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Naz Foundation (India) Trust
   Last updated: 16.08.02
An Implementer’s Perspective of the Healthy Highways Project
Implementers

The Naz Foundation (India) Trust, based in New Delhi, was established in 1994 to serve community needs that were not being met by Government or other agencies. Naz India is committed to reducing the spread of HIV/AIDS through education and to providing support to those living with the virus, their families and communities. There are currently six programmes at Naz India: the Care and Support Programme, the Healthy Highways Project, the National Level Master Training Programme, the Men Who Have Sex With Men Programme and the Women’s Sexual Health Programme.

The organisation consists of teams of programme officers and outreach staff headed by co-ordinators. These co-ordinators report to Programme Managers, who are under the supervision of an Executive Director, who is accountable to the Board of Trustees of Naz India.

Background
In December 1997 Naz India conducted a study of the risk behaviours and spread of HIV and STDs among truck drivers, their crews and their sexual partners. This study found overall lack of knowledge and high level of myths and misconceptions surrounding sexual practices and the risk of STDs, which left the truckers at a high risk of contracting STDs including HIV. There was also a lack of treatment programmes for STDs, as well as a high social stigma associated with these diseases.

In response to the findings, the Healthy Highways Project opened the Top Gear Clinic in Azadpur Transport Mandi, one of the largest transportation centres in Asia. This trucking service centre, or “mandi”, houses between 4,500 and 5,000 trucks at any time. The adjoining wholesale fruit and vegetable market brings in many more thousands of people.

The demand for services at the centre grew so quickly that the programme had to be scaled up almost immediately. This required hiring an additional doctor and counsellor and doubling the number of outreach staff. Outreach staff also determined that services should be extended to the nearby village of Bharola, where truckers frequently went for casual/commercial sex. Project co-ordinators requested an additional 2 female outreach workers, one female doctor, and one female counsellor for this expansion.

Outreach also expanded to the fruit and vegetable market centres where there was a high level of MSM (men who have sex with men) activity.

Objectives and main activities
The primary objective of the scaling up was to increase the capacity of the clinic and its related outreach programmes so that more people could be served. On an average day, 30 to 40 people came to the clinic. This number increased to more than 60 on days when staff put on mobile exhibitions. Even though the clinic focused on treatment of STDs, it could not exclude people seeking treatment for other medical problems, at the risk of generating resentment and further stigmatisation.

Resources and timeframe
From the beginning, the Department of International Development (DFID) has funded nearly 30 Healthy Highways Projects throughout India. State AIDS Control Societies (SACS) are taking over the projects in phases and DFID will not in future have any financial or administrative control.

The primary obstacles in the scaling up process were financial. There was a lack of resources to train the additional community outreach workers needed, and lack of funding to increase condom distribution outlets. Some simple but essential material goods were lacking, such as boots needed for outreach staff during the rainy season.

DFID did not fully understand and agree with the projected budget for the scaling up. The expanded Women’s Sexual Health Programme in Bharola received funding for only one female outreach worker and no female doctor or counsellors.

Under the new guidelines of the National AIDS Control Organisation (NACO) and State AIDS Control Societies (SACS), doctor’s salaries would be cut in half.

Medicines that were initially distributed free of cost are now charged to the clients, exempting only women, children and the elderly.

Outputs/outcomes
Truck drivers are a highly mobile population, but also form a fairly close community of their own. Truckers get most of their information, or misinformation from other truckers. Those who have visited clinics or received outreach counselling through the Healthy Highways Project are likely to tell their friends. The outreach staff at Azadpur regularly encounter men who have come in for the first time, often with a vast amount of misinformation.

The programme has been successful in dispelling many myths and providing factual information about the transmission of STDs and HIV/AIDS. This change is reflected in the information documented by outreach staff in their daily reports.

Because the clinics do not refuse those seeking treatment for general ailments, they were not stigmatised. Truckers may come in with some other medical problem, and then feel comfortable requesting STD treatment. Since the beginning of the project there has been a considerable behaviour change about condom use as awareness about proper usage has increased.

Another issue with the truckers is the high level of drug and alcohol addiction. Most cases of unprotected or risky sex are reported to occur while under the influence of alcohol. Staff now regularly refers cases to the de-addiction centre run by the NGO Sharan based in New Delhi.

The original targets of the scaling up have been far exceeded:

Reporting period: July 1999 – March 2000

Activity: No. of contacts made
Target: 11,880
Achieved: 16,350
% Achievement: 137.63

Activity: No. of STD cases treated
Target: 1,000
Achieved: 1,536
% Achievement: 153.6

Activity: No. of condoms distributed
Target: 80,000
Achieved: 200,497
% Achievement: 250.62

Co-operation from secondary stakeholders like truck owners associations and police has largely increased as well, but individual truck company owners have not been generally co-operative. They do not consider the health problems of their employees as their business or concern.

Sustainability of the project remains a big issue, as the reliance on community resources must increase.

Internal organisational implications
Staff and peer educators welcomed the scaling up as they could now respond adequately to the needs of the community. The scaling up did, however, strain the already limited resources, forcing transfer of funds from some other programmes.

Evaluation
No formal evaluation was done before scaling up, but the Naz Foundation does have a very strong ongoing monitoring system within every programme. All outreach and other activities are extensively documented at the end of the day. The programme team meets weekly to review the performance of the past week. Every month there is general staff meeting to share programme experiences, seek input from other teams and discuss future plans. This system of internal monitoring has been functioning effectively for the last five years.

Lessons learned
• Behaviour change, though often slow, is the only effective way of reducing the transmission of STDs including HIV/AIDS.
• Groups at particular risk, such as the women of Bharola village are eager for education and support. Women accessed the clinic even without a female doctor.
• Behaviour change communication (BCC) materials are an extremely effective way to reach clients.
• A successful programme for this particular population must include treatment for drug and alcohol addiction.
• Clients who receive effective counselling and treatment encourage their partners to participate.
• There must be great care not to stigmatise the treatment of STDs and HIV/AIDS. Truckers are feeling increasingly alienated as they are perceived as a high-risk group.

Source: A Question of Scale
This is an extract from A Question of Scale: The challenge of expanding the impact of non-governmental organisations’ HIV/AIDS efforts in developing countries,
by Jocelyn DeJong, published by the Horizons Project of the Population Council with the International HIV/AIDS Alliance in 2001. To view the whole report follow this link.

To download, complete with graphics, in pdf format (which requires Adobe Acrobat software to read it) follow this link (file size 1.43 Mbytes).