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Evaluation design for large-scale HIV prevention programmes: the case of Avahan, the India AIDS initiative

Chandrasekaran, Padmaa; Dallabetta, Ginaa; Loo, Virginiab; Mills, Stephenc; Saidel, Tobid; Adhikary, Rajatashuvrae; Alary, Michelf,g; Lowndes, Catherine Mh,i; Boily, Marie-Claudej; Moore, Jamesafor the Avahan Evaluation Partners

doi: 10.1097/01.aids.0000343760.70078.89

Background: Closing the HIV prevention gap to prevent HIV infections requires rapid, worldwide rollout of large-scale national programmes. Evaluating such programmes is challenging and complex, requiring clarity of evaluation purpose and evidential approaches substantively different to those employed for pilots and small programmes.

Objectives: This paper describes the evaluation design for the implementation phase of Avahan, the India AIDS initiative, a large HIV prevention programme funded by the Bill and Melinda Gates Foundation. Avahan, which began in December 2003, has a 10-year charter to impact the Indian epidemic and its response by implementing an HIV prevention programme targeting core and bridge groups in 83 districts of six Indian states, transferring the programme to the Government of India, and disseminating programme learning.

Methods: The foundation commissioned an external process to design Avahan's evaluation framework. An independent advisory group oversees and guides course corrections in the execution of this framework.

Results: Avahan's evaluation framework comprises: trend and synthetic analysis of data from core, bridge and household biobehavioural surveys in a subset of intervention districts, denominator estimates and programme monitoring from all intervention districts, and government's antenatal surveillance (two sites per district in all districts); bespoke transmission dynamics modelling to estimate infections averted (subset of districts); cost effectiveness studies (subset of districts). In addition, there are other knowledge-building and quality-monitoring activities.

Conclusion: Rather than a small set of monofocal outcome measures, scaled programmes require nuanced evaluations that approximate programmatic scale by collecting data with different levels of geographical scope, synthesize multiple data and methods to arrive at a composite picture, and can cope with continuous environmental and programme evolution.

aBill and Melinda Gates Foundation, New Delhi, India

bIndependent consultant, formerly with the Bill and Melinda Gates Foundation, New Delhi, India

cFamily Health International, Vietnam

dIndependent consultant, formerly with Family Health International, New Delhi, India

eFamily Health International, New Delhi, India

fCentre Hospitalier affilié Universitaire de Québec, Québec, Canada

gUniversité Laval, Québec, Canada

hLondon School of Hygiene and Tropical Medicine, London, UK

iHealth Protection Agency, London, UK

jDepartment of Infectious Diseases Epidemiology, Imperial College, London, UK.

Correspondence to Padma Chandrasekaran, Avahan, the India AIDS Initiative, The Bill and Melinda Gates Foundation, Sanskrit Bhawan, Aruna Asaf Ali Marg, A-10 Qutab Institutional Area, New Delhi 110061, India. Tel: +91 11 4100 3100; fax: +91 11 4100 3101; e-mail:

© 2008 Lippincott Williams & Wilkins, Inc.