It is now largely accepted that an important cause of the spread of Human Immunodeficiency Virus (HIV) is the migration of young men to large cities for employment, leaving behind families in the rural areas. In India, the National AIDS Control Organisation (NACO) considers the State of Rajasthan a low prevalence State. However, the economic realities and socio-demographic milieu makes it vulnerable to HIV because many men are being forced to leave their traditional roles as agricultural labourers due to drought and are moving to big cities to find work. The State’s vulnerability to HIV is also increased by the presence of a number of mines attracting migrant workers. Heavy traffic passes along its national highways, bringing truck drivers who engage in casual sexual activity. In order to meet the challenge posed by HIV/AIDS, the Canadian International Development Agency (CIDA) provided assistance through the India Canada Collaborative HIV/AIDS Project (ICHAP). One major initiative under this assistance was to design, implement and demonstrate a replicable programme model for HIV prevention and care for migrant men and their sexual partners from two states - Rajasthan and Karnataka. The project is referred to as the HAMARA project.
The Rajasthan HAMARA project works in the Shekhawati region of Rajasthan (place of origin) and in Ahmedabad, Gujarat (place of transit) and Mumbai, Maharashtra (place of destination). The primary target groups are the spouses of migrants including the return migrants and potential migrants. The ICHAP collaborated with the State AIDS Control Society and partnered with four organisations for designing and implementing the programme - Bhoruka Charitable trust, M.R. Morarka GDC Rural Research Foundation, Saral and Jyoti Sangh.
(i) Needs assessments: A situation needs assessment was done in all blocks of three districts of Rajasthan – Churu, Jhunjhunu and Sikar in October- December 2002. At the same time, a needs assessment was done in Mumbai (place of destination).
(ii) Baseline study: A baseline study was done during January-March 2003 in those blocks that showed high out migration and cases of HIV were identified.
(iii) NGOs identified: Identified the grass root level agencies to implement the programme at place of origin, transit and destination. The two agencies selected have been working in remote corners of the Shekhawati region and work in tangent with Rajasthan State AIDS Control Society.
(iv) Training: Capacity building exercises were done for the partnering implementing agencies and HAMARA designated staff to work in the area of Sexually Transmitted Infections (STI), HIV, AIDS and public health approaches. The training was on how to carry out community needs assessment, how to talk about sex and sexuality, how to work with high-risk groups and the general population and how to promote condom use and STI treatment.
(v) Cluster offices opened: In the areas of operation, the implementing partners opened cluster offices for every 18,000-20,000 population and for each cluster recruited one male and one female health worker. Other staff involved in implementation included one project coordinator, two assistant project coordinators and 5 administrative staff for the whole project.
(vi) Links formed: The project established linkages with the Government-run Primary Health Centres (PHC). This included training 50 PHC doctors on syndromic management of STI/Reproductive Tract Infections (RTI) and care to people living with HIV/AIDS and involving them in holding STI camps in villages. Medicines were procured and distributed to PHC doctors for management of STI cases. The partnering agencies mobilised community support by partnering with smaller partner non-government organisations in the area of operation. Village Health Committees (VHCs) were formed in every village and the platform was used for HAMARA programmes.
(vii) Condom depots: The project established condom depots at strategic locations within the villages. The needs assessment studies and baseline survey undertaken at the beginning of the project revealed that the reason for low condom use was difficulty in accessing free condoms. In Rajasthan, each village is divided into mohalla (locality) and in each mohalla a meeting was organised to identify condom depot holders. In keeping with the culture of the area, the meeting was arranged separately for men and women. The project now has 50 condom depot holders and half of them are women. The condoms were provided by the government sources.
(viii) Peer educators: Male and female Peer Educators (PE) were selected from the villages. The PE was the contact between the implementing agency and the community. They used to report to health workers of HAMARA project. About 1,200 volunteers were selected and trained to carry out household surveys, identify potential migrants and refer cases from the community to PHCs run by government and NGOs.
(ix) Publicity: The project developed a lot of communication material on HIV in the Hindi language such as flip STD cards, stickers, pamphlets, snake and ladder games related to HIV, booklet etc.
(x) Monitoring: The project prepared a household register consisting of household characteristics including migration status. The PE updated the register regularly for identify potential migrants and arrange one to one or one to group meetings.
(xi) Destination: From mid-late 2004, Hamara has been working with Rajasthani migrants in Piplaj, Ahmedabad and in Kherwari, Mumbai. In Ahmedabad, local resource agency, SARAL, and an NGO, Jyothi Sangh. In Mumbai, ICHAP is undertaking direct implementation with Rajasthani staff recruited through one of the Hamara partner NGOs in Rajasthan, BCT. In Ahmedabad, through a partner NGO, an outreach team of six is reaching almost 3,500 Rajasthani migrants. This outreach team distributes free condoms, conducts VCT and STI referrals, and organizes popular IEC cultural events. A team of 15 trained Shekhawati peer educators is in place to support community outreach. In addition, 17 condom depots have been established. In Mumbai, 6-person outreach team distributes free condoms and provides VCT and STI referrals, and reaches 2,200 Shekhawati migrants. Seven peer educators have been trained and support program outreach.
The Rajasthan States AIDS Control Society (RSACS) was involved from the very beginning of the HAMARA project i.e., in the design, training and monitoring of the project. At the destination level (in Ahmedabad and Mumbai) there is also a technical agency monitoring the project and providing all the technical support. Overall project management responsibility is with the Project Officer who reports to the State Coordinator.
The project covered 30,000 Migrants, 24,000 migrants’ wives and 6,000 “potential” migrants.
The key achievements of the project are as follows:
(i) Condoms are promoted through condom depot holders, separately for men and women in all villages.
(ii) An enhanced STI management system with quality referral service is operational in all sites. Over 70 government doctors have been trained in syndromic case management.
(iii) The capacities of 2 Non-Governmental Organisations (NGO) – Borukha Charitable Trust and Morarka Foundation have been strengthened for effective programme implementation. The two agencies, in turn, are partnering with 8 grass root level NGOs.
(iv) During the project period in 133 villages spread across Sikar, Jhunjhunu and Churu, the project was able to identify 4,609 STI cases and 3,735 cases were treated.
(v) The condom use at the beginning of the project was almost negligible in the project area. The available statistics culled from monthly progress report of the project shows that by the end of February 2006, the cumulative condom distribution figure was 1,319,513 at district of origin in Rajasthan.
(vi) Awareness on STI/HIV has increased. The number of one-to-one contacts and one-to-group contacts was 62,537 and 1, 19,249 respectively.
After the completion of the project in March 2006, the activities undertaken in HAMARA will be up-scaled by Rajasthan State AIDS Control society. Till this happens, a trust namely, India Health Action Trust has been formed to oversee the project activities.