Sustainability of Structural Interventions for HIV Prevention: Lessons From a Sex Workers' Community Mobilization Intervention in Southern India

In two funding cycles in 2003 and 2009, the Bill & Melinda Gates Foundation’s Avahan initiative committed $338 million to prevent the spread of HIV in India. Working in six high-prevalence states with high-risk groups (female sex workers, men who have sex with men, injecting drug users and truckers), one of the primary goals of Avahan was to “build an HIV prevention model at scale”.  A key feature of the initiative was its efforts at implementing structural interventions, i.e., broadening the scope of implementation from changing individual behaviors to altering the context within which individuals engage in health behaviors or make health related decisions. To this end, Foundation-funded NGOs were mandated to mobilize marginalized communities to not only bring peers to intervention-run clinics, seek STI treatment and get tested for HIV but also, among others, mobilize to prevent violence, including police-related atrocities. At the time of writing,  interventions are transitioning ownership from the Gates Foundation to the Indian government and, with an eye towards sustainability, from local NGOs to, wherever possible, sex worker-run community-based organizations. This paper uses in-depth ethnographic data collected over a 6-year period in the East Godavari district in the southern state of Andhra Pradesh to examine sex worker mobilization to tackle police violence.  We show that with the backing of a global funder and a committed NGO, sex workers were able to collectivize and use a form of networked governance to regulate a powerful state actor. However, in the transition process, as the prominent non-governmental actors backing sex workers retreat from center stage, the mobilized sex workers continue to engage with the police, but with different results. The evidence we present is instructive in understanding the factors that enhance and impede implementation of structural interventions and has implications for HIV prevention efforts in other settings.