This paper presents one of the first systematic evaluations of a large-scale prevention program for HR-MSM and TGs in Tamil Nadu. An adequacy and plausibility evaluation design  was used to evaluate data from Avahan program monitoring, large-scale surveys and social marketing of condoms. The findings provide strong evidence that the Avahan program achieved high coverage of HR-MSM and TGs, increased program intensity over time, and was linked to increased condom use by HR-MSM with their commercial and non-commercial partners.
According to program monitoring data, the percentage of HR-MSM and TGs who were ever contacted by a peer educator or had ever visited a clinic increased over time to over 100 percent, by March 2009. Unique monthly contacts (against the estimated denominator) by Avahan peer educators increased to 77 percent by March 2009, close to the program’s saturated coverage target of 80 percent. IBBA data from a subset of districts showed that by 2009, 90 percent of HR-MSM and TGs had been contacted in the previous month. These IBBA findings validate the monitoring data and bolster confidence in monitoring data for the districts that were not covered in IBBA.
A plausible explanation for the increase beyond 100 percent for those who were ever contacted and had ever visited a clinic is the turnover in the HR-MSM and TG population, that is, some target population who had accessed the services had moved out and were not counted as part of the denominator in March 2009. MSM and TG populations are known to be mobile, so it is likely that some who had received the services moved out of Avahan coverage areas over time.
Examination of scale-up and intensity measures showed that the targets established for program infrastructure (peers and outreach workers) were in place by June 2007. The observed reduction in the number of active peers in March 2007 and June 2008 was likely due to revised program strategies  and the transition of some districts from Avahan to the state as part of phase III of the national program.
Increasing frequency of HR-MSM who reported being contacted by peer’s points to the increasing uptake of program services. Continuous quality monitoring assessments of Avahan STI clinics (reported annually) have also shown consistent improvement in the quality of STI clinical management, operations and performance [28, 29].
Analysis of condom availability data indicates that the program distributed a large number of condoms; this was validated by the IBBA data. The analysis also indicated that the minimum number of condoms required to cover the estimated commercial sex acts by HR-MSM had been made available by March 2008. Other studies also provide evidence that a sufficient number of condoms were made available through social marketing; more than 80 percent hot spots in Avahan districts were found to have a greater number of condom distribution outlets , and condom procurement and use among bridge groups was 79 percent in 2008 . The state Behavioral Surveillance Study (BSS) in 2009 also put the voluntary condom procurement by MSM across the state at 88 percent in 2009 .
IBBA data on HR-MSM profile characteristics showed considerable change over the two rounds of IBBA, with a substantial increase in the proportion of HR-MSM who reported their self-identity as a kothi (MSM who are generally receptive during anal sex) . This change may have been an indirect result of the intervention, in that the increasing intensity of intervention allows MSM to ‘come out’ and gain an increased understanding of their sexual orientation and self-identity. The sampling method used may have also contributed to these profile differences. Since PPS sampling was used following the mapping exercises in both IBBA rounds, different PSUs/sites could have been selected during the sampling in each round. This is an inherent limitation of a cross-sectional survey using PPS methodology, which helped provide a representative sample at the district level. Further, the sampling frame universe developed during each round of the IBBA survey represents a universe of HR-MSM and TGs in each surveyed district, which is impacted by population changes and turnover.
Significant increases were seen in condom use with the regular male partner, paying male partners (when selling sex) and casual male partners. Evaluation of HR-MSM programs with a similar package of services in other Asian countries has shown increasing condom use with commercial and non-commercial partners after program implementation . A meta-analysis of interventions for MSM, mainly in western countries, found that behavioral interventions significantly reduced unprotected anal sex by 23% among MSM, similar to results found in our study .
Although consistent condom use increased between the two rounds, many high-risk sexual practices with both commercial and non-commercial partners were still being reported. In addition, reported consistent condom use with paid partners did not increase, suggesting the need for greater programmatic effort. Additional studies and analyses are required to better understand the factors affecting condom use patterns among MSM with multiple/different partners, so as to inform programs in developing more effective behavior change communication. The finding that condom use outcomes were linked to Avahan program exposure is strongly suggestive of the program’s effectiveness. However, causality could not be determined with the current analysis, given the lack of a proper control group and the limitations of cross-sectional data.
Our evaluation showed that the prevalence of HIV stabilized (9.7 percent to 10.9 percent) and the prevalence of syphilis declined (14.3 percent to 6.3 percent) in the HR-MSM in IBBA districts. Data prior to Avahan is available only from small studies in select locations. For example, in Chennai, a study of 774 men reported HIV prevalence of 6.5 percent and prevalence of any laboratory-diagnosed STI at 22 percent among HR-MSM . Another study conducted in 2008, using non-probability-based methods, across 18 cities in Tamil Nadu, reported 9 percent HIV prevalence and 8 percent syphilis prevalence , quite similar to our IBBA findings.
Increased HIV prevalence in HR-MSM of ages 18–20 years, though not statistically significant, is still an issue of concern and requires in-depth examination. In some IBBA districts, such as Chennai and Coimbatore, increase in HIV prevalence despite increased program exposure is a cause of concern. The program in Chennai was transitioned to the Tamil Nadu state in 2008, but Coimbatore continued to be an Avahan intervention district throughout the study period. Given that consistent condom use in general remained low in HR-MSM, inconsistent condom use could likely have been a major contributor to HIV transmission, resulting in our finding that overall HIV prevalence did not change between the two rounds of IBBA.
Male-to-female TGs formed an important part of our interventions. Interestingly, we found similar HIV prevalence in TGs and other MSM. These findings are in contrast with findings from other parts of the country. Indeed, studies from Mumbai and Pune (in western India) consistently reported HIV prevalence in TGs to be significantly higher than MSM [8, 34, 35]. Setia and colleagues found that HIV prevalence in TGs was 68 percent, compared to 17 percent in MSM. Similarly, Sahasrabuddhe and coworkers reported HIV prevalence among TGs at 45 percent, compared to 19 percent in MSM . As reported elsewhere , TGs were more likely than MSM to report sex work as a main source of income; in fact, this was reported by a majority of TGs in our sample. Although consistent condom use increased with regular and casual male partners over the two rounds of IBBA, condom use during last sex act with a paying male partner and casual male partner showed a reduction. Thus, while sex work was reported by a higher number of TGs, there was simultaneous reduction in condom use with paying partners, putting TGs at a higher risk for HIV and STI transmission. As stated earlier, TGs are a separate socio-economic group from other MSM; thus, public health programs should be encouraged to have separate interventions specifically designed for this group.
This assessment is among the first to show evidence of declining STI prevalence in MSM in Tamil Nadu after the implementation of a large-scale prevention program. Although the finding is encouraging, one of its limitations is that only urethral STIs were examined in this assessment. Given the difficulties in field implementation, it was not possible to collect samples for assessing rectal STIs, which other studies have shown to be high among HR-MSM . There was found to be no link between decline in STIs and program exposure; however the prevalence of STIs in Tamil Nadu was low, therefore the analysis of exposed versus non-exposed was based on small numbers of cases and likely limited by lack of statistical power.
While the sentinel surveillance data has limitations of a small sample size and potential bias due to non-representative recruitment methods, data from two sites (250 sample from each) in Tamil Nadu notably indicated HIV prevalence at 6.8 percent in 2004, which increased to 7.6 percent in 2007 and then declined to 3.6 percent in 2008 [37, 38]. However, sentinel surveillance data on HIV prevalence among male attendees of STI clinics suggests that HIV prevalence among men in general has been increasing in many districts [37, 38].
The major limitations of cross-sectional studies apply to the current analysis as well. While the sampled population was representative of the HR-MSM and TG populations in each round of IBBA, changes in the universe of these populations must be accepted. Further, the denominators used to assess coverage also have limitations. Estimates of HR-MSM and TG denominators were based on formal mapping exercises by Avahan NGOs. However, size estimates varied in terms of rigor and frequency of updation, with size estimation information in some areas being updated only once every one or two years.
One key limitation of the current evaluation is the lack of proper baseline data and control groups. Round 1 of IBBA was conducted in 2006, about 14 months after the Avahan program was implemented in the state. Due to ethical considerations, control groups were not included in evaluation design. Therefore, it is impossible to definitively attribute outcomes to the program. Although some other programs have ongoing HR-MSM and TG interventions in other districts of Tamil Nadu, data from these programs is not available for comparison. Since Avahan was the sole intervention in the IBBA districts (except Chennai) and high levels of coverage was achieved (based on program size estimates), sub-analysis of IBBA data from HR-MSM and TGs who were not exposed to Avahan program had limited power because of small numbers.
Notably, in a majority of Avahan districts (except Chennai) Avahan’s was the first and only intervention for HR-MSM and TGs. Given this, our findings have provided early evidence of the effectiveness of Avahan program for HR-MSM in Tamil Nadu. However, further analysis and studies are required to better understand the factors that affect the condom use patterns of HR-MSM and TGs with their different partners. Understanding these factors would help HIV prevention programs develop more effective behavior change communication strategies.
The practical considerations discussed earlier, the mobile nature of HR-MSM and TGs, diffusion effect of the intervention, and the program’s intent to rapidly scale-up and transition to existing government programs made it difficult to have any control groups  for the evaluation. Therefore in the current evaluation, we used the accepted approaches for evaluating large-scale public health programs [39–42]. The strength of our analysis is that it provides early evidence of the effectiveness of Avahan program for HR-MSM and TGs according to the program logical framework, providing ‘congruency’ of expected trends .