HIV/AIDS was first detected in India in 1986 among women sex workers in Chennai (Madras). At that time, government policy was to test women picked up for prostitution without their consent and to detain indefinitely those women testing HIV-positive. Responding to a petition to free detained women in early 1990, the court ordered the release of close to 700 women being held by the southern Indian State of Tamil Nadu. The court ruled that under the Indian constitution, a State could not imprison its citizens because of the threat of HIV. The South Indian AIDS Action Programme (SIAAP) was born out of this experience.
Between 1990 and 1996, the South India AIDS Action Programme (SIAAP) began building community-based support structures to contain the rapid spread of HIV. Working within a network of 45 NGOs in the states of Tamil Nadu, Andhra Pradesh and Karnataka in South India, SIAAP established largely preventive interventions among truckers, female sex workers and blind people. Interventions included education, free condom distribution, access to STI referral and access to care. Advocacy was a strong thread running through all interventions, from ensuring improvement of condom quality, equitable treatment for sexually marginalised communities at public hospitals and inclusion of PLWHAs at decision-making fora. SIAAP also advocated co-ordination with the National Commission for Women and the National Commission for Human Rights in addressing issues important to PLWHAs and female sex workers. Although the line between advocacy and service was thin many times, one clearly built upon the other.

Advocacy and lobbying for counselling

SIAAP also advocated for integration of quality counselling services into the national HIV/AIDS policy. SIAAP argued that counselling services at STI clinics would bridge the efforts between prevention and cure. Placing NGO staff within government hospitals would strengthen both partners. Upgrading existing infrastructure and facilities is essential in a resource-scarce country such as India, and building partnerships with local communities and service providers would increase demand and encourage quality and accountability.

From the advocacy perspective, the objectives were straightforward:

• 1.Strengthen NGO-government collaboration for increased sustainability
• 2.Maximise effectiveness of existing health services
• 3.Increase recognition of counselling as an important element of HIV intervention
• 4.Increase acceptance of counselling by doctors and nurses
• 5.Improve and help set minimum standards for counselling interventions
• 6.Strengthen bridging between institutions and communities

Building partnerships: a key strategy

SIAAP's advocacy strategy was based essentially on building partnerships at all levels. This required a sound understanding of the issues involved and the nature of the institutions, as well as personal relationships with the people working  in the  institutions.
Equally essential was a consistent presence in communities. In negotiating partnerships, SIAAP representatives had to have personal credibility and integrity and, most of all,  sheer persistence: more than three years of ongoing --often frustrating-- discussions elapsed before the project was cleared.

Partnership with government

Because SIAAP's policy is to strengthen existing services, it was imperative to work with the government, the largest public health service provider in the country. Although quality of service is often poor, personnel, materials and structures can be provided for, at least in principle. The principle was important to keep in mind, so as  not be prejudiced by the existing standards of practice. It was also important to build upon the strengths and not concentrate on the weaknesses.

SIAAP held discussions with the Tamil Nadu government in 1995, before counselling was acknowledged as important, even essential, by most hospitals around the country. Rather than dwell upon the need for counselling, the discussions focused on the possibility of Tamil Nadu becoming the first state in the country to have trained counsellors in all of its hospitals. In doing so, Tamil Nadu would secure its position as the premier state for HIV-related work in the country, achieving what the World Health Organization (and later UNAIDS) and the World Bank advocated. SIAAP stressed that Tamil Nadu was not being asked to make huge investments, other than granting permission for SIAAP trained counsellors to be placed in all of its hospitals. SIAAP's past achievements  lent  credibility to buttress its arguments.

Partnership with associations of STI specialists

Early on, SIAAP had been attempting to persuade the associations of STI doctors in the state to obtain their patients' permission before testing and to provide more privacy and sensitivity. In these discussions, SIAAP understood that the doctors felt completely overshadowed and undervalued in the HIV prevention programmes decision-making process. The doctors felt, justifiably, that STI treatment was an integral part of HIV prevention, yet they were barely present in decision-making bodies and were never recognised as equal partners by the prevention programmes. To encourage the doctors to view SIAAP interventions in a positive light, SIAAP invited  some doctors to join in SIAAP activities as colleagues and to participate in key national meetings. SIAAP also publicly acknowledged the doctors' services in HIV prevention. Since many of the doctors worked in government hospitals or were friends of those who did, there was a degree of built-in support for SIAAP in the workplace and not merely among policymakers.

Partnership with communities

SIAAP decided to integrate its grass-roots community outreach interventions with counselling.  SIAAP expects trainees to provide counselling at the hospitals in the mornings and outreach in the afternoons. SIAAP recognises that, although India has many excellent institutions offering excellent quality of service, the people who need them rarely access them, because of government bureaucracy.

Partnership with professionals

At the outset, SIAAP decided that its project would seek inputs from highly respected professionals in the field. In India, individual-centred counselling is not common. Usually, there are two varieties of counsellors: medically trained psychiatrists and social workers with no special training in counselling skills. Although many professional counsellors bridged the two fields, most had not dealt with the issues of sexuality and HIV/AIDS.  To put a training programme in place and overcome domestic limitations, SIAAP formed an alliance with the Netherlands Gestalt Foundation. This partnership led to two full-time trainers partnering with part-time Indian trainers.

For the graduation of its second batch of trainees, SIAAP invited representatives from the government's AIDS Control Societies in the three southern states to participate in the evaluation. It also invited Indian professionals not connected with the programme, to be part of the process. This increased the professional communities' understanding of the programme and encouraged endorsement for the programme within the professional community and  government.

Outcomes

A measure of the success of SIAAP's interventions can be gauged from an impact study of the programme conducted in July 2000. The study highlights:

• Significant increases in people accessing and completing treatment
• Significant increases in women accessing services
• Marked improvements in privacy, confidentiality and sensitive treatment of patients
• Non-judgmental treatment for PLWHAs, female sex workers and gay/bisexual men
• Widespread recognition and acknowledgement of counselling as a critical intervention for HIV/AIDS
• A network of 84 counsellors in three Indian states
• Endorsement of SIAAP training programmes by state governments
• SIAAP director chosen by the National AIDS Control Organisation, (NACO) and UNAIDS to review the national counselling policy
• Doctors' requests  for counsellor placement in hospitals where the service is unavailable
• Doctors' insistence on SIAAP-trained counsellors to ensure minimum standards.

Conclusion

The counselling programme was officially launched in 1997. However, a substantial amount of spadework had been done without specific planning for the programme in the preceding years. Because they are not integral to the planning process, advocacy strategies are often not recognised as such until they have come to pass. To ensure effectiveness and sustainability, planning must include an advocacy component in all projects.  SIAAP's  project is currently successful. Will it be sustainable?