluation report is as follows:
· Executive Summary – concisely state the most salient findings and
recommendations (2pp);
· Introduction – purpose, audience, and synopsis of task (1pp);
· Background - brief overview of HIV in India and Tamil Nadu (1pp);
· USAID’s Assistance Approach – describe the USAID program strategy and
activities implemented in response to the problem (1pp);
· Findings/Conclusions/Recommendations – for each SOW area (10pp);
· Lessons Learned (1pp)
· Issues – provide a list of key technical and/or administrative if any (1pp);
· Future Directions (2-3pp)
· Annexes – useful for covering evaluation methods, schedules, interview lists, and
tables – should be succinct, pertinent and readable (not to exceed 25pp)
The report should be submitted to USAID/Delhi in hard copy and also provided on a
diskette (12 point type should be used throughout and page margins should be 1-inch
top/bottom, left/right. The report format should be restricted to MS Office products only.
The report should contain the following information on the title page:
1) Title
2) Author names
3) Project Activity number
4) Contract Award Number
5) Sponsoring USAID Office
6) Contractor/Grantee Name
7) Date
DELIVERABLES
The following deliverables are included required:
· Final Draft of report prior to departure (hard and electronic copies)
· Technical Briefing to PHNO Staff
· Presentation of Findings to Indian Colleagues (VHS & NACO)
· Exit Briefing for Senior Mission Staff (Director/Deputy Director)
· PowerPoint Copies of all presentations/briefings for PHNO use
RELATIONSHIPS AND RESPONSBILITIES
The team will work under the direction of the APAC evaluation. This subgroup consists
of Dr. Victor K. Barbiero (Director, Office of Population, Health and Nutrition), Mr.
N.Ramesh (Office of Program), Dr. Dora Warren (Office of Population Health and
Nutrition), and Anita Ravishankar (Office of Population Health and Nutrition). This
group will coordinate all external meetings with NACO and other institutions.
PERFORMANCE PERIOD
The expected period of performance in India will be from January 24, 2000 through
February 19, 2000.
WORK DAYS AND SCHEDULE
Position Work Days
1. U.S.Expert/Team Leader 26
2. U.S. Expert 26
3. Indian Expert 24
4. Indian Expert 24
Work Days include travel and return from United States to New Delhi by two experts,
travel and return to New Delhi by Indian . It will also include travel within India by all
team members. Six-day workweek is recommended.
The tentative schedule for the assignment will be as follows:
First Week
· New Delhi
· Meet with USAID/New Delhi staff
· Meet with NACO Staff
· Meet with Donor Agencies
· Desk review
Second & Third Week
· Chennai (with USAID Staff introductions)
· Meet VHS Staff
· Visit project sites
Fourth Week
· New Delhi
· Discussions with USAID staff and other related counterparts
· Report writing
· Preliminary presentation of technical findings, conclusions and recommendations
· Presentation of findings to NACO and PMC
· Presentation to Senior Staff
· Submission of final report – (preferably not more than 20 pages)
CONSULTANT QUALIFICATIONS
General Qualifications – Excellent writing, organizational and communication skills are
also a key requirement for each Team Member. Familiarity with Microsoft Office
(Word, PowerPoint, and Excel) is required.4
 Fluency in English is required. Knowledge
of Hindi and/or Tamil is desirable as is knowledge/experience of India. Other
qualifications for the team members are as follows:
Team Leader (TL) (U.S.) - The Team Leader (TL) will be responsible for the overall
organization of the report and presentations. She/He will be the chief liaison with the
Mission’s PHN Office and staff. The TL will provide guidance to other Team Members,
assign appropriate tasks, and ensure the timely completion of specific tasks as well as the
entire evaluation. She/He should have extensive experience in team leadership and a
strong technical grounding in the HIV/AIDS arena. Previous team leadership(s) is a
prerequisite for this position. The TL must be able in provide technical as well are
administrative leadership to the team. She/He should consult with PHNO staff regularly
throughout this exercise to ensure progress is sound and key SOW issues are being
addressed. The team leader should have 8-10 years of experience in AIDS sector,
preferably in developing countries. She/He should also be well versed with the current
developments in AIDS prevention. Although the TL should have a solid technical
background, her/his strengths should accentuate the management skills and experience
required in the SOW. The TL will be responsible for organizing and editing the entire
evaluation, and making final editorial and technical adjustments, as necessary, based on
the in-country reviews.
Program Management Expert (PME) (U.S.) – The PME should have robust
operational experience on the implementation and program management of HIV/ADIS
prevention and control programs. She/He should have 5-10 years of international
experience and understand the complexities of project management, including start-up,
procurement, staff recruitment and management, and logistics. The PME should be a
seasoned individual who can assist the TL with report writing and the definition of key
programming issues facing APAC in the future. It is envisioned she/he will take the lead
on the implementation section of the SOW and provide insights into the success and
shortcomings of the APAC project, including the fiscal and administrative aspects of
project implementation. The PME will also contribute to the preparation of the “Future
Directions” section of the evaluation.
NGO Expert (NGO/E) (Indian) - The NGO/E will be responsible for writing sections
#2 and #5 of the SOW, and will contribute the Future Directions section with the rest of
the Team. The NGO/E should have an in-depth knowledge of NGO activities in India,
and particularly in Tamil Nadu. She/He should have 5-8 years of experience in the NGO
community and fully understand the pros and cons of NGO involvement in HIV/AIDS
prevention and control as well as the general role of NGOs in Tamil Nadu and India. This
expert should be conversant with GOI policies in Tamil Nadu and fully understand
impediments to NGO’s in realizing their potential in Tamil Nadu and other States.
 
4
The Team should travel with at least one laptop computer, preferably two or more.
STD Expert STD/E) (Indian) – The STD/E should be a senior person with a broad
knowledge of STD programs in India. She/He must be familiar with the technical aspects
of STD transmission and the latest approaches regarding the syndromic management of
STIs. She/He should also understand the programmatic aspects of STI case management
and the potential and limitations of diagnosis and treatment at the community level. The
STD/E should command an in-depth knowledge of STD transmission in India and
especially in Tamil Nadu. She/He should be able to assess the technical aspects of
diagnosis and treatment in fixed facilities and also understand the potential medical
barriers to expanded treatment, especially to target groups. The STD/E should
understand the stigmas associated with STDs in the Indian context and potential political
issues associated with diagnosis, treatment and information transfer regarding STD
prevention and control. She/He should possess programming and clinical knowledge of
STD prevention and be able to identify practical and innovative approaches to prevention
and control within the Tamil Nadu context. The STD/E should have demonstrable
technical, analytical, writing, communication and organizational skills. She/He will serve
as the technical keystone for the team and provide technical backstopping to the other
team members. The STD/E will contribute to Section #3 with the PME, and will have
technical input into all SOW areas.
ANNEX B
PERSONS CONTACTED
PERSONS CONTACTED
NEW DELHI
Prasada Rao, Director, National AIDS Control Organization (NACO)
Neelan Kapur, Deputy Director, NACO
Dr. P. L. Joshi, Joint Director/Technical, NACO
S. Ramasundaram, former head, Tamil Nadu State AIDS Society (TNSACS)
Dr. K. Sudhakar, The World Bank
Peter Heywood, The World Bank
Dr. Dinesh Nair, Department for International Development (DFID), India
Gordon Alexander, Joint United Nations Programme on HIV/AIDS (UNAIDS)
Mr. Pradeep, UNAIDS
Rekha Masilamani, Pathfinder International
Tom Philip, Country Representative, Family Health International (FHI)
Linda Morse, USAID/India, Mission Director
Victor K. Barbiero, Acting USAID Health, Population and Nutrition (HPN) Director
Dora Warren, USAID Advisor, Infectious Diseases; APAC Project Manager
Peter Thormann, USAID Program Office Director
N. Ramesh, USAID Project Development Specialist
Rohini Gambhir, USAID Budget/Finance Office
Anitha Ravishankar, USAID HPN Program Officer
Barbara M. Bever, Communications Manager, USAID
Vathani Amirthanayagam, AVERT Program Officer
Charles Gardner, U.S. Embassy Science Attaché
 and other USAID PHN and Mission staff
CHENNAI
Dr. N.S. Murali, Honorable Secretary, Voluntary Health Services (VHS)
Dr. P. Krishnamurthy, Director, AIDS Prevention and Control Project (APAC) and staff:
 Dr. Bimal Charles, Assistant Director, NGO Programs; Acting Director 2/7/00
 Dr. Zafrullah, Assistant Director, STD
 Dr. Lakshmi Bai, Specialist, Monitoring, Evaluation and Research
 S. Chandrasekhar, Manager, Finance, Contracts and Administration
 P. Arvind Kumar, Specialist, Condom Promotion
 A. Sivan, Specialist, Communication
 S. Santhya, Administrative Officer
Dr. N. Kumarasamy, Medical Officer, Centre for AIDS Research and Education at VHS
Dr. Vimala Ramalingham, Blood Safety Advisor, TNSACS
Dhanika Chalam, Nongovernmental Organization (NGO) Advisor, TNSACS
U. Jayraj Rau, Vice President, Hindustan Thompson Associates Ltd., and staff
John A. Joseph, Director, State Resource Center (SRC), and staff
M. Sundaramurthy, Founder/Secretary, Bro. Siga Social Service Guild
Staff, Counsellors, and Street Performers of Bro. Siga Social Service Guild
Thiru K. Allaudin, Tamil Nadu Commissioner of Sugar; former Project Director, TNSACS
Aniruddah Deshmukh, Executive Director, J. K. Ansell Ltd.
S. Kalyanaraman, Senior Regional Manager, J. K. Ansell Ltd.
Dr. Ruben Jacobson, Director, Scudder Memorial Hospital
Dr. Manorama, Director, Community Health Education Society
Dr. Cranapathy, Dr. Mallika Johnson, and Dr. Kantraraj, Institute of Venereology
A.V. Surya, Assistant Research Manager, A.C.Nielsen (BSS survey firm), and staff
15 representatives of APAC–supported NGOs not directly visited by the evaluation team,
convened for a roundtable discussion at APAC headquarters, February 4, 2000
9 consultants providing regular consultant services to APAC–supported NGOs, convened for a
roundtable discussion at APAC headquarters, February 5, 2000
MAHABALIPURAM
A. J. Hariharan, Secretary, Indian Community Welfare Organization (ICWO)
Staff, commercial sex workers (CSWs), peer educators, counselors, medical doctors associated
with ICWO interventions
VILLUPURAM
A. Bakthavatchalam, Executive Director, Association for Rural Mass Media (ARM)
Staff, CSWs, peer educators, registered Indian medical practitioners (RIMPs), lodge
managers, and condom salespersons associated with ARM interventions
Dr. Subramaniam, STD Specialist
MADURAI
Dr. R. Jayaraman, Member Secretary, Centre for Entrepreneur Development (CED)
S. Gnana Haran, Senior Consultant, CED
Dr. N. Krishnamurthy, Director, Meenakshi Mission Hospital and Research Center (MMHRC)
Felix Raj, Program Officer, and physicians, administrators and staff of MMHRC
Jacob C. Varghese, M.J., M.S., Management Consultant, MMHRC
Dr. Neelakantan and Dr. Jayaraman, RIMPs
Mrs. Rita James, APAC Project Coordinator, Teddy Trust
Staff, Peer Counselors, Social Workers, CSWs and RIMPs associated with Teddy Trust
 interventions; also, DFID/Teddy Trust Highway Project Coordinator
Dr. Mallika, Medical Officer, Madurai Corporation dispensary
John Dalton, Satish Samuel and staff of Arokya Agam rural NGO
Dora Scarlett, Founder, Seva Nilayam Hospital and rural outreach program
Dr. Chandrasekhar, Medical Director, and CHWs, counselors and staff of Seva Nilayam
WASHINGTON
Denise C. Lionetti, Deputy Director, TvT Associates/Synergy Project
Saha AmaraSingham, Ph.D., Program Monitoring and Evaluation Specialist, TvT/Synergy
Lena Thompson, Office Manager, TvT/Synergy
Messaye Girma, Program Planning and Design Specialist, TvT/Synergy
Tony Bennett and Carol Laravee, FHI/Washington
Paurvi Bhatt, USAID/Washington, HIV–AIDS Division
Charles Llewellyn, USAID/Washington
Kai Spratt, USAID/Washington
ANNEX C
MAP OF NGO SUPPORT IN TAMIL NADU

ANNEX D
BSS DATA
Knowledge on AIDS Prevention
BSS1
BSS2
BSS3
*Significant at 0.05 level
86
98 99
95 97 97
93
98 98
81
94
89*
0
100
10
20
30
40
50
60
70
80
90
CSW TH MFW FFW
 n=403 n=829 n=1915 n=1533
Percent
CSW = Commercial Sex Workers
TH = Truck Drivers and Helpers
MMF = Male Factory Workers
FFW = Female Factory Workers
Sexual Intercourse with a Nonregular Partner
48
35
32*
15
11
9*
0
5
10
15
20
25
30
35
40
45
50
TH MFW FFW
BSS1
BSS2
BSS3
n=273 n=177 n=19
*Significant at 0.05 level
Percent
3
1.4 1.1
Knowledge that Condoms Prevent AIDS
89
97 97
77
86
91*
81
89
92*
56
63
51*
0
10
20
30
40
50
60
70
80
90
100
CSW TH MFW FFW
BSS1
BSS2
BSS3
*Significant at 0.05 level
n=392 n=784 n=1830 n=876
Percent
Condom Use during Sexual Intercourse
 with a Nonregular Partner
56
74
80*
44
51
66*
17
25
50*
20
13
26
0
10
20
30
40
50
60
70
80
CSW TH MFW FFW
BSS1
BSS2
BSS3
 n=325 n=180 n=89 n=5
*Significant at 0.05 level
Percent
Voluntary Condom Procurement by CSWs
11.7
14
19.2
0
2
4
6
8
10
12
14
16
18
20
BSS1 BSS2 BSS3
Percent
Condom Distribution in Tamil Nadu
(in million pieces)
27
5
21.4
24.1
9.7
12.6
15.5
24.3
4.1
2.3
5.2
22.7
17.1
15.6
0
5
10
15
20
25
30
1994 1995 1996 1997 1998
Fully Priced
Subsidized
Free Supply
ANNEX E
APAC PROJECT DATA
Condom Promotion - Priced - All Intervention Projects
0
10000
20000
30000
40000
50000
60000
70000
Apr-98
May-98
Jun-98
Jul-98
Aug-98
Sep-98
Oct-98
Nov-98
Dec-98
Jan-99
Feb-99
Mar-99
Apr-99
May-99
Jun-99
Jul-99
Aug-99
Sep-99
Oct-99
Nov-99
Dec-99
No. of Condoms
Condom Promotion - Free - All Intervention Projects
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
Apr-98
May-98
Jun-98
Jul-98
Aug-98
Sep-98
Oct-98
Nov-98
Dec-98
Jan-99
Feb-99
Mar-99
Apr-99
May-99
Jun-99
Jul-99
Aug-99
Sep-99
Oct-99
Nov-99
Dec-99
No. of Condoms
STD cases Identified & Referred - All Intervention 
Projects
0
500
1000
1500
2000
2500
Jan-98
Feb-98
Mar-98
Apr-98
May-98
Jun-98
Jul-98
Aug-98
Sep-98
Oct-98
Nov-98
Dec-98
Jan-99
Feb-99
Mar-99
Apr-99
May-99
Jun-99
Jul-99
Aug-99
Sep-99
Oct-99
Nov-99
Dec-99
No. of STD cases
STD cases Treated - All Intervention Projects
0
500
1000
1500
2000
2500
3000
3500
Jan-98
Feb-98
Mar-98
Apr-98
May-98
Jun-98
Jul-98
Aug-98
Sep-98
Oct-98
Nov-98
Dec-98
Jan-99
Feb-99
Mar-99
Apr-99
May-99
Jun-99
Jul-99
Aug-99
Sep-99
Oct-99
Nov-99
Dec-99
No. of STD cases
ANNEX F
PARTICULARS OF CONDOMS DISTRIBUTED IN TAMIL NADU
PARTICULARS OF CONDOMS DISTRIBUTED IN TAMIL NADU
Quantity in Lakh Pieces
Year Fee Supply Fully Priced Subsidized Total
1995
1996
1997
1998
1999*
156
171
214
290
290
126
155
241
270
279
52
23
41
50
32
334
349
496
610
600
*Estimated
Source: For free distribution: The Tamil Nadu Demographers Report
For subsidized and fully priced: Retail Audit Report of Operations Research Group
ANNEX G
OPERATIONAL RESEARCH TOPICS FOR STI MANAGEMENT
OPERATIONAL RESEARCH TOPICS FOR STI CASE MANAGEMENT
1. STD Risk Assessment: Feasibility of training community-level providers and referral￾level providers in nonjudgmental, innovative ways of inquiry regarding sexual
behavior of women and/or their partners.
2. Simple Screening Tests: Use of existing laboratory facilities in the present OR
projects is sufficient (provided optimum standards are maintained) to diagnose
selective conditions such as syphilis, gonorrhea, BV, trichomoniasis, and Candida.
The OR projects need to make an attempt to use (and document) risk assessment,
clinical examination, and laboratory tests to study correlations between symptoms
and actual pathology. No additional resources to the projects are necessary. One￾time training of staff members to orient them to this package and periodic technical
assistance to support the documentation process and supervise quality control may be
necessary.
3. Study ways to improve male responsibility in women whose STI is a result of their
partner’s high-risk behavior.
4. Development of effective linkages with private providers to improve referral to the
OR study sites to both obtain larger coverage and provide high-quality care.
5. CLIPs: Study the possibility of converting the CLIPs into model clinics that offer a
combination of high-quality clinic services and a community-outreach component
with a substantial communication element in order to reach high-risk groups as well
as vulnerable populations. The CLIPs are based in organizations that do have
outreach services; thus, the second component only needs some communication
support. The lessons learned from this study offer the potential of replication in
several hospital-based NGOs across the country. In addition, the lessons learned
from the clinic interventions (improved quality of care, including risk assessment and
sensitive counseling methods) may benefit public sector programs.