40544 Corporate Responses to HIV/AIDS Case Studies from India Corporate Responses to HIV/AIDS Case Studies from India © 2007 e International Bank for Reconstruction and Development/ e World Bank 1818 H Street NW Washington DC 20433 All rights reserved Manufactured in the United States of America First printing June 2007 is volume is a product of the sta of the International Bank for Reconstruction and Development/ e World Bank. e ndings, interpretations, and conclusions expressed in this paper do not necessarily re ect the views of the Executive Directors of e World Bank or the governments they represent. e ndings, interpretations, and conclusions expressed in this book are entirely those of the authors and should not be attributed in any manner to the World Bank, to its a liated organizations, or to members of its Board of Executive Directors or the countries they represent. e World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility for any consequence of their use. e boundar- ies, colors, denominations, and other information shown on any map in this volume do not imply on the part of the World Bank Group any judgment on the legal status of any territory or the endorsement or acceptance of such boundaries. 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ISBN-10: 0-8213-7171-1 ISBN-13: 978-0-8213-7171-8 e-ISBN: 0-8213-7172-X DOI: 10.1596/978-0-8213-7171-8 Library of Congress Cataloging-in-Publication Data has been applied for. Design and layout: James E. Quigley, World Bank Institute Photos courtesy of the World Bank, Reliance Industries Limited, Transport Corporation of India Limited, Delhi Metro Rail Corporation, DCM Shriram Consolidated Limited, and Hindustan Lever Limited. Contents Foreword vii Acknowledgments xi Acronyms and Abbreviations xiii Executive Summary 1 Introduction 9 Case Study: Reliance Industries Limited 19 Case Study: Transport Corporation of India Limited 33 Case Study: Delhi Metro Rail Corporation Limited 49 Case Study: DCM Shriram Consolidated Limited 63 iii iv Contents Case Study: Hindustan Lever Limited 75 References 87 Tables 1. Summary of the case studies 6 2. Khushi clinics in India 40 3. Outreach indicators for DMRC program, January­ September 2005 58 Figures 1. Examples of how HIV and AIDS information is disseminated in local villages by the Reliance program 23 2. Reliance program: Activities and implementing partners 27 3. e Kavach model 42 4. Workers' recall of modes of HIV transmission in the DMRC program 59 5. Workers' recall of methods of preventing HIV transmission in the DMRC program 59 Boxes 1. An HIV and AIDS workplace policy to guide future programs 53 2. An HIV and AIDS policy shaped by many actors 65 3. e HIV and AIDS policy of HLL 77 4. Reaching rural villages through Project Shakti 82 Pictures 1. Medical o cer at a Khushi clinic 37 2. Activity aimed at generating HIV and AIDS awareness among long-distance truckers 41 Contents v 3. A display of posters with information on HIV and AIDS 55 4. Explaining sexually transmitted diseases using pictorial ashcards 56 5. A peer educator during a session at a construction site 56 6. HIV and AIDS awareness session for DSCL employees in the urea bagging area 66 7. eme poster enlisting people in the ght against HIV and AIDS 67 8. eme poster quoting a speech by Nelson Mandela 67 9. DSCL visitor's pass with HIV and AIDS messages 68 10. Awareness session for truckers at the entrance to the materials section of the Kota plant 69 11. Session being conducted at the Mangalore unit by the doctor who is the o cer in charge of the local voluntary counseling and testing center 79 12. Mangalore factory manager A.T. Krishnan giving a blood sample for an HIV test 80 13. Employees queuing up to give blood samples for HIV testing at the Mangalore factory 80 14. A Sanjivini camp in progress 81 Foreword Businesses su er from the e ects of HIV and AIDS, but they can ght back. Corporations can take decisive early action to prevent HIV and reduce stigma--before the epidemic becomes generalized in the popu- lation and more di cult and costly to control. Businesses interact with most people in a country--directly, with employees, as well as more in- directly, with employees' families and with customers and community members. By playing a more active role, together with government and civil society, companies have an opportunity to exercise leadership in a way that helps millions and makes both business and moral sense. At the micro level the impact of AIDS on enterprises--through their employers, managers, and workers--is well documented where the epidemic has hit hardest. In those areas AIDS increases the cost of do- ing business, and companies are recognizing that becoming involved in stemming the spread of the epidemic is good not only for corporate citi- zenship but also for corporate self-interest, even survival. AIDS has a direct impact on companies' pro tability. In the worst- case scenario the economic e ects are observed in greater absenteeism vii viii Foreword and sta turnover, higher recruitment and training costs, and higher costs in medical care or insurance coverage, retirement funds or funeral fees. A less obvious but equally important cost is declining morale and productivity among employees. AIDS not only a ects the health of work- ers; it also takes a toll on their savings, the resources of their families, and their productivity as they start spending more time taking care of the sick. In India this scenario can be prevented by businesses taking bold action now. At the macro level HIV and AIDS hit hardest among those in their most productive years, ages 15­24. Evidence from other parts of the world suggests that India's booming and talented workforce is becom- ing increasingly vulnerable to the virus as people become more mobile, lifestyles change, and disposable incomes rise. is is important not only to the information technology and business service companies but to the country as a whole--because it is young adults who are the driving force behind India's impressive growth today and its potential growth and prosperity in the coming years. e government of India has taken signi cant measures to curb the spread of HIV, at both national and state levels. But much remains to be done. Businesses can play an important part, particularly in HIV preven- tion but also in care and treatment of AIDS patients. is collection of case studies aims to contribute to the growing evi- dence on private sector engagement in the ght against HIV and AIDS and the challenges businesses are overcoming in this ght. By capturing the experiences of the local private sector, it seeks to foster a more active response from the business community and to encourage new partner- ship approaches from government, civil society, and development orga- nizations to leverage the goodwill and competencies of the private sector. In a country as large as India, more active engagement of the private sec- tor is critical to achieve the scale of intervention needed to get ahead of HIV and AIDS. We hope the lessons of these case studies will be of inter- Foreword ix est not only to private and public partners in India but also to partners in other countries in South Asia and beyond. Praful Patel Simon Bell Vice President Sector Manager World Bank South Asia Region South Asia Finance and Private Sector Acknowledgments is report was prepared by the World Bank's South Asia Finance and Private Sector (SASFP) unit and the South Asia Regional AIDS (SAR AIDS) team, in collaboration with the Business, Competitiveness, and DevelopmentteamoftheWorldBankInstitute(WBI)and eEnergyand Resources Institute (TERI). e report team was led by Samuel Munzele Maimbo, Shanthi Divakaran, and Mehmet Can Atacik in collaboration with Jenny Gold. Overall guidance was provided by Mariam Claeson, Simon Bell and Djordjija Petkoski. TERI members included Swetha Dasari and Satyajeet Subramanian, under the guidance of Annapurna Vancheswaran. At various stages the team received valuable inputs from Hnin Hnin Pyne, Suneeta Singh, and Sabine Durier. e dra report bene ted greatly from the review and comments received from Sujatha Rao (National AIDS Control Organization), and Gina Dallabetta (Bill & Melinda Gates Foundation). e report was edited by Alison Strong and designed by James Quigley. Maria Marjorie Espiritu provided adminis- trative support. xi Acronyms and Abbreviations AIDS Acquired immunode ciency syndrome DMRC Delhi Metro Rail Corporation DOTS Directly Observed Treatment, Short-course DSCL DCM Shriram Consolidated Limited FHI Family Health International GSNP+ Gujarat State Network of People Living with HIV HIV Human immunode ciency virus HLL Hindustan Lever Limited ILO International Labour Organization JBIC Japan Bank for International Cooperation LVS Lok Vikas Sanstha NACO National AIDS Control Organization NACP National AIDS Control Program NGO Nongovernmental organization NH National highway PATH Program for Appropriate Technology in Health PSI Population Services International xiii xiv Acronyms and Abbreviations RIL Reliance Industries Limited Rs Rupees STD Sexually transmitted disease STI Sexually transmitted infection TB Tuberculosis TCI Transport Corporation of India UNAIDS Joint United Nations Programme on HIV/AIDS WHO World Health Organization Executive Summary Businesses have an enormous stake in the ght against HIV and AIDS, an epidemic that a ects their workforce and, if le unchecked, can rob them of their workers and their markets. ey stand to gain from supporting interventions aimed at preventing HIV both at the workplace and in lo- cal communities--and from taking early decisive action while there is still opportunity to prevent a generalized epidemic. Moreover, businesses bring critical advantages to these e orts, including management skills, resources, and in uence over the general workforce. Lessons from HIV and AIDS interventions by Indian businesses In India both private and public sector companies are pursuing notable programs of HIV and AIDS awareness and prevention for employees and for local communities. All these programs have faced challenges. e ways they have addressed those challenges o er lessons that may be use- ful to other interventions by private and public sector businesses, both current and future: 1 2 Executive Summary · Leveraging partnerships. Partnerships with local NGOs, State AIDS Control Societies, and other agencies have proved critical to the success of several programs. One program, for example, developed its approach to HIV prevention through discussions with the State AIDS Control Society and broadened its outreach by partnering with an active network of people living with HIV. Programs operating clinics along national highways for long-dis- tance truckers depend on partnerships with local NGOs across the country. Others rely on construction contractors to ensure that migrant workers are exposed to HIV and AIDS awareness programs. · Communicating messages e ectively. Companies have used sever- al approaches to communicate HIV and AIDS messages to their workforce and local communities. One company in this collec- tion of case studies customizes information, education, and com- munication material in imaginative ways to capture the attention of its target audience--producing cassettes that intersperse HIV and AIDS messages with popular Hindi lm songs and having talented employees convey messages through songs and poems at company events. Most such communication e orts, however, need better monitoring and evaluation to assess their e ectiveness in changing attitudes and practices. · Keeping up with highly mobile target groups. Many target groups, such as sex workers and their clients, are highly mobile. To sup- port and track one such group, long-distance truckers, one pro- gram operating clinics along highways issues each participat- ing trucker a "passport" recording the trucker's medical history. Truckers present their passport on each visit to any of the clinics, allowing them easy access to services and giving medical sta easy access to their medical history. Executive Summary 3 · Coping with poor public health infrastructure. Lack of government health facilities has created challenges in several cases. One pro- gram has found that because government medical and testing fa- cilities are closed on weekends, laborers o en turn to fake doctors. Mobile health clinics could help overcome this challenge by pro- viding laborers easier access to medical services on weekdays. · Countering social stigma. Predictably, most programs have en- countered resistance to HIV and AIDS messages because of the stigma attached to the epidemic and to topics related to sex. Pro- grams have had to use repeated awareness programs to encourage employees to pick up free condoms. And among those that have set up medical centers to treat AIDS patients, one had to address concerns among villagers that a center's proximity to their homes could expose them to contagious diseases. · Overcoming message fatigue and negative branding. Programs tar- geted to truckers found that messages became ine ective with too much repetition. Moreover, repeated interventions targeted to truckers saddled them with negative branding because of the stigma associated with HIV and AIDS. To counter these e ects, one program, for example, has experimented with theater perfor- mances featuring truckers as protagonists while communicating HIV and AIDS messages. The approaches used by five Indian companies is report features ve case studies illustrating approaches that private and public sector companies have used in HIV and AIDS interventions. Other companies in India have pursued similar activities. rough the "IFC Against AIDS" program, for example, the International Finance 4 Executive Summary Corporation, a member of the World Bank Group, works with four Indian companies implementing HIV and AIDS interventions: Ambuja Cement, Apollo Tyres, Ballarpur Industries Limited (BILT), and Usha Martin.1 e details and lessons of these interventions and those of the ve case studies in this report may be helpful to other companies design- ing or implementing HIV and AIDS interventions for their workforce and communities. e interventions of the ve companies highlighted in the report have ranged from advocacy and generation of awareness to prevention and treatment (table 1): · Reliance Industries Limited, India's largest private company, set up a well-equipped medical center near its industrial site in Hazira, Gujarat, where it provides both tuberculosis and AIDS treatment. Since inception of the program in 2004, company physicians and local NGOs have together reached nearly 300,000 people through awareness initiatives, testing and counseling services, and antiret- roviral therapy. · Transport Corporation of India (TCI), recognizing the importance of truckers to its business and the vulnerability of the trucking community to HIV and AIDS, established a network of clinics along national highways. Operated by local NGOs, these clinics serve long-distance truck drivers and their assistants, providing treatment for sexually transmitted infections and counseling ser- vices aimed at preventing HIV. · Delhi Metro Rail Corporation (DMRC), a public sector company, is constructing the metro rail system in Delhi. is enormous con- struction project draws migrant workers, a population typically at high risk for HIV infection, from across India. DMRC initiated an 1. International Finance Corporation, "IFC Against AIDS: Projects," http://www.ifc.org/if- cext/aids.nsf/Content/Projects. Executive Summary 5 HIV and AIDS program for contractors and workers that includ- ed advocacy, peer education, and promotion of condom use. is nine-month program reached more than 3,000 workers. e com- pany has ensured that the e orts will be extended: its agreements with contractors now require that they carry out HIV prevention activities for employees working on DMRC projects. · DCM Shriram Consolidated Limited (DSCL), a company with in- terests mainly in chemicals and agribusiness, initiated an HIV and AIDS program at its plant in Kota, Rajasthan, aimed at providing a safe and healthy work environment. e program draws on the local culture, adapting information, education, and communica- tion material to local sensibilities and using cultural performanc- es to convey HIV and AIDS messages. is strategy has helped broaden the appeal of its messages and gain acceptance for the program among the local population. · Hindustan Lever Limited (HLL), a fast-moving consumer goods company with more than a hundred manufacturing plants across India, has initiated workplace programs aimed at protecting the health of its skilled young workforce. With technical assistance from the International Labour Organization, the company's fac- tories have built HIV and AIDS awareness programs into their health and safety training. HLL has also used its expertise in dis- tribution and management to spread HIV and AIDS awareness through initiatives with rural entrepreneurs. And in the future it plans to use its extensive marketing network in rural areas to pro- mote use of condoms. 6 Executive Summary Table 1. Summary of the case studies Location of Intervention Company Industry intervention areas Beneficiaries Partners Reliance Petrochemicals, Hazira, Gujarat Awareness and Contract work- Confederation of Industries textiles, others prevention, HIV ers, migrant Indian Industry, Limited testing, treat- workers, truck- Gujarat State ment for AIDS, ers, employees, AIDS Control advocacy local commu- Society, Gujarat nity, local enter- State Network prises of People Living with HIV, Lok Samarpan, Lok Vikas Sanstha, Reliance Life Sciences Transport Cargo transport Andhra Awareness and Long-distance Avahan, CARE, Corporation Pradesh, Delhi, prevention, truckers, local Family Health of India Jharkhand, treatment for community International, Karnataka, sexually trans- Population Ser- Madhya mitted infec- vices Interna- Pradesh, tions, advocacy tional, Program Maharashtra, for Appropriate Orissa, Technology in Rajasthan, Health (PATH) Uttar Pradesh Delhi Public transport Delhi Awareness and Migrant workers International Metro Rail prevention, ad- employed by Labour Organi- Corporation vocacy contractors zation, Japan Bank for Interna- tional Coopera- tion, Modicare Foundation DCM Shriram Agribusiness, Kota, Rajasthan Awareness and Employees, Confederation of Consolidated chemicals, prevention, contract work- Indian Industry, Limited plastics, others treatment for ers, truckers, The Energy and AIDS, advocacy local community Resources Insti- tute, Rajasthan State AIDS Con- trol Society Hindustan Fast-moving Southern, Awareness and Employees, Confederation of Lever Limited consumer goods eastern, prevention, HIV contract work- Indian Industry, western, and testing, advo- ers, truckers, International northern cacy local and rural Labour Organi- corporate communities zation, National regionsa AIDS Control Or- ganization, local NGOs, hospitals a. Hindustan Lever Limited's southern region encompasses Andhra Pradesh, Karnataka, Kerala, and Tamil Nadu (program activities reported from Karnataka and Tamil Nadu); its eastern region, seven northeastern states along with Assam, Jharkhand, Orissa, and West Bengal (program activities reported from Assam); and its northern region, Delhi, Himachal Pradesh, Jammu and Kashmir, Punjab, Rajasthan, Uttaranchal, and Uttar Pradesh. Executive Summary 7 Key recommendations Experience in combating HIV and AIDS in India points to several key recommendations for private and public sector programs: · Take early decisive action. Companies that carry out HIV and AIDS interventions do so to safeguard the health of their employ- ees and because these e orts accord with their values and mis- sion. Such e orts can meet resistance--at the corporate level, at the workplace, and in the local community--especially where ac- tion is taken early to stem an epidemic before it has become gen- eralized, when the perceived risk may be low. But taking early de- cisive action on prevention before the epidemic gets out of control pays o for companies: it reduces the future burden of death and disability and averts the high cost of treating and caring for large numbers of people living with AIDS. · Document cost and e ectiveness. ere is much to learn from ac- tions taken by businesses to prevent HIV and treat and care for AIDS patients. It is important to learn by doing. But beyond this, formal, independent evaluation is needed to assess the e ectiveness of these interventions. Better monitoring and evaluation will help in planning and implementing programs, in identifying gaps, and, importantly, in sustaining, scaling up, and expanding initiatives. · Ensure sustained commitment and nancing. A challenge for both the private and the public sector is to sustain the nancing for prevention, treatment, and care. Continued nancing is especially essential for treatment programs, which, once initiated, must not be interrupted. Developing strategies for sustaining programs-- whether run by businesses or by government--will become in- creasingly important, providing a strong impetus for greater pri- vate-public partnership and sharing of knowledge. Introduction Indian businesses have become an important stakeholder in the ght against HIV and AIDS. According to the National AIDS Control Organization, 5.2 million adults ages 15­49 in India are HIV-positive, representing one-eighth of global HIV cases (Chandrasekaran and oth- ers 2006). A large share of this HIV-positive population are employees of Indian industry. The case for business involvement India has maintained an average annual growth rate of more than 7 per- cent in the decade since 1994,2 and by January 2006 had built up its for- eign exchange reserves to more than US$139 billion (India, Ministry of Finance 2006). e country also is becoming a leading destination for foreign investment. But while Indian industry has been growing at an impressive pace, it faces potentially large risks from increasing social challenges. 2. U.S. Central Intelligence Agency, "India: Economy Overview," in e World Factbook, https://www.cia.gov/cia/publications/factbook/geos/in.html (last accessed November 15, 2006). 9 10 Introduction Particularly alarming are the potential repercussions of the HIV and AIDS epidemic. India does not have the high prevalence of HIV infec- tion that African countries do, but it has the second largest number of people living with HIV and AIDS a er South Africa. Moreover, India's population, already more than one billion, is expected to surpass Chi- na's by 2010. In this scenario even a small increase in the prevalence rate could mean a staggering number of infections. Already HIV has spread across the nation, reaching both urban and rural pockets. While India faces mainly concentrated epidemics, among high-risk groups, several states face generalized epidemics (Moses and others 2006). e groups most at risk are sex workers and their clients, many of whom are migrant workers, truckers, and others who spend long periods away from home; injecting drug users and their sexual partners; and men having sex with men. For India the challenge of ghting the epi- demic is made even more daunting by illiteracy, mass poverty, and socio- economic disparities between men and women, all of which contribute to HIV and AIDS. AIDS kills primarily young and middle-aged adults during their peak productive years. By reducing the labor supply and disposable in- comes, a generalized epidemic can have broad macroeconomic e ects, dampening markets, savings rates, investment, and consumer spending. Assessing the economic impact of AIDS is di cult. But studies suggest that some of the hardest-hit countries with generalized epidemics may forfeit 2 percent or more of annual GDP growth (World Bank 2006). As India becomes a global economic power, it is important that Indi- an businesses continue to bear in mind their corporate social responsibil- ity, pursuing business practices and policies that are in the best interest of the community at large. Businesses have much to gain from early decisive action to prevent HIV and reduce the cost and social impact of AIDS. e heterogeneous nature of the epidemic in India suggests that there is no one strategy for Indian businesses in the ght against HIV Introduction 11 and AIDS. Businesses that employ groups most at risk, such as truck- ers, may need to implement targeted interventions. But all businesses can contribute to curbing the epidemic through a set of activities that include the following: · Generating awareness about HIV and AIDS. · Reducing stigma (for example, destigmatizing HIV testing by pro- moting an HIV testing day or having a high-pro le person in the company be publicly tested). · Pursuing high-level advocacy e orts (such as by having corporate leaders speak publicly about HIV and AIDS). · Creating an HIV policy for the workplace. · Providing referrals for counseling and testing. What industry gains from setting up HIV and AIDS programs e HIV epidemic can have a direct impact on businesses through its e ect on their workforce. Yet in India only a small share of the private sector--around 70 companies--are engaged in ghting HIV and AIDS.3 Farsighted companies have incorporated the ght against HIV and AIDS into their corporate strategy because they are convinced that there is a business case for doing so: · Control of the cost of HIV and AIDS. While India has a relatively low national prevalence of HIV, prevalence rates vary (from high to low) between and within states, and the total number of HIV- positive people is high. HIV and AIDS can impose large costs on 3. Based on discussion with the HIV and AIDS team of the International Labour Organi- zation, Delhi, on November 14, 2005. 12 Introduction businesses through higher medical and health insurance spend- ing and the need to recruit and train new sta to replace those who are lost. Where prevalence rates are high, the epidemic also leads to higher costs, and to lower revenues, as a result of greater absenteeism and sta turnover, lower productivity, declining mo- rale, and a shrinking consumer base. Where the epidemic con- tinues to grow, companies may face a shortage of healthy labor in the long run, leading to a migration of workers between cities and states to ll labor needs. Companies would have to bear the long- term cost of this migration, including the cost of relocating sta and providing housing and other bene ts. · Con ict reduction in the workplace. Within companies a lack of awareness and understanding of HIV and AIDS can lead to con- ict in the workplace and thus disruptions for management. HIV and AIDS awareness programs can help reduce these con icts that arise because of lack of information and communication. · Strong markets. Businesses survive and succeed in settings where people have the capacity to purchase. In regions heavily a ected by HIV and AIDS the general pattern of expenditure is skewed to- ward health care and medication. It is thus in the interest of busi- nesses to stem the spread of the epidemic so as to retain and build markets for their products and services. · General goodwill and better relations with stakeholders. e danger of HIV and AIDS has raised concern throughout society. us companies that launch HIV prevention programs gain from the publicity bene ts of engaging in corporate social responsibility. Establishing an HIV and AIDS program also improves relations with labor and with other key stakeholders, such as investors, the government, and civil society. Introduction 13 What advantages businesses bring to the fight Businesses, particularly private sector ones, have been an e ective partner in addressing HIV and AIDS in South Asia. Companies have many com- parative advantages that they can mobilize in the ght against AIDS: · Coverage and in uence. A large share of the HIV-a ected popula- tion work for businesses, giving these businesses signi cant in u- ence over the general workforce. Businesses can harness this in- uence to spread HIV and AIDS education and awareness among employees and their families. eir organizational structure also provides mechanisms for reaching out to a larger group of people. Firms have in uence over supply chain networks and other play- ers with links to the general workforce. us companies that want to extend their e orts beyond their own workplace can develop ways to encourage their suppliers and distributors to help prevent the spread of HIV. e in uence of businesses in mainstreaming HIV and AIDS initiatives is also important in reducing stigma. · Lobbying power. Businesses have the power to form strong lobby groups that can in uence government policy. Collectively, Indian companies could work through business associations and coun- cils to promote HIV prevention programs at the workplace in all sectors. ey could also raise and donate funds for strengthening communications infrastructure and connectivity to provide easy access to useful information on HIV and AIDS. · Special expertise. Private companies generally have the manage- rial skills to run a program more e ectively than the public sector. ey o er a range of capabilities--logistics expertise, technical know-how, nancial and accounting skills, and communications, media, marketing, and training skills. All these can be brought to bear in changing opinions, attitudes, and behaviors on a large 14 Introduction scale so as to reduce the stigma associated with HIV and AIDS and stem the spread of the epidemic. · Financial resources. Private rms typically have the nancial re- sources and infrastructure to carry out HIV and AIDS interven- tions such as awareness programs. ey can also nd innovative ways to nance and sustain programs. · Results orientation. e private sector's typically higher e ciency (compared with the public sector's) could help in achieving more e cient and e ective HIV and AIDS interventions, if well moni- tored and evaluated. How the Indian government supports companies involved in HIV and AIDS interventions India has both national and state organizational structures for combating HIV and AIDS. At the national level the government has established the multisector National Council on AIDS, chaired by the prime minister. At the state level each State AIDS Council is chaired by the state's chief minister and the vice chair of its Ministry of Health. In addition, the Indian government leads a broad-based national program on HIV and AIDS through the National AIDS Control Orga- nization, a semiautonomous agency set up in the Ministry of Health in 1992.4 is agency, along with the local State AIDS Control Societies, has a role in steering the ght against HIV. It has a dedicated senior core sta 4. National AIDS Control Organization, "About NACO," http://nacoonline.org/abt_faq. htm (last accessed November 15, 2006). Introduction 15 whose work includes mainstreaming HIV and AIDS prevention, treat- ment, and care; developing capacity; and providing hands-on support across sectors. e national program includes: · Targeted interventions for HIV and AIDS prevention and aware- ness. · Control of sexually transmitted infections (STIs). · Information, education, and communication. · Treatment, care, and support for AIDS patients. · Training (such as for medical and paramedical sta of blood banks and for NGOs or companies implementing HIV and AIDS programs). · Sentinel surveillance (monitoring of HIV infection trends in spe- ci c high- and low-risk groups).5 · Program management. · Advocacy and social mobilization. · Strategies and interventions for blood safety and training. e National AIDS Control Organization and local State AIDS Con- trol Societies have partnered with several Indian industry coalitions and companies in carrying out HIV and AIDS interventions. 5. In India sentinel surveillance of high-risk groups includes people attending drug addic- tion treatment centers, clinics for sexually transmitted infections, and clinics for men having sex with men. Low-risk segments include mothers attending prenatal clinics, a category taken as a proxy for the general population (National AIDS Control Orga- nization, "Facts and Figures: An Overview of the Spread and Prevalence of HIV/AIDS in India," http://www.nacoonline.org/facts_overview.htm, last accessed November 15, 2006). 16 Introduction The case studies Among the Indian companies already engaged in the ght against HIV and AIDS, what shape do their e orts take and what are the lessons of their experience? To nd out, case studies were conducted to highlight the work of companies promoting HIV and AIDS awareness and provid- ing HIV- and AIDS-related services at the workplace and in local com- munities. To identify the case studies, a shortlist was prepared of companies that had HIV and AIDS programs with clear objectives and dedicated resources, including sta and infrastructure. From this shortlist ve com- panies were selected that re ect a variety of sectors, partnership models, target groups, and intervention mechanisms: · Reliance Industries Limited. · Transport Corporation of India. · Delhi Metro Rail Corporation. · DCM Shriram Consolidated Limited. · Hindustan Lever Limited. All the companies except Delhi Metro Rail Corporation are in the private sector. e case studies were researched using a mix of methods: standard questionnaires administered to companies; meetings with senior man- agement, human resource personnel, and corporate social responsibility teams at factory locations or the corporate o ce; telephone interviews; review of internal documents; and written correspondence. e case studies illustrate the importance of integrating multiple stakeholders in the ght against HIV and AIDS. ey also highlight the growing investment of businesses in that ght--an investment that rec- ognizes their vulnerability to the economic and social impact of the epi- Introduction 17 demic. And they show what businesses can achieve by tackling HIV and AIDS through the workforce. Each of the ve businesses contributes its unique perspective, ex- pertise, and skills to helping to curb the HIV and AIDS epidemic in the microcosm in which it operates. By showcasing their achievements and illuminating the lessons of their experience, these case studies seek to convince other businesses that taking part in the ght against HIV and AIDS is both within their reach and in their interest. Case Study: Reliance Industries Limited Overview Reliance Industries Limited is India's largest private enterprise, with busi- nesses straddling several sectors and a workforce of 25,000 employees.6 Its large workforce and extensive operations give it a big stake in the ght against HIV and AIDS. e company's HIV and AIDS program is unusual among those ini- tiated by private companies in India in that it not only promotes aware- ness of HIV and AIDS but also provides treatment. Another unique fea- ture of the program is its broad coverage: it provides antiretroviral thera- py to anyone in the community who is HIV-positive, whether or not that person is an employee of the company. e program began by establishing a well-equipped health center at Hazira, in Gujarat, to provide tuberculosis treatment based on the strat- egy recommended by the World Health Organization (WHO), known as DOTS (Directly Observed Treatment, Short-course). e center, which 6. e information in the Reliance case study is based on personal interviews with Reli- ance o cials responsible for the company's HIV and AIDS program, site visits, and internal documents shared by the company. e information is current as of September 2006. 19 20 Case Study: Reliance Industries also o ered information on HIV prevention, later expanded to treatment and other services for AIDS patients. It also provides counseling, educa- tion, and training and disseminates information on nutrition. Reliance has worked closely with partners to help extend the pro- gram's reach. In villages near Hazira local NGOs disseminate informa- tion and refer HIV-positive people to the center. While education pro- grams and the center itself initially encountered resistance because of the social stigma associated with HIV and AIDS, repeated awareness activi- ties have helped gain acceptance. e program has already reached nearly 300,000 people--truckers (drivers and crew members), contract and migrant workers, employees of local enterprises, and members of the local community. Reliance is now initiating a process of replicating the program at other company sites. Business background Reliance is a big presence in the Indian economy, with annual sales of US$20 billion, a net worth of US$11 billion, and total assets of US$21 bil- lion. Its activities include oil and gas exploration and production, petro- leum re ning and marketing, petrochemicals (polyester, ber interme- diates, plastics, and chemicals), and textiles. Its exports reach As a global business leader, we are equally concerned about the society we nearly 100 countries across the live in and our environment. We have globe, totaling US$7 billion an- constantly pursued businesses that will trigger high growth and promote nually. sustainable development, and this has e company operates been and must continue to be one of our manufacturing facilities at sev- guiding philosophies. eral sites in Gujarat. e Nar- --Mukesh D. Ambani, Chairman oda facility, near Ahmedabad, Reliance Industries houses a textile plant. e Pa- Case Study: Reliance Industries 21 talganga complex, near Mumbai, has polyester, ber intermediate, and linear alkyl benzene manufacturing plants. e Hazira complex, near Su- rat, has a naphtha cracker feeding downstream ber intermediate, plas- tics, and polyester plants. And the Jamnagar complex has a petroleum re nery and associated petrochemical plants that produce plastics and ber intermediates. Why do something about HIV and AIDS? As an industrial site, Hazira has a large migrant workforce employed in several local industries. e presence of these industries has also con- tributed to a large, oating population of truckers in Hazira. Concerned about the risk of infectious diseases in such a population, the local gov- ernment sought corporate support to set up HIV and tuberculosis pro- grams at the workplace and in medical camps in local villages and on local highways. In 2004 the district tuberculosis program approached Reliance about collaborating in e orts to address tuberculosis in Hazira. Around the same time, at the World Economic Forum, Reliance committed to working toward combating HIV and AIDS in India. Together, these two events gave management the impetus to initiate a full-time HIV and tu- berculosis program at the company's Hazira location. e company's management began by discussing possible interven- tion strategies with Lok Vikas Sanstha (LVS), a local NGO specializing in public health. In 2004 LVS had conducted a baseline survey on the preva- lence of sexually transmitted infections in Hazira and found that among the local population of migrant workers and truckers the prevalence rate was close to 12 percent (LVS 2004). e discussions with LVS led Reliance to set up a DOTS tuberculosis and HIV center at Mora village on May 15, 2004, to provide medical ser- 22 Case Study: Reliance Industries vices (both general and tuberculosis related) and information on HIV pre- vention for local villagers, truckers who halt for long hours, and the neigh- boring communities of migrant and contract workers. e center is housed in a community hall provided by Mora's gram panchayat.7 Involving the panchayat helped create a sense of ownership among the local villagers. The program e Reliance HIV and AIDS program has two components: awareness and education, and treatment and support. Awareness and education Before launching its awareness program, Reliance held a series of discus- sions with the Gujarat State AIDS Control Society aimed at better under- standing the nature of HIV prevalence in Hazira. ese discussions made it clear that generating awareness among high-risk groups was a priority in stemming the spread of the epidemic. Reliance thus ensured that its awareness program extended beyond its employees and local villagers to high-risk groups in local industries. Reliance employees Reliance initiated the awareness program in-house, as part of its health, safety, and environment training for contract workers, supervisors, and 7. Every Indian village elects a panchayat, a ve-person team that presides over the village's development a airs. Case Study: Reliance Industries 23 security sta . Conducted once a week by the company's on-site physi- cian and LVS trainers, this training program has reached more than 5,000 workers. Besides basic information about preventing the transmission of HIV, sessions include discussions among workers to help clarify misper- ceptions about HIV and AIDS. Initially those conducting the sessions faced challenges due to the strong stigma associated with HIV and AIDS. But Reliance has found that regular sessions and e orts to generate mass awareness among work- ers have substantially reduced fears relating to the epidemic. Local community ReliancehasdevelopedamultiprongedapproachtoHIVandAIDSaware- ness and education in the local community. In nearby villages it conducts mass awareness programs through health camps. Sessions held at these camps discuss other health issues along with HIV, to di use the focus and Figure 1. Examples of how HIV and AIDS information is disseminated in local villages by the Figure 1. Examples of how HIV and AIDS information is disseminated in local villages by the Reliance program Reliance program 24 Case Study: Reliance Industries thus lessen the discomfort of addressing HIV-related topics. A commu- nity mobilization team, with representatives from both Reliance and LVS, frequently visits neighboring villages (Damki, Suvali, Batlai, Junagaon, Vasva, and Rajgiri) to disseminate information ( gure 2). Diagnostic and referral services are also provided in the health camps. Reliance bears the cost of both the health camps and any subsequent treatment. As part of the e ort to generate mass awareness, Reliance has also posted several educational banners in Surat and used street plays, poster exhibits, and video shows. anks to outreach e orts such as these, 25 HIV-positive sex workers from nearby villages are being monitored and treated by the medical center. Reliance has also worked to generate awareness among truckers vis- iting its truck parking area, which draws nearly 1,000 trucks a day. Sta share information, distribute brochures printed in Hindi, Gujarati, and English, and hand out packs of condoms. To strengthen its e orts in the community, Reliance has provided training to a group of young people who expressed interest in sharing information about HIV and AIDS with their neighbors and peers. ese volunteers, who serve as a link between the medical center and the village population, received training in communication skills and on such topics as modes of HIV transmission, safe behavior, condom promotion, and identi cation of sexually transmitted infections. Reliance has also provided training to local medical personnel aimed at increasing their awareness of and responsiveness to the con- cerns of HIV-positive people. e program has targeted doctors from urban health centers, the Employee State Insurance Scheme hospital, primary health centers of Surat district, and other private practitioners. Some 80 doctors and more than 100 paramedical sta have attended training programs. Case Study: Reliance Industries 25 Local enterprises Having established awareness programs both at the company and in the local community, Reliance extended its e orts to high-risk groups in the local diamond and textile industries. ese industries hire contract and migrant workers who live away from their families and in localities where prostitution is common, making them more susceptible to HIV infec- tion. In collaboration with the Confederation of Indian Industry, an asso- ciation that represents industry on business and sustainable development issues, a team of Reliance and LVS sta visited a di erent enterprise each week to conduct HIV awareness sessions. A typical program would be- gin with a management meeting, followed by sensitization sessions with the workforce. It would conclude with the management signing an HIV and AIDS policy based on the International Labour Organization (ILO) workplace policy. In 2004­05 these sessions provided training to more than 8,000 workers in 67 textile and 24 diamond enterprises. Treatment and support rough its outreach activities Reliance discovered that Hazira and the nearby areas lacked adequate medical care and services for HIV- positive people. It therefore converted the DOTS tuberculosis and HIV center in Mora into an HIV testing, counseling, and treatment center o ering a wide range of services. And it sent its physicians for special training on clinical intervention and so er skills needed to deal with HIV-positive patients. e center provides a number of medical tests free for HIV-positive patients and at a heavily subsidized cost for others, including pregnancy tests, blood screening for syphilis (Venereal Disease Research Labora- 26 Case Study: Reliance Industries tory test), urine microscopy, and biochemical examinations such as liver function tests, blood sugar, and lipid pro le. Patients seeking treatment for sexually transmitted infections receive counseling on such topics as modes of HIV transmission, the relationship between HIV and sexually transmitted infections, and the use of condoms. e center also provides antiretroviral therapy. And it o ers emergency care including intrave- nous drugs and uids and ambulance services. Also among the services o ered at the center are counseling, yoga training, pranayama coaching (breathing exercises to boost physical and mental spirits), and nutritional support. Malnutrition patients weighing less than 40 kilograms receive food and nutrition supplements. Partnerships Reliance management played a key leadership role in shaping the pro- gram and extending its outreach beyond company employees to the neighboring community. But partners have also been critical in imple- menting the program ( gure 2): · Lok Vikas Sanstha, through its team of 100 peer educators, has been responsible for organizing awareness campaigns in local ar- eas and for the migrant workforce of Reliance on identi cation and treatment of sexually transmitted infections. · Gujarat State Network of People Living with HIV (GSNP+), an ex- tremely active network of 1,600 members, has helped strengthen outreach by referring potential HIV-positive cases to the center. GSNP+ has provided counseling to HIV-positive people with no funds from Reliance. It encourages members of the network to take their medications regularly and coordinates with Reliance in providing medication and transport to the center. GSNP+ has also Case Study: Reliance Industries 27 Figure 2. Reliance program: Activities and implementing partners Figure 2. Reliance program: Activities and implementing partners Reliance TB and HIV control center, Hazira Prevention activities Care and support activities · In-house HIV awareness programes Medical and clinical support · HIV awareness programs for truckers · HIV management · HIV education in schools · STI management · Industrial contacts · TB management · Peer education in surrounding villages · Awareness banners Other support · Nutritional support · Counseling · Yoga and pranayam practice · Help from Reliance Ladies Club · Transport support · Sensitization and education of doctors Implementing partners Reliance Industries Prevention Sanstha Lok Vikas activities Gujarat State Network of People Living with HIV worked with Reliance to sensitize local government authorities, which has led to the establishment of an AIDS information desk at the government hospital in Surat. · Reliance Life Sciences, a research-oriented subsidiary in Mumbai focusing on medical, plant, and industrial biotechnology, has pro- vided viral load testing (which determines the stage of HIV infec- tions) at a subsidized cost. 28 Case Study: Reliance Industries · Lok Samarpan, a local blood bank, conducts CD4 tests (which re- port on the strength of the body's immune system and thus help assess the stage of the HIV infection and predict the risk of com- plications) at a subsidized rate of Rs 650 (US$14.50) per test. Fur- ther subsidy by Reliance reduces the cost to Rs 300 (US$6.50) per test. All costs are waived for widows and orphans. Funding In 2005­06 program costs amounted to Rs 100 lakhs (US$222,000). Reliance contributed Rs 75 lakhs (US$167,000), while the government covered the rest through the Gujarat State AIDS Control Society. Outreach e Reliance center has provided counseling to around 13,950 patients. Of these, 330 are patients receiving active antiretroviral therapy,8 and 166 are tuberculosis patients receiving DOTS. In addition, 1,450 patients have been treated for sexually transmitted infections. A separate group of 626 HIV-positive patients are receiving regular monitoring and follow- up. e program has enabled nearly 250 HIV-positive people to return to regular work a er beginning antiretroviral therapy. Beyond the center, a mobile medical van pays weekly visits to nearby villages to o er free consultation and basic medication for general ail- ments. Between January 2005 and March 2006 this initiative bene ted more than 140,000 villagers and 60,000 migrant workers. 8. e cost of providing antiretroviral therapy for one patient is Rs 1,500 (US$33) a month. Case Study: Reliance Industries 29 Lessons learned e program has identi ed success factors, challenges, and lessons based on its experience. Key success factors · Outreach. In collaboration with program partners, the Reliance center has been able to provide quality services not only to com- pany employees but also to a wide range of people in the commu- nity and at local enterprises. Indeed, patients from across south- ern Gujarat visit the center, some from as far as Amreli and Juna- garh. e company attributes the success of its outreach e orts to the quality of services provided by the center and the referral network set up by partners. · NGO partnerships. Top managers at Reliance have contributed greatly to the program's e ectiveness through their involvement and commitment. But NGO partners have played a crucial role in enabling the program to expand and reach out to villagers, indus- trial workers, truckers, and the HIV-positive population. Key challenges · Poor public health services. e government's public health system o en lacks the basic medical services and expertise required to administer quality care to AIDS patients. While this may not di- rectly hinder operation of the center, an e ective government sys- tem would help both support the services o ered by the Reliance center and extend coverage to more patients. 30 Case Study: Reliance Industries · Retention of village outreach workers. Retaining village outreach workers has been a challenge for the program sta , with workers o en dropping out a er receiving training. Continually training new outreach workers has been costly and time consuming. · Social stigma. Reliance faced initial challenges in its awareness and education programs because of the social stigma associated with HIV and AIDS and sexually transmitted infections. Work- ers hesitated to ask questions during training sessions, though they o en returned to clear up misconceptions. And villagers were concerned about the proximity of the medical center to their homes, fearing that it could expose them to infections from visit- ing patients. · Monitoring and evaluation. Reliance sta believe that monitor- ing and evaluation of the program need to be strengthened, with clearly de ned targets established for evaluating all partners. Other lessons learned · Financial sustainability. e Gujarat State AIDS Control Society provides funds to LVS for its counseling, training, and dissemina- tion services and for the cost of medicines. us the continued sup- port of LVS as a program partner depends largely on the continued nancial support of the Gujarat State AIDS Control Society. Future plans At the Hazira site, where Reliance has largely concentrated its e orts, the company has begun to construct a new center that can accommodate more patients. Future plans also call for replicating the program at other Case Study: Reliance Industries 31 company sites. In addition, the company is considering implementing similar HIV and AIDS initiatives at Reliance gas stations on the high- ways, targeted to the trucking population. Given the plans to extend and expand the program, evaluating its impact to date and assessing the ef- fectiveness of its interventions will be especially important. Case Study: Transport Corporation of India Limited Overview Long-distance truckers have been found to be at high risk for HIV and other sexually transmitted infections.9 Transport Corporation of India (TCI), as a major cargo transport company, recognized the importance of truckers in its business and launched a project speci cally targeted to this population. is ve-year HIV prevention project, Project Kavach (a Hindi word meaning protection or shield), is being implemented by TCI's social arm, the TCI Foundation, and by the Avahan India AIDS Initiative, which is funded by the Bill & Melinda Gates Foundation. e project is a comprehensive, integrated approach to reducing the transmission of HIV and other sexually transmitted infections among long-distance truckers by: · Providing diagnosis and treatment of sexually transmitted infec- tions through project clinics. 9. e information in the TCI case study is based on personal interviews with TCI Foun- dation o cials in Delhi and personnel responsible for implementing the program in Bangalore as well as internal documents shared by foundation sta during site visits in Delhi and Bangalore. e information is current as of September 2006. 33 34 Case Study: Transport Corporation of India · Using behavior change communication to encourage truckers to adopt safer sexual behavior and practices. · Promoting condom use among the target population. Because long-distance truckers are highly mobile, they need access to medical facilities where they travel. Project Kavach has therefore lo- cated its "Khushi" (a Hindi word for happiness) clinics at 17 major truck- er halt points in nine Indian states. Each halt point sees about 20,000­ 30,000 truckers a year as they stop to rest and to repair their vehicles and the like. ese project sites were selected with the aim of reaching a target group of about 1.4 million long-distance truckers (drivers and crew mem- bers) nationwide through clinics, peer education, and condom distribu- tion. To run the clinics and undertake other activities, the TCI Founda- tion has contracted with NGOs across the country. Truckers' mobility also means that medical records are hard to main- tain. e project deals with this challenge by issuing truckers a "Khushi passport"--a diary recording their medical history, diagnoses, and medi- cations--that they can present at any project clinic. e project has reached large numbers of truckers and others. Be- tween January 2005 and March 2006 alone, its clinics treated nearly 43,000 people for sexually transmitted infections, 82 percent of them truckers. During the same period the project also distributed more than 700,000 condoms.10 Business background Established in 1958, TCI is now among the leading conventional cargo transport companies in Asia. It transports cargo ranging from raw ma- 10. Condoms are also widely available along the truck routes through social marketing. Case Study: Transport Corporation of India 35 terials and agricultural and industrial products to consumer durables and drugs and pharmaceuticals. Recently TCI has started also trans- porting more sophisticated cargo, such as refrigerated, time-sensitive, and high-value items. e company's 4,000 trucker employees and eet of more than 3,000 owned or contracted trucks move 4 million metric tons of goods annually. e company's annual turnover is Rs 1,000 crores (US$220 million). Why do something about HIV and AIDS? Studies show that long-distance truckers are at high risk for HIV and other sexually transmitted infections. Among India's 5­6 million truckers, nearly half work on long-distance routes across the country. Approximately 300,000 long-distance truckers in India are living with HIV. HIV and AIDS interventions for truckers in India have been under state government programs, which lack oversight by a national program. Moreover, most government HIV and AIDS interventions We have begun this program because we have lacked strategic locations feel morally responsible for an important stakeholder: the trucker community. Our and adequate health services efforts will continue to address the HIV for this high-risk population. and AIDS epidemic. To address this prob- --D. P. Agarwal, Vice Chairman and lem, the Bill & Melinda Gates Managing Director, TCI Foundation launched the Ava- han India AIDS Initiative, a large-scale HIV prevention program, in December 2003. is program focuses on the needs of several target groups: sex workers and their cli- ents, men who have sex with men, long-distance truckers, and injecting drug users. 36 Case Study: Transport Corporation of India Asked by Avahan to participate in the program, TCI agreed, consid- ering this an opportunity to reach out to one of its key stakeholders, the Indian trucking community. The program TCI's HIV program centers on Project Kavach. Launched in December 2003 and operated by TCI's social arm, the TCI Foundation, this ve- year project is targeted to around 1.4 million long-distance truckers in nine states (about 30 percent of the country's trucking population and 60 percent of its long-distance truckers).11 e project is implemented through a chain of Khushi clinics at 17 high-volume transshipment hubs where truckers halt for at least 12 hours. Located along the Golden Quadrilateral--the 5,846-kilometer network of highways connecting Delhi, Kolkata, Chennai, and Mum- bai--these clinics each serve an in ow of 100 truckers a day on average. e clinics also serve the local community, including workers employed at the halt points. e program also uses some nontraditional outlets, such as tea shops, tobacco outlets, and roadside cafes and eateries, to distribute condoms. While interacting with truckers, shopkeepers at these outlets provide back- ground information about HIV and AIDS and the dangers of not using condoms. e program enlists the services of truckers for peer education too. Both the shopkeepers and the truckers involved in peer education-- referred to as secondary peer educators--o er their services voluntarily. 11. Initially the program targeted truckers through services at truck stops and halt points in 15 states. But in 2006 a strategic redesign narrowed the focus to an improved pack- age of services delivered at high-volume truck stops where truckers spend signi cant time--transport hubs that link almost all major national highways in India. Clinics at halt points with smaller in ows of truckers were closed. Case Study: Transport Corporation of India 37 Interventions for truckers Project Kavach has four main components: · Clinical management of sexually transmitted infections and re- lated counseling. · Behavior change communication. · Condom promotion and social marketing. · Community mobilization. Because management of sexually transmitted infections is consid- ered an important factor in stemming the spread of HIV, STI treatment and counseling have been a vital part of Project Kavach. To provide such services, the clinics are sta ed by 80 quali ed doctors, nurses, and coun- selors (picture 1). Other project e orts are designed around truckers' activities. Dur- ing their halts truckers receive orders and payments, service their ve- hicles, and transact business with contractors and brokers (agents who book vehicles). e project uses the spare time that truckers have le to share information and educate them on such topics as the risks of unpro- tected sex and the advantages of using condoms. e Khushi clinics are also equipped to treat general ailments, since trucking hubs, located along stretches of highway outside cities, lack basic medical facilities. Position- ing Khushi clinics as general health and STI treatment centers has the added advantage of reducing any hes- itance truckers may feel about enter- ing a clinic. Picture 1. Medical officer at a Khushi clinic 38 Case Study: Transport Corporation of India Other features of the project are also designed to t the circumstanc- es of truckers, including their mobility. Innovations for medical tracking A trucker making a rst visit to a clinic is issued a "Khushi passport," a diary recording details of the trucker's medical history and the diagnosis and any medication given during that visit. e trucker is expected to bring this diary each time he visits a clinic. e diary also contains the addresses of all 17 Khushi clinics in India to encourage the trucker to use their services when traveling in the area where they are located. Each trucker visiting a clinic also has a unique identi cation number, which helps clinic sta track his medical records in their database. is central database is maintained by the TCI Foundation's national project management unit in Gurgaon, Delhi, which collects the data from each Khushi clinic. e management information system not only allows ac- cess to medical records, it also supports analysis providing useful insights into the prevalence of HIV and other sexually transmitted infections and helps in the annual monitoring and evaluation of the program. Treatment and services Each Khushi clinic follows comprehensive clinical operating procedures that were designed by Family Health International and the WHO, based on Indian clinical guidance where available. While registration and consultation at the clinics are free, truckers are required to pay for medicines (priced at cost) to encourage them to take the treatment more seriously. During the consultation each trucker is also counseled on basic facts about sexual health and safety. Case Study: Transport Corporation of India 39 Khushi clinics do not have laboratory services, instead relying on their referral system for these. e project has established links with gov- ernment laboratories to provide syphilis testing (rapid plasma reagin and Venereal Disease Research Laboratory screening). Rapid HIV testing is conducted at only one project site, that in Neelamangala, Bangalore. Setup and operation of the clinics Setting up Khushi clinics involved a number of steps. e TCI Foundation rst had to research trucker long-halt points to identify strategic loca- tions for clinics. At the same time it also had to identify, for each site, a local NGO that had the capacity and willingness to be responsible for a Khushi clinic and carry out behavior change communication. In addi- tion, the foundation had to seek permission from the local State AIDS Control Society to operate in the area. is step was important so as to avoid duplicating interventions, since several halt points have more than one NGO operating through various targeted HIV and AIDS programs. Operation of each clinic has been contracted to an NGO with re- sponsibility for running the clinic, disseminating information, provid- ing referrals, and the like (table 2). e clinic sta , comprising outreach workers, doctors, and nurses, are all full-time employees of these NGOs. e TCI Foundation provides the NGOs the funds to run the clinics. With its national team of 33 professionals, the foundation supervises the work of the NGOs to ensure that they are complying with the minimum standards set for all NGOs participating in the program for truckers. In addition to a static Khushi clinic that serves as the hub of project activities at each halt point, there are tents, mobile vans, and clinics in the premises of brokers and local transporters (picture 2). ese satellites were established because a transshipment hub or halt point covers a large area and cannot reach all truckers. 40 Case Study: Transport Corporation of India Table 2. Khushi clinics in India Region and clinic NH NGO operating the clinic State Bangalore Neelamangala DTT 4 Bhoruka Charitable Trust Karnataka Hyderabad Autonagar 7 & 8 Bhoruka Charitable Trust Andhra Pradesh Icchapuram 5 BPWT Andhra Pradesh Hubli-Dharwad 4 Bhoruka Charitable Trust Karnataka Jamsola 6 Bhoruka Charitable Trust Orissa Delhi Delhi SGTN 1 Child Survival India Delhi Delhi UP Border 2 CEVA Uttar Pradesh Kanpur 2 Nirman Seva Sanstha Uttar Pradesh Jaipur VIA with JK satellite at intersection 8 VATSALYA Rajasthan at Transport Nagar Agra 2 CREATE Uttar Pradesh Varanasi 2 Jankalyan Maha Samiti Uttar Pradesh Nagpur Mumbai Kalamboli 4 Bombay Leprosy Project Maharashtra Indore 3 Bhartiya Gramin Mahila Sangh Madhya Pradesh Pune Nigdi 4 Seva Dham Trust Maharashtra Nagpur Pardi with satellite at Wadi 6 Indian Institute of Youth Welfare Maharashtra Jamshedpur 33 TSRDS Jharkand Dhanbad 2 & 23 Gram Pradyogik Vikas Sanstha Jharkand Note: NH is national highway number. Source: TCI Foundation. Interventions for the community Besides providing services to truckers, the NGO sta at each site also reaches out to the community and educates the local populace about HIV and AIDS. ese activities have been particularly helpful in addressing the social stigma and discrimination associated with HIV and AIDS. e development of interpersonal relations tools customized for the di erent target groups has helped in making these awareness activities e ective. Case Study: Transport Corporation of India 41 Picture 2. Activity aimed at generating HIV and AIDS awareness among long-distance truckers Internal workplace program A er launching Project Kavach, TCI began to develop its own workplace policy on HIV and AIDS, with support from the ILO, Delhi. In 2004 the company initiated an HIV program for its workplace. It has begun to cre- ate a cadre of peer educators who will share HIV and AIDS information with their colleagues at the workplace and distribute information, educa- tion, and communication materials. e company would like to eventu- ally reach out to all 4,000 employees. In addition to its awareness program, the company is funding the cost of antiretroviral therapy for two to three employees. 42 Case Study: Transport Corporation of India Partnerships Project Kavach depends on a range of partnerships. e program draws expertise not only from the partner NGOs operating the clinics but also from other Avahan partners: Program for Appropriate Technology in Health (PATH) for e ective communication campaigns, Population Services International (PSI) for social marketing of condoms, Family Health International (FHI) for medical training, and CARE for com- munity involvement ( gure 3). Each of these provides their services in the transshipment hubs serving the trucking population. e TCI Foundation provides infrastructure such as o ce space and equipment Figure 3. The Kavach model Avahan, Bill & Melinda Gates Foundation Financial, strategic, and technical support Technical partners Implementing partner (FHI, PSI, PATH, CARE) NGOs at all clinic locations Technical support for each Implementation support for of the program components field activities of the project Behavior Clinical Condom Community change management promotion mobilization communication of STIs Case Study: Transport Corporation of India 43 through its regional o ces (Pune and Bangalore). And Avahan provides funding for medicines and for sta salaries (for the TCI Foundation and partners). As noted, the TCI Foundation supervises the work of the partner NGOs to ensure quality of implementation and e ciency of service. e foundation's sta is also responsible for networking and coordinating the program with the other Avahan partners. e project has worked to build the capacity of the NGOs through training programs to ensure that these organizations can continue the ght against HIV and AIDS even a er the project ends. To further decen- tralize the program, steering committees made up of local brokers, truck owners, and truckers are being set up to form important nodal points for projects in the local communities. Funding Avahan of the Bill & Melinda Gates Foundation is providing US$8 mil- lion for the ve-year program. e TCI Foundation is exploring a strat- egy for ensuring that the program can be self-sustaining a er 2008. Outreach e project's outreach--through communication, condom marketing, and treatment--involves impressive numbers. Consider the achieve- ments of the project's team of 197 outreach workers and 942 secondary peer educators: · On average the team has made 63,000 e ective contacts monthly through one-on-one and group discussions. 44 Case Study: Transport Corporation of India · By March 2006 the team had made more than one million con- tacts with truckers alone. e project's condom marketing e orts have been extensive: · e project has set up 979 nontraditional condom outlets nation- wide. · Between January 2005 and March 2006 outreach workers, con- dom outlets, clinics, and peer educators distributed 706,250 con- doms. e record of treatment provided by clinics is similarly impressive. Between January 2005 and March 2006: · Clinics provided treatment of sexually transmitted infections for 4,000 people a month on average, and for a total of 42,906 people. Of these, 35,059 (82 percent) were truckers. e rest were local shopkeepers, mechanics, vendors, and others in the local population. · Clinics provided treatment of general ailments for 9,000 people a month on average, and for a total of 92,053. Of these, 64,488 (70 percent) were truckers. Lessons learned e TCI Foundation monitors Project Kavach by periodically meeting with its partner NGOs to discuss the progress of their interventions and areas of possible improvement. is regular monitoring, considered one of the strengths of the program, has identi ed useful lessons. Case Study: Transport Corporation of India 45 Key success factors · Wide network of implementing partners. e TCI Foundation's success in implementing the HIV program on such a large scale is due largely to the network of NGOs that form the backbone of the project. Besides outreach, this network provides the program with technical support and local knowledge. · Location of clinics. e location of the clinics along highways not only helps ll the gap in medical services for truckers, it also leads to a big in ow of patients, which has helped the program acquire a national reputation. · Diverse expertise from other Avahan partners. Project Kavach has been able to take a holistic approach to delivering services because it can draw on the diverse expertise of other Avahan partners. Key challenges · Sensitizing other industry stakeholders. TCI has been seeking partnerships with other companies that also interact with the trucking industry on a large scale, including oil and gas com- panies with gas stations along the highways. But it has found that many companies have not yet realized the enormity of the HIV and AIDS problem, its repercussions, and the high cost of inaction. e company is therefore conducting advocacy e orts through industry bodies and with individual companies to sen- sitize businesses to the issue. · Behavioral change. Truckers repeatedly exposed to the same in- formation experience message fatigue. In addition, repeated in- terventions targeted at the trucking community have resulted in negative branding, stigmatizing truckers as people who practice 46 Case Study: Transport Corporation of India unsafe sexual behavior. e program is therefore devising new forms of communication to increase its acceptability to the truck- ing community. One innovation, Magnet eater, involves truck- ers themselves as the protagonists in theater performances. In ad- dition, the TCI Foundation has found that e orts to change be- havior may not be entirely successful unless they simultaneously address such factors as harsh working conditions and exposure to a high-risk environment. Other lessons learned · Payment as a way to create ownership. A key lesson from the pro- gram is that when truckers pay for their medication, they devel- op a sense of ownership for the entire treatment process and take their treatment more seriously. · Importance of easy access to services. e TCI Foundation observed that truckers rarely leave their halt points to go into the city to use medical facilities. Khushi clinics, located at trucker halt points, have been successful because they provide easy access. · Myths about HIV and AIDS. Many myths and misconceptions about the spread of HIV persist, leading to unsafe behavior among truckers. For example, many truckers practiced unsafe sex with their male cotravelers because they believed that HIV does not spread through sex with men. e program has therefore focused on addressing misconceptions through its information, educa- tion, and communication material and sessions. Case Study: Transport Corporation of India 47 Future plans e TCI Foundation is exploring several plans and ideas for making Project Kavach more e ective: · Strengthening links with testing and treatment facilities around each clinic so as to develop a strong referral network. · Enabling each Khushi clinic to undertake HIV testing. · Building a mechanism to track truckers' movements. e project now has no way of ensuring that truckers needing further treat- ment would return to a clinic (and truckers o en lose their Khushi passports). · Documenting the lessons and achievements of the program to help in developing a future strategy. As part of the e orts to make the project more e ective, it will be important for the TCI Foundation to evaluate the project's impact and the cost and e ectiveness of its interventions. Case Study: Delhi Metro Rail Corporation Limited Overview Building the metro rail system in Delhi has been a massive construction project drawing workers from across India.12 Migrant workers typically are especially at risk for HIV, as a study focusing on the project's workforce con rmed. To help reduce the risk of HIV among this population, Delhi Metro Rail Corporation (DMRC), the public sector company responsible for constructing, operating, and maintaining the metro rail system, initi- ated an HIV and AIDS program targeted to the laborers working on one of the metro lines. e program focused mainly on increasing HIV and AIDS aware- ness and promoting the use of condoms. Lacking the technical capacity to carry out the program, DMRC contracted with an NGO, Modicare Foundation, to do so. e program, originally planned to run from Janu- ary through June 2005, was extended through September 2005 and cov- ered more than 3,000 workers. 12. e information in the DMRC case study is based on responses by DMRC and Modicare Foundation to questions sent to them by email; personal interviews and interactions with the DMRC o cial responsible for implementing the program and with Modicare Foundation o cials; and a project report by Modicare Foundation (2006). e informa- tion is current as of September 2006. 49 50 Case Study: Delhi Metro Rail Corporation DMRC has used its in uence over contractors to further its goals in combating HIV and AIDS: the contracts it signs with these companies now require that they carry out HIV prevention and control activities for employees working on DMRC projects. DMRC has developed an HIV and AIDS policy to guide contractors in implementing these programs. Business background DMRC was formed in May 1995 by the national and Delhi state govern- ments to provide a rail-based transport system that will alleviate Delhi's ever growing transport congestion and vehicular pollution. e govern- ment of Japan has contributed more than half the cost of this project, through a so loan disbursed by DMRC's major funding agency, the Japan Bank for International Cooperation (JBIC). Delhi's metro rail system, to be constructed in four phases covering 245 kilometers, is scheduled to be nished in 2021. Today three function- ing lines connect central Delhi to east, north, and southwest Delhi. DMRC is responsible not only for construction of the system but also for its operation and maintenance. It has 450 personnel in its con- struction department and 3,000 sta for system operation and mainte- nance. Supply chain partners provide critical support, including labor, machinery and components, and maintenance services. Why do something about HIV and AIDS? e impetus for DMRC's HIV and AIDS program came from a study commissioned by JBIC in accordance with its guidelines for approving loans and investments.13 Conducted by the Voluntary Health Association 13. In approving loans and investments, JBIC is required by its guidelines to examine such issues as impact on indigenous peoples and their heritage, gender issues, children's Case Study: Delhi Metro Rail Corporation 51 of India, the study assessed the vulnerability to HIV of the workforce on one line of phase 1 of the Delhi Metro project (VHAI 2003). e study produced disturbing ndings: · In the sample of 1,000 workers surveyed, 59.3 percent had little or no knowledge about HIV and AIDS. · Around 86.4 percent had little or no knowledge about how HIV is transmitted. · e practice of using condoms to prevent transmission of HIV was unknown. · Around 80­90 percent of the workers had a negative attitude to- ward people living with HIV and AIDS. · Respondents reported visits to sex workers. e study highlighted the predominance of migrant workers in the workforce on the Delhi Metro project and the vulnerability of this popu- lation to HIV. According to a project document (Modicare Foundation 2006), around 15,000 workers have participated in the Delhi Metro proj- ect, a substantial number of them migrant workers from other Indian states--Bihar, Chhattisgarh, Madhya Pradesh, Orissa, Rajasthan, and West Bengal. ese migrant workers face conditions that can encourage high-risk sexual behavior: separation from family, alienation from socio- cultural norms, loneliness, and a sense of anonymity that o ers greater sexual freedom. In addition, the workers are uneducated, live in unhy- gienic, o en crowded quarters, and are unaware of safe health practices. All these factors increase their vulnerability to communicable diseases such as tuberculosis and also to HIV. Based on this study, DMRC decided to initiate an HIV and AIDS program and fund it entirely through its own resources. JBIC helped in rights, and HIV and AIDS. JBIC also actively encourages the mitigation of adverse so- cial impacts and promotes social participation for certain projects. See JBIC (2005). 52 Case Study: Delhi Metro Rail Corporation Our program is a proactive step to creating a strategy for the pro- safeguard our workers and also uphold gram through appropriately de- our social responsibility as corporate citizens. ned objectives, action plans, --C. B. K. Rao, Director, and time frame. Delhi Metro Rail Corporation The program e program initiated by DMRC was aimed at preventing HIV by pro- moting awareness and improved sexual behavior, attitudes, and practices among migrant workers on the Delhi Metro project. Recognizing that it lacked the technical capacity to implement the program, DMRC used a bidding process to recruit the services of an organization with the techni- cal expertise needed. is led to the selection of Modicare Foundation, a well-respected NGO with experience in carrying out HIV and AIDS programs, as the implementing partner. To extend program activities to future DMRC projects, the company developed an HIV and AIDS policy with expectations for contractors en- gaged in those projects (box 1). Awareness and prevention activities at the workplace e program's target group initially was around 2,000 migrant workers who were employed by DMRC's contractors on the site for phase 1, spe- ci cally those working on line 3 from central to southwest Delhi. But when DMRC extended the program by three months, through September 2005, it expanded the target group by 1,000. Modicare pro led the target group as follows: Case Study: Delhi Metro Rail Corporation 53 Box 1. An HIV and AIDS workplace policy to guide future programs To provide clear guidelines for HIV and AIDS programs implemented in future projects, DMRC developed the "Workplace Policy on HIV/AIDS Prevention & Control for Workmen Engaged by Contractors," based on the International Labour Organization's code of practice on HIV and AIDS. The policy expects DMRC contractors: · To create awareness about HIV and AIDS among their workers. · To build institutional capacity for HIV and AIDS programs through training. · To establish links for diagnosis and treatment of affected workers; for monitoring, implementation, and documentation of program activities; for peer education; and for social marketing of condoms. DMRC established this policy only after soliciting inputs from its contractors and checking with them on the policy's feasibility. The company also took into account its own experience in implementing projects. The process was facilitated by Modicare Foundation. DMRC has incorporated the policy into the contract it signs with its contractors and suppliers. The agreement also expects contractors to extend organizational support to the HIV and AIDS program and identify peer educators. When peer educators who have been trained as part of the program leave a contractor's employment, the contractor has to identify and train a replacement. · e age group of the workers was 20­45. · Two-thirds were married men, living away from their families. · e workers lived in makeshi rooms at the construction sites or in rented accommodations in nearby slums. · Even small rooms were usually shared by 10­15 people. e program had four main components aimed at HIV and AIDS awareness and prevention: 54 Case Study: Delhi Metro Rail Corporation · Advocacy. · Institutional capacity building. · Peer education. · Condom promotion. Advocacy e advocacy e orts began by developing information, education, and communication material suited to the program. is included posters, pamphlets, calendars with messages on HIV and AIDS, and lists of STI clinics, voluntary counseling and testing centers, and outlets distributing condoms. Some posters were developed by Modicare Foundation; others were brought in from the National AIDS Control Organization and other sources (picture 3). In addition, activities sought to generate awareness among workers in the target group using the behavior change communication model. Modicare developed modules for its facilitators to use in sharing infor- mation on HIV and AIDS within groups of 15­20 workers. Institutional capacity building To help ensure e ective implementation, the program set up a techni- cal advisory committee--formed of representatives from DMRC, JBIC, the ILO, and Modicare--to provide technical support and to monitor the program. It also held an orientation session for DMRC safety managers, safety o cers, and engineers and for project managers of construction companies working for DMRC. is was intended to sensitize them to issues relating to HIV and AIDS as well as to ensure their participation and cooperation in future program activities. Case Study: Delhi Metro Rail Corporation 55 Picture 3. A display of posters with information on HIV and AIDS To help overcome the lack of its own medical facilities, the program worked to develop links with STI clinics and voluntary counseling and testing centers--critical for a successful HIV prevention program. e program succeeded in establishing links with 13 government hospitals close to Delhi Metro project sites where it could encourage the target group to obtain treatment and counseling. Peer education e program used peer education to encourage the ow of information on HIV and AIDS and related issues from informed workers to their col- leagues. Informal communication has been found to create greater ac- ceptance of information than more formal ways of communication. e 56 Case Study: Delhi Metro Rail Corporation use of peer education was also aimed at creating a nondis- criminatory and nonstigmatiz- ing environment. e program identi ed peer educators on the basis of their literacy, sensitivity, lead- ership qualities, communica- tion skills, and popularity with Picture 4. Explaining sexually transmitted infections using pictorial flashcards colleagues. Modicare carried out an intensive training pro- gram for peer educators to en- sure that they were su ciently knowledgeable about HIV transmission and prevention and equipped to address issues related to sexual health. It also gave each one a kit contain- ing material on HIV and other sexually transmitted infections Picture 5. A peer educator during a session at a and condoms for demonstra- construction site tion and distribution. Peer educators were asked to reach out to their colleagues through both one-on-one and group discussions, addressing queries about HIV and other sexually transmitted infections (picture 4), encouraging safe sexual behavior by promoting and distributing condoms, and distribut- ing information, education, and communication material. Peer educators also referred people to STI clinics and voluntary counseling and testing centers. Settings for peer education sessions included the construction site (picture 5). Case Study: Delhi Metro Rail Corporation 57 Condom promotion During one of my sessions a boy shared with me that he had been suffering from Promoting the correct and an STI and that he had had sex with an unknown woman a few months back. On consistent use of condoms as my advice he underwent [HIV] testing an essential factor in prevent- and was found to be negative. He took ing HIV and other sexually treatment for STI and is leading a normal life, free of infection now. transmitted infections was an important part of the program. --Mahesh Kumar, peer educator e program found that dis- tributing condoms was a major factor in increasing the demand for them and resulted in correct and habitual use by the members of the target group. Some 90 percent of the workers covered by Modicare, and 67 per- cent of those covered by the peer educators, accessed condoms. Project monitoring, reporting, and documentation e program put into place a systematic monitoring plan, under the technical advisory committee, to track implementation. Modicare Foundation used forms soliciting feedback from its facilitators to assess e ectiveness. Monthly reports consolidated information on activities conducted, including street plays and informal sessions by peer educa- tors. Peer educators and Modicare Foundation coordinators and facili- tators met regularly. Periodic meetings were also held between DMRC o cials, the technical advisory committee, and the project team leader from Modicare Foundation. 58 Case Study: Delhi Metro Rail Corporation Funding e program budget was close to Rs 6.5 lakhs (US$14,500), funded en- tirely from DMRC's own resources. Outreach e program reached 3,270 workers, exceeding the target of 3,000 (table 3). In addition, nearly 3,000 workers obtained condoms from Modicare. Following up with workers contacted as part of the program proved di cult, since the workers changed jobs o en. But Modicare Foundation conducted follow-up discussions with 10 percent of the workers to assess their information recall a er their initial information session with a fa- cilitator, usually 10­15 days a er that session. Results of this follow-up, based on 308 questionnaires, showed that: · About half the workers questioned recalled three modes of HIV transmission, and more than a third recalled two ( gure 4). · Almost all the workers recalled use of a condom as a method for preventing transmission of HIV ( gure 5). Table 3. Outreach indicators for DMRC program, January­September 2005 Item Number Workers covered 3,270 Peer educators trained 47 Metro stations covered 29 Construction companies covered 13 Street plays and puppet shows arranged 48 Magic shows arranged 27 Condom demonstrations held 229 Persons obtaining condoms from Modicare Foundation 2,946 Source: Modicare Foundation, 2006. Case Study: Delhi Metro Rail Corporation 59 FigureFigure 4. Workers' recall of modes oftransmission in theinDMRC program 4. Workers' recall of modes of HIV HIV transmission the DMRC program 200 156 150 esponsesr 107 of 100 50 22 23 equency Fr 0 Recall of Recall of Recall of Recall of 1 mode 2 modes 3 modes 4 modes Source: Modicare Foundation 2006. Figure 5. Workers' recall of methods of preventing HIV transmission in the DMRC program 350 300 method 250 200 ecallingr 150 100 50 orkers W 0 Condom HIV-free Disposable Faithfulness use blood syringe to partner Source: Modicare Foundation 2006. Even more important, the sessions led to changes in behavior among the workers: · Some 25 percent (78 out of 308) reported using condoms a er sessions. · Referrals and visits to HIV and STI clinics increased. · Some peer educators reported changing their own formerly high- risk behavior and attitudes a er being sensitized by peer educator training. 60 Case Study: Delhi Metro Rail Corporation e feedback from program participants has been positive. e workers have expressed a desire for the program to be continued, and the peer educators continue to counsel their colleagues even though the program has ended. Lessons learned e program identi ed several success factors, challenges, and other les- sons based on its results. Key success factors · Partnership of multiple stakeholders. A key factor in the program's success was its access to diverse expertise through a partnership of multiple stakeholders--with Modicare Foundation as the im- plementing partner, the International Labour Organization as the technical adviser, and the Japan Bank for International Coopera- tion as a strategy adviser. · Peer education. Involving peer educators helped both expand out- reach and establish contact with sex workers, who were persuaded to keep condoms for clients. Around 20 percent of the peer educa- tors are still active and have been in regular touch with Modicare Foundation. · Cooperation from contractors. e special e ort made to sensitize the contractors to the issues was key in gaining their support for the program. Contractors even gave their workers time o to par- ticipate in the meetings on issues relating to HIV and AIDS. · Informal outreach to workers. Using informal means to reach out to migrant workers--such as meeting them on their home ground Case Study: Delhi Metro Rail Corporation 61 or using their dialect when conversing with them--made the workers feel comfortable and helped immensely in achieving the targets. Key challenges · Poor access to health services. With government medical and test- ing facilities unavailable on weekends, laborers o en ended up go- ing to fake doctors. Good health services, including mobile health facilities, need to be made more accessible to the workers. · Mobility of workers. e high mobility of workers made it di cult for Modicare Foundation to follow up with the target group a er the initial information session. Even so, the agency achieved a fol- low-up rate of 10 percent. e high mobility also created a chal- lenge for peer education: trained peer educators could leave their jobs, and training replacements was costly. To help strengthen and stabilize the peer education system, DMRC has incorporated a clause into its agreement with contractors and suppliers requir- ing that they identify a peer educator likely to stay for a long time. If a peer educator leaves a contractor, the contractor has to get a replacement trained at its own cost. · Access to condoms. e unpredictability of workers' job loca- tions made getting condoms to the workers a challenge. Modi- care Foundation suggests that DMRC could work with Hindu- stan Latex Limited (an Indian government enterprise) or another manufacturer of condoms to provide condom vending machines at selected sites. ese machines could be kept under the custody of the contractor in charge of the construction site. Alternatively, DMRC could rely on peer educators and nontraditional outlets such as tea and cigarette vendors to distribute condoms. 62 Case Study: Delhi Metro Rail Corporation Other lessons learned · Importance of links with health services. DMRC found that creat- ing links with existing health services is important: it enables the target group to gain access to services not provided by the pro- gram and also avoids duplicating services. · Programs for all cadres of employees. Modicare Foundation be- lieves that HIV and AIDS programs should cover all cadres of employees, not just contract workers. Awareness among senior employees will ensure that they appreciate the need for such pro- grams, support activities, encourage peer educators, and help create a nonthreatening environment for dealing with HIV and AIDS. And greater awareness among all workers will reduce the stigma associated with HIV and AIDS. · Importance of monitoring and evaluation. e program's moni- toring system was an important feature, allowing the company to track progress in implementation and assess the program's ef- fectiveness. Future plans DMRC plans to implement a similar program in the next phase of the Delhi Metro construction, identifying a new implementing partner for this program. e company's HIV and AIDS policy for contract workers, to be implemented in this next phase of construction, is further evidence that DMRC has taken the risks posed by HIV and AIDS to this popula- tion seriously. Case Study: DCM Shriram Consolidated Limited Overview DCM Shriram Consolidated Limited (DSCL), a company with interests mainly in chemicals and agribusiness, operates in western and northern India.14 e western state of Rajasthan is home to the company's main manufacturing plant, in Kota, which has also been the site of its HIV and AIDS program. e program is uniquely local, drawing on local culture and adapting information, education, and communication material to appeal to local sensibilities. Committed to providing a safe and healthy working environment, the company holds regular group sessions to build HIV and AIDS aware- ness among its employees. DSCL's occupational health doctor speaks on the basics of HIV and AIDS awareness and prevention. But then follows a song or poem in the local dialect to convey messages more light-heart- edly. e company also uses cultural performances at festivals or other important events at the Kota plant to generate mass awareness. 14. e information in the DSCL case study is based on DSCL's response to a questionnaire sent to the company by email; personal interviews with the company's chief executive o cer and with the o cials responsible for implementing the program; and a site visit. e information is current as of September 2006. 63 64 Case Study: DCM Shriram Consolidated Limited Communicating messages in ways that t the local culture and local sensibilities has helped the program capture the attention of the target audience. It has also helped the program gain acceptance among the lo- cal population. Business background DSCL has diverse business interests ranging from agribusiness (sugar, fertilizers, agri-retail) to chemicals (chlorine, caustic soda), plastics (PVC resins, polymer compounds), and others (cement, textiles, energy ser- vices, real estate development). e corporate o ce is in New Delhi, and the main manufacturing plant in Kota, in the western state of Rajasthan. e Kota plant, the site of the company's HIV and AIDS interven- tion, houses manufacturing facilities for fertilizers, plastics, chlor alkali, and cement as well as a captive power plant. is site has 1,600 full-time employees, 1,500 daily contract workers, and 500 sta for security, man- ual labor, and the like. e company's annual sales are Rs 23 billion (around US$500 mil- lion). DSCL's main supply chain partners--public enterprises and small and medium-size suppliers--provide raw materials such as coal, salt, naphtha, and limestone. Why do something about HIV and AIDS? DSCL's decision to initiate an HIV and AIDS program was motivated largely by its belief that AIDS is a public health challenge that could a ect its workforce, its supply chain, its value chain partners, and the broader community. Looking at the experience of other countries, the company recognized that the business community, particularly in manufacturing, Case Study: DCM Shriram Consolidated Limited 65 Box 2. An HIV and AIDS policy shaped by many actors DSCL's policy on HIV and AIDS focuses on providing a safe and healthy work environment, educating employees, and ensuring confidentiality and nondiscrimination. Adapted from the policy statement circulated by the Confederation of Indian Industry, the policy was shaped through detailed discussions held at various levels of the organization, including with employees, trade unions, and management. needed to contribute to the ght against HIV and AIDS. us while no HIV-positive cases have yet been reported at the company's sites, advo- cacy e orts by industry associations in India convinced senior manage- ment that DSCL, as a responsible corporate citizen, needed to take part. e company has adopted an HIV and AIDS policy out of a belief that the policy could serve as a key driver in initiating intervention pro- grams (box 2). The program DSCL identi ed two potential target groups for its program: Its own steadily growing employee base, a large captive audience that could be informed about HIV and AIDS at the workplace and the large number of truckers who came to its factories (particularly in the sugar division, where many truckers o oaded sugarcane). At an initial meeting to allocate responsibility for the program, DSCL decided to assign the program to an o cial who volunteered his e orts. e human resources unit normally would have led the program. But the o cial's demonstrated eagerness to be involved in an HIV pro- gram made him a promising choice. e program began in January 2005 by gathering information about the issue, identifying resources such as organizations providing techni- 66 Case Study: DCM Shriram Consolidated Limited cal services, and developing information, education, and communication material. As many programs have done, DSCL's has created pamphlets containing information about HIV and AIDS, but much of its material shows unusual innovation. Cassettes intersperse HIV and AIDS mes- sages with popular Hindi lm songs. And songs are written in the local dialect to appeal to the diverse community working in the plant and liv- ing around it. Awareness and prevention activities at the workplace e company's awareness activities at the workplace center on group meetings where the occupational health team shares information about HIV and AIDS with DSCL employees. Sessions take place on the shop oor or near the factory entrance (picture 6). Meetings usually consist of a talk by the company's medical o cer, messages on HIV and AIDS conveyed through poems, songs, or jokes in the local dialect, and a quiz to see whether participants have grasped the information. Sessions end with distribution of free condoms. To encourage its contract employees to participate, the company sought the coopera- tion of the contractors in con- ducting the awareness sessions. Contract employees are more willing to spend time at these sessions if their employers are agreeable. Outside the meetings, the Picture 6. HIV and AIDS awareness session for DSCL occupational health team dis- employees in the urea bagging area seminates information about Case Study: DCM Shriram Consolidated Limited 67 HIV and AIDS to employees and workers through pam- phlets, posters, and billboards created in-house. Some posters call out to the target audience to join the ght against HIV and AIDS (picture 7). Others quote a powerful speech by Nelson Mandela portraying HIV and AIDS as everyone's responsibil- ity (picture 8). Awareness ma- terial is placed in prominent Picture 7. Theme poster enlisting people in the fight locations at the plant, such as against HIV and AIDS in the visitors' lobby and on the notice board. DSCL has made good use of the company's own resources incommunicatinginformation. For example, employees skilled in music, drama, writing, and poetry use their arts to convey messages about HIV and AIDS. Picture 8. Theme poster quoting a speech by Nelson One such employee, a talented Mandela singer and poet as well as a bril- liant orator in the local dialect, accompanies DSCL's chief medical o cer to awareness sessions. ese artists also convey messages during perfor- mances at interdepartmental cultural competitions, plant days, and other festive occasions. e company disseminates information in other innovative ways as well. Its visitors' passes now include HIV and AIDS messages (picture 9). Films, plays, and cultural performances impart HIV and AIDS awareness 68 Case Study: DCM Shriram Consolidated Limited Picture 9. DSCL visitor's pass with HIV and AIDS messages at public functions held to commemorate important company days or re- ligious festivals. Films are screened occasionally in the canteens while the workers gather to eat. Films on HIV and AIDS are also shown to o cers trained at the company's training institute. For more informal communication with employees about HIV and AIDS, DSCL relies on its welfare o cers. ese o cers, each responsible for the well-being of a certain number of employees, act as conduits be- tween management and workers and as support systems and con dants for employees and their families. eir deep engagement with employees makes them well placed to spread awareness about HIV and AIDS and to provide individual counseling. e medical doctors in the plant and trained polyclinic sta also provide counseling. DSCL does not have its own medical facilities for HIV and AIDS. But the city of Kota has a government-established blood testing and de- tection center. And DSCL's medical sta has received specialized train- Case Study: DCM Shriram Consolidated Limited 69 ing on HIV and AIDS, on such issues as primary care, visual diagnosis and management of opportunistic infections, lab diagnosis, and antiretrovi- ral therapy. e sta conducts regular medical checkups on employees and is trained to Picture 10. Awareness session for truckers at the notice symptomatic indicators entrance to the materials section of the Kota plant of HIV and AIDS. While DSCL reports having no HIV-positive employees, it can ar- range for antiretroviral therapy at the Kota government hospital. e company now covers the cost of treatment for some AIDS patients in the city of Kota even though they are not DSCL employees. Interventions for the community DSCL also conducts awareness sessions beyond the shop oor, for truck- ers who transport material to and from the company. e method is the same as that for employees: in a group session the company doctor shares information on HIV and AIDS, and then free condoms are distributed. e sessions for the truckers take place while their goods are being load- ed or unloaded (picture 10). DSCL has sometimes faced challenges in implementing its HIV and AIDS program while managing the varying expectations of the local community. But the company plans to reach out to the wider community through similar programs for local slum dwellers and drug addicts and through programs in commercial areas. 70 Case Study: DCM Shriram Consolidated Limited It has been a challenge for the company Partnerships to keep the community and our workers motivated to participate in the program. We have to deal with diverse demands e DSCL program has re- from the stakeholders and sometimes lied on partnerships from the their other needs are more pressing. But outset. In designing the initial we have nevertheless kept the program going. strategy, the o cial taking re- sponsibility for the program --K. K. Kaul, Executive Director, DSCL's Kota plant consulted with area organiza- tions that deal with HIV and AIDS, including industry asso- ciations and government entities. And those in the company who have implemented the program have o en bene ted from inputs from part- ners. ese partners include: · e Rajasthan State AIDS Control Society, the government orga- nization responsible for the state AIDS program in Rajasthan. · e Confederation of Indian Industry and its Social Development Council in the northern region. e council interacts with com- panies that are confederation members on issues of corporate so- cial responsibility. · e Energy and Resources Institute (TERI). Funding e program is funded entirely through internal resources of DSCL. Management allocates Rs 500,000 (around US$11,000) a year for the program through the annual budget. But if program needs exceed the allocated budget, management can approve additional support. Case Study: DCM Shriram Consolidated Limited 71 Outreach Mass awareness programs at the workplace and in the surrounding com- munity have covered about 75,000 people. ese include contract work- ers, truck drivers and their assistants, and citizens of the city of Kota who visit the company during local festivals. Lessons learned e program has identi ed key factors in its success as well as key chal- lenges and other lessons. Key success factors · Management commitment. e continued interest and involve- ment of senior management since the program's inception has been critical, providing the impetus and motivation for successful implementation. As noted, DSCL's HIV and AIDS intervention is nanced by the company and thus has a greater likelihood of sus- tainability than if it depended on external sources of funding. · Enthusiasm and innovativeness of the responsible o cial. e o - cial responsible for the program was no expert on HIV and AIDS. But he devised unique strategies for the program by combining information from more knowledgeable sources What gets monitored gets done. with his own knowledge of the local area. is --Ajay S. Shriram, Chairman and Senior Managing Director, DSCL innovative spirit led to 72 Case Study: DCM Shriram Consolidated Limited interesting ways of spreading information, such as songs, poems, stories, and street plays (nukkad nataks) in the local dialect. Key challenges · Stigma associated with HIV and AIDS in a conservative, semiur- ban area. DSCL confronted ignorance, inhibitions, and miscon- ceptions among the local population--and thus resistance to the HIV and AIDS program. e company's engagement with the local population to counter its fears and to persuade it that the program was in the interest of public health helped overcome the resistance. · Lack of infrastructure and potential partners. Key challenges have been the inadequate government HIV and AIDS facilities in the area (the local government hospital has only a voluntary counsel- ing and testing center, though sta ed by a doctor) and the di cul- ty in nding local NGOs to act as e ective project partners. e company overcame these obstacles by designing its own informa- tion, education, and communication material and relying on its own employees and occupational health team to spread awareness about HIV and AIDS. Other lessons learned · Sensitivity to local culture and local sensibilities. Using informa- tion, education, and communication material and dissemination mechanisms that suit local sensibilities helped the program gain acceptance among the local population. Case Study: DCM Shriram Consolidated Limited 73 · Use of existing internal resources. e program has bene ted from DSCL employees' skills and capabilities in creating information, education, and communication material. Relying on employees rather than an external agency to create awareness about HIV and AIDS has also helped build a greater sense of ownership for the program within the company. is approach o ers a good exam- ple of how to mainstream HIV and AIDS activities and might help in institutionalizing and sustaining the response over time. Future plans e company's future plans for its HIV and AIDS program, outlined in its initial strategy, cover several areas of e ort. e HIV prevention and detection plan calls for: · Conducting awareness programs in the city of Kota for school- children, the police, and high-risk groups such as drug users and local jail inmates. · Proactively distributing condoms. · Conducting blood testing campaigns to detect HIV. · Providing nancial assistance to those suspected of being HIV- positive but who cannot a ord the test to detect HIV. e AIDS treatment plan includes: · Providing antiretroviral drugs to those needing them. · Providing nancial assistance for nutritional enhancement for those undergoing treatment. 74 Case Study: DCM Shriram Consolidated Limited Finally, the rehabilitation plan covers several actions: · Creating a nondiscriminatory environment in the workplace con- sistent with the company's HIV and AIDS policy. · Transferring HIV-positive employees to positions involving less physical strain if that is important for their health. · Partnering with other organizations to help AIDS patients earn income to support themselves and undergo treatment. Case Study: Hindustan Lever Limited Overview Hindustan Lever Limited (HLL), a leader in the fast-moving consumer goods business, is among the top ve exporters in India.15 HLL's distribu- tion network, with more than 3,400 distributors and 16 million outlets, markets more than a thousand products manufactured in more than a hundred plants across India. e company's HIV and AIDS program, initiated in 2002, focuses on protecting the health of its skilled young workforce. Its factories have HIV and AIDS awareness initiatives built into their health and safety training. e program also extends beyond the workplace, spreading aware- ness about HIV and AIDS through two vehicles: Project Sanjivini, which provides medical care to the poor in remote villages of eastern India, and Project Shakti, which focuses on microcredit, training, and empower- ment of women. Here HLL makes good use of its expertise in distribu- 15. e information in the HLL case study is based on HLL's response to a questionnaire sent to the company by email; a personal interview with the company's vice president for medical and occupational health at Mumbai; telephone conversations with the medical o cers of the company's northern and southern regions; and HLL's 2005 annual report (HLL 2006). is information is current as of September 2006. 75 76 Case Study: Hindustan Lever Limited tion and management to work with rural entrepreneurs in spreading awareness. Business background HLL is a multinational company 51 percent owned by the Anglo- Dutch company Unilever. Its product portfolio features household and personal care products--including such leading household brands in India as Surf--as well as foods and beverages. e company distrib- utes nearly a thousand products through its network of 4 warehouses, more than 40 agents, 7,500 wholesalers, and many large institutional customers. It also sources raw materials, intermediates, and packaging materials from more than 2,000 suppliers. Net sales in 2005 totaled US$2.2 billion. Since the 1980s HLL has directed most of its investments to des- ignated backward areas and zero-industry districts, helping to revive several sick industries and develop local entrepreneurship. e com- pany also focuses on a range of community support activities, including water management, empowerment of women, and health and hygiene education. Why do something about HIV and AIDS? As a subsidiary of Unilever, HLL is committed to providing a safe and healthy working environment for all employees in accordance with both Unilever standards on occupational health and national and internation- al public health regulations and requirements relating to HIV and AIDS. is commitment is re ected in the company's HIV and AIDS policy (box 3). Case Study: Hindustan Lever Limited 77 Box 3. The HIV and AIDS policy of HLL In 2004 HLL formulated an HIV and AIDS policy that assures employees of a nondiscriminatory work environment and assistance in seeking appropriate treatment that is currently available. The overarching goal is to protect employees' health. The policy was drafted by HLL's Occupational Health Division under the Unilever HIV and AIDS guidelines and communicated to all employees as well as to supply chain partners, including suppliers and distributors. Further impetus to strengthen HIV and AIDS awareness programs across all units came from the company's belief that the epidemic poses formidable challenges to development and social progress in India. e primary goals of HLL's program are to reduce absenteeism and health costs and increase productivity and life expectancy. The program HLLlauncheditsHIVandAIDSinitiativein2002intheunitsinitssouth- ern region. In 2004 it extended the initiative to its eastern and To succeed requires the highest western regions, and in early standards of corporate behavior toward our employees, consumers, and the 2005 to its northern region. societies and the world in which we live. e basic approach in all As a part of this corporate behavior HLL is HLL units includes reaching strongly committed to ensure appropriate workplace prevention and control of HIV out to all employees and busi- and AIDS, and we will share this expertise ness partners through HIV and across the supply chain and communities among which we operate. AIDS awareness programs and educating people living with --Douglas Baillie, Chief Executive Officer HIV. But to ensure commit- HLL, India and Group Vice President, South Asia, Unilever. ment from those implementing 78 Case Study: Hindustan Lever Limited the program, the company allows each unit to improve or modify the program according to local needs. In areas with a high national prevalence of HIV, such as those in the western and southern states, HLL units support comprehensive work- place programs that cover nondiscrimination, prevention education, ac- cess to counseling and testing, and care, support, and treatment. Units in areas less a ected by the epidemic support community initiatives in HIV and AIDS education and awareness along with other health issues. Some HLL units have established voluntary blood testing for HIV antibodies. Many units distribute free condoms at strategic locations. e HIV and AIDS program is spearheaded by HLL's occupation- al health team and Human Resources Department and implemented through its unit medical o cers. All HLL units have occupational health centers with basic health facilities to treat patients with support from government-designated medical institutions. HLL also makes continual e orts to build the skills of medical sta in di erent units. In collaboration with the Confederation of Indian In- dustry and the ILO, it has provided training for company physicians on issues relating to HIV and AIDS. In addition, the Confederation of In- dian Industry and the National AIDS Control Organization conducted a "train the trainers" workshop for the medical sta . is workshop includ- ed discussions on the development and progression of HIV infection, dis- ease monitoring including clinical criteria based on WHO speci cations, and the latest diagnostic techniques. e company's medical sta has also received training in antiretroviral therapy and drug administration. To ensure the success of the program at the unit level, each HLL unit integrates shop oor employees and managers into the core team, made up of the unit head, human resource personnel, shop oor manager, and a workforce representative. is core team is sensitized to HIV and AIDS issues at the beginning of the unit's program. e team participates in the Case Study: Hindustan Lever Limited 79 quarterly review of the program undertaken in each unit, meeting with other partners if needed. Awareness and prevention activities at the workplace Southern and western regions HLL's workplace program in the southern and western re- gions consists of group aware- ness programs, training of peer educators, and sensitization of general employees. Units con- duct programs in both English and local languages in collabo- ration with district health au- Picture 11. Session being conducted at the Mangalore unit by the doctor who is the officer in thorities, local AIDS cells (gov- charge of the local voluntary counseling and testing center ernment bodies responsible for HIV prevention and control ac- tivities), and voluntary organizations (picture 11). e units also conduct awareness programs for truckers and contract workers through posters, audiovisual sessions, mass education activities, information booklets in regional languages, and interactions with neighboring industries. Since HLL's southern region has had a few reported cases of HIV infection, the company introduced voluntary blood testing in 25 units in the region. Managers lead the way in the testing to set an example for others (pictures 12 and 13). While the company keeps an aggregate record of these blood tests at the unit level, it maintains a high level of con dentiality for individual employees and contract workers. 80 Case Study: Hindustan Lever Limited e company allows paid leave for employees requiring medical attention for HIV or AIDS. More important, it also provides support and counsel- ing to their family during the treatment period. Picture 12. Mangalore factory manager A.T. Krishnan Northern region giving a blood sample for an HIV test HLL's northern region, whose eight units together are the largest supplier of HLL prod- ucts across India, received sup- port from the ILO for its HIV and AIDS initiative. e pro- gram informed top manage- ment about the HIV situation in India and educated employ- ees about how to reduce risky Picture 13. Employees queuing up to give blood samples for HIV testing at the Mangalore factory behavior and contribute to a discrimination free work envi- ronment. In addition, an initial sensitization session with the ILO briefed all unit heads and human resource managers on how to implement an HIV and AIDS program. e northern region also sought ILO's technical assistance to reach out to other companies within the group and to supply chain partners. HLL has signed a memorandum of understanding with the ILO on the plan for implementing the HIV and AIDS awareness program. And NGOs trained by the ILO are conducting a knowledge, attitude, beliefs, Case Study: Hindustan Lever Limited 81 and practices (KABP) survey in all northern regional units under a time- bound action plan. Interventions for the community In the southern region HLL implements focused awareness programs and promotes and distributes condoms among high-risk groups in the community. At the Tea Estate Division in Valparai, Tamil Nadu, for ex- ample, the company initiated a voluntary screening program for HIV and conducts special HIV and AIDS awareness programs for high-risk groups. e program also includes screening for all pregnant women at the end of their second trimester and in routine surgical cases among company employees. e eastern region, in Assam, reports having had no cases of HIV. But units in the region hold training classes on HIV and AIDS awareness and also provide general medical care. e HLL factory in Doom Doo- ma, Assam, has formed local partnerships to provide basic medical ser- vices in remote villages that lack access to modern health facilities. is is done through an HLL-funded medical project, Sanjivini, through which the company supplied two am- bulances. e project holds Sanjivini camps, where the vans visit remote villages and provide basic medical services (picture 14). is project aims to reach out to 70,000 people in remote villages. e project also conducts a range of health awareness programs in associa- tion with local district authori- Picture 14. A Sanjivini camp in progress 82 Case Study: Hindustan Lever Limited Box 4. Reaching rural villages through Project Shakti In 2001 HLL initiated Project Shakti in Nalgonda district, Andhra Pradesh, to provide microcredit and to train women to become direct-to-home distributors through self-help groups in rural areas. As an extension of this project, HLL set up Internet kiosks--commonly referred to as "iShakti"--in these rural areas to disseminate information in local languages, including material on health education. Today Project Shakti has spread to 15 Indian states, reaching 85,000 villages in 385 districts through 20,000 female entrepreneurs, or "Shakti ammas." The distribution network formed by these female entrepreneurs could in the future distribute condoms in rural areas. HLL estimates that by 2010 the network will grow to around 100,000 trained women covering 50,000 villages. ties. e company hopes to use Sanjivini to spread knowledge about HIV and AIDS to these remote communities. Another HLL-funded initiative, Project Shakti, distributes health in- formation in rural areas. And it holds promise for playing a far larger role in the future (box 4). Partnerships Each HLL unit relies on partnerships to implement the company's HIV and AIDS and health programs. Partners include: · Medical college hospitals, for clinical expertise. · e Confederation of Indian Industry, the ILO, and the National AIDS Control Organization, for training support. · Community opinion leaders. Case Study: Hindustan Lever Limited 83 · Local NGOs. · Public health o cials. · Neighboring industries. ese partnerships ensure local and government involvement. Moreover, by integrating HLL's HIV and AIDS initiative with local orga- nizations and with the company's overall health program, they help the company gain credibility with its employee base and the general com- munity. Given our large workforce, it does not make business sense for us to engage Funding in a group medical policy or similar insurance or medical schemes. It is better Since occupational health is a to provide complete care and treatment for the needy may it be for HIV and AIDS priority for HLL, the corporate or any other ailment. budget for HIV and AIDS ini- tiatives is exible. at allows --Dr. T. Rajgopal, Vice President, Medical and Occupational Health, HLL units to function with some independence. It also makes it possible to give units support for unbudgeted expenses on short notice if needed. Lessons learned e program has several observations about the key factors in its success and its key challenges. 84 Case Study: Hindustan Lever Limited Key success factors · Management-led initiative. HLL's management-led initiative has been a critical factor in ensuring sustainability of the HIV and AIDS program to date. · Commitment at all levels. Allowing each unit to develop initiatives and providing budgetary support as needed ensure commitment to the program at all levels. Key challenges · Overcoming stigma. Employees initially were reluctant to take condoms, though distributed at no cost, because of the stigma attached to the use of condoms. Repeated awareness programs helped to overcome this resistance. e company also faced initial di culty in gaining acceptance of voluntary testing. Repeated ses- sions again helped, convincing stakeholders of the importance of testing. Unit heads, managers, and o cers also helped by leading the way at the voluntary testing sessions. Future plans HLL wishes to further extend its HIV and AIDS program through its dis- tribution network. It would also like to improve health care in rural areas through its strong network of female entrepreneurs, known as "Shakti Case Study: Hindustan Lever Limited 85 ammas." Before the program is expanded, it will be important to evaluate its e ectiveness. References Chandrasekaran, Padma, Gina Dallabetta, Virginia Loo, Sujata Rao, Helene Gayle, and Ashok Alexander. 2006. "Containing HIV/AIDS in India: e Un nished Agenda." e Lancet Infectious Diseases 6 (8): 508­21. HLL (Hindustan Lever Limited). 2006. Annual Report 2005. Mumbai. India, Ministry of Finance. 2006. "Foreign Exchange Reserves." In Union Budget 2005­06. New Delhi. http://indiabudget.nic.in/es2005-06/ chapt2006/chap617.pdf. JBIC(JapanBankforInternationalCooperation).2005."AddressingSocial Concerns Related to Project Undertakings." In JBIC Environmental and Social Activities Report. Tokyo. LVS (Lok Vikas Sanstha). 2004. "STD Prevalence in Hazira." Surat, Gujarat. Modicare Foundation. 2006. "HIV/AIDS Intervention with Migrant Workers: Project Undertaken by Delhi Metro Rail Corporation Ltd." Delhi. Moses, Stephen, James F. Blanchard, Han Kang, Faran Emmanuel, Sushena Reza Paul, Marissa L. Becker, David Wilson, and Mariam Claeson. 2006. AIDS in South Asia: Understanding and Responding to a Heterogeneous Epidemic. Washington, D.C.: World Bank. 87 88 References UNAIDS (Joint United Nations Programme on HIV/AIDS). 2006. Report on the Global AIDS Epidemic 2006. New York. VHAI (Voluntary Health Association of India). 2003. "Study Awareness Campaign for Mitigation of HIV/AIDS Risks under Delhi Mass Rapid Transport System Project." Delhi. World Bank. 2006. " e Business Case for AIDS." South Asia Multi Sector Briefs on HIV/AIDS. June. South Asia Region, Finance and Private Sector, Washington, D.C. Company Web sites · DCM Shriram Consolidated Limited: http://www.dscl.com/ · Delhi Metro Rail Corporation: http://www.delhimetrorail.com/ index.htm · Hindustan Lever Limited: http://www.hll.com/ · Reliance Industries Limited: http://www.ril.com/ · Transport Corporation of India: http://www.tcil.com/ Other Web sites · Avahan: http://www.gatesfoundation.org/GlobalHealth/ Pri_Diseases/HIVAIDS/HIVProgramsPartnerships/Avahan.htm · IFC Against AIDS: http://www.ifc.org/ifcext/aids.nsf/content/ home · International Labour Organization: http://www.ilo.org/ · National AIDS Control Organization: http://www.nacoonline. org/ · SAR AIDS: http://www.worldbank.org/saraids · UNAIDS India: http://www.unaids.org.in · World Bank Institute: http://www.worldbank.org/wbi Eco-Audit Environmental Benefits Statement The World Bank is committed to preserving Endangered Forests and natural resources. The Office of the Publisher has chosen to print Corporate Responses to HIV/AIDS on 25 percent postconsumer recycled paper, FSC certified. The World Bank has formally agreed to follow the recommended standards for paper usage set by Green Press Ini- tiative--a nonprofit program supporting publishers in using fiber that is not sourced from Endangered Forests. For more information, visit www.greenpressinitiative.org. In 2004, the printing of these books on recycled paper saved the following: Trees* Solid Waste Water Net Greenhouse Gases Electricity 3 116 1,006 307 2 * 40' in height and Pounds Gallons Pounds Million BTUs 6-8" in diameter How should the corporate sector engage in fighting the global burden of the AIDS epidemic? India's relatively low HIV prevalence rate often raises the question of whether it is in corporate sector interest to allocate resources to combat HIV and AIDS. The five case studies in this report feature a selection of Indian companies that felt compelled to engage in this fight and did allocate resources in order to do so. The challenges these companies encountered and innovative methods they used to surmount these challenges serve as useful lessons for those interested in launching similar initiatives. ISBN 978-0-8213-7171-8