government accountable for quality HIV prevention, testing and treatment services. The prevention community is coming to terms with the complexity of HIV prevention and being urged to make better use of existing data, to ensure resources are directed to where the epidemic is and to what drives it, to address vulnerability and structural determinants, and to apply what we know works with sufﬁcient quality, intensity and scale.8 13 14 These are the principles that have characterised Avahan’s approach from the start. The fact that, this many years into the epidemic, we are also rediscovering the importance of sex-worker interventions makes Avahan’s achievement over the last 5 years even more remarkable. Avahan stands as a rare example of the enormous power of data and communitydespecially when working togetherdto challenge an epidemic and a mindset, and to overcome both. The ﬁndings and conclusions in this report are those of the authors and do not necessarily represent the ofﬁcial position of the US Centers for Disease Control and Prevention. Competing interests None. Provenance and peer review Commissioned; externally peer reviewed. Accepted 27 November 2009 Sex Transm Infect 2010;86:i6ei7. doi:10.1136/sti.2009.039255 REFERENCES 1. Vuylsteke B, Das A, Dallabetta G, et al. Preventing HIV among sex workers. In: Mayer K, Pizer HF, eds. HIV prevention. London UK: Academic Press, 2008:376e406. 2. Laga M, Alary M, Nzila N, et al. Condom promotion, sexually transmitted diseases treatment, and declining incidence of HIV-1 infection in female Zairian sex workers. Lancet 1994;344:246e8. 3. Ghys PD, Diallo MO, Ettiegne-Traore V, et al. Increase in condom use and decline in HIV and sexually transmitted diseases among female sex workers in Abidjan, Cˆote d’Ivoire, 1991e1998. AIDS 2002;16:251e8. 4. Levine WC, Revollo R, Kaune V, et al. Decline in sexually transmitted disease prevalence in female Bolivian sex workers: impact of an HIV prevention project. AIDS 1998;12:1899e906. 5. Kerrigan D, Moreno L, Rosario S, et al. Environmentalestructural interventions to reduce HIV/ STI risk among female sex workers in the Dominican Republic. Am J Public Health 2006;96:120e5. Avahan: the transition to a publicly funded programme as a next stage Prasada J V R Rao Avahan the ﬂag ship programme of the Bill & Melinda Gates Foundation (BMGF) for the prevention of HIV in India was projected as a unique business model that brought private sector efﬁciency to a public health programme. However, within a period of 3 years after its launch, the programme already started planning for a phased withdrawal and a ‘graceful transfer’ into a publicly funded programme.1 Avahan with a US$250 million project cost was effectively complementing the Government of India’s efforts to control UNAIDS, Regional Support Team for Asia and the Paciﬁc, Bangkok, Thailand Correspondence to Dr Prasada JVR Rao, 9th Floor, Block A, United Nations Building, Rajadamnern Nok Avenue, Bangkok 10200, Thailand; raojvrp@unaids.org This paper is freely available online under the BMJ Journals unlocked scheme, see http://sti.bmj.com/site/ about/unlocked.xhtml Sex Transm Infect February 2010 Vol 86 No 1 Suppl 1 AIDS through its own publicly funded National AIDS Control Program (NACP). Avahan was tasked to deliver to scale, high quality prevention interventions to high-risk community groups in six high prevalence states and make an impact on the progres- sion of the epidemic in these states. Six years later, despite its impressive success in rapid scale up and efﬁcient management of programme delivery, Avahan is coming under criticism for trying to wind up early from India, and worse, for experimenting with a model that is high cost in terms of unit costs of intervention. The programme, which aimed at ultimate community ownership of the interventions, has initiated the process of transfer before this objective is fully realised. The feasibility of Avahan’s proposed transition into a publicly funded pro- gramme can only be assessed against the background of the importance given to prevention programmes among high-risk groups in NACP. Editorials 6. Jana S, Bandyopadhyay N, Mukherjee S, et al. STD/HIV intervention with sex workers in West Benghal, India. AIDS 1998;12(B Suppl):101e8S. 7. Basu I, Jana S, Rotheram-Borus MJ, et al. HIV prevention among sex workers in India. J Acquir Immune Deﬁc Syndr 2004;36:845e52. 8. Bertozzi S, Laga M, Bautista-Arredondo S, et al. Making HIV prevention programmes work. Lancet 2008;373:831e44. 9. Chandrasekeran P, Dallabetta G, Loo V, et al. Evaluation design for large scale HIV prevention programs: the case of Avahan, the India AIDS Initiative. AIDS 2008;22(5 Suppl): 1e15S. 10. Reza-Paul S, Beattie T, Syed H, et al. Declines in risk behaviour and sexually transmitted infection prevalence following a community-led HIV preventive intervention among female sex workers in Mysore, India. AIDS 2008;22(5 Suppl):91e100S. 11. Moses S, Ramesh B, Nagelkerke N, et al. Impact of an intensive HIV prevention programme for female sex workers on HIV prevalence among antenatal clinic attenders in Karnataka state, south India: an ecological analysis. AIDS 2008;22 (5 Suppl):101e8S. 12. Piot P, Bartos M, Larson H, et al. Coming to terms with complexity: a call to action for HIV prevention. Lancet 2008;372:845e59. 13. Gupta G, Parkhurst J, Ogden J, et al. Structural approaches to HIV prevention. Lancet 2008;372:764e75. India’s national programme2 was ahead of its time in 1999 when it earmarked 14% of its programme budget for ‘targeted interventions’ in the prevention pro- grammes for high-risk populations. Four years later, when BMGF launched the Avahan programme, it had a ready-made model of focused interventions among these risk groups to adopt, reﬁne and upgrade. The upgraded model of focused interventions was allotted 57% of the US $250 million of committed resources for Avahan.3 The ﬁrst phase of Avahan ended in 2008 with impressive impact results on the coverage of high-risk populations, strengthening prevention infrastructure and the delivery of services. While the general impression was that Avahan will continue to deliver these services under the new business model, the BMGF had other priorities. The strategy of the Foundation seems to have shifted to the transfer of ownership to Government, much earlier than originally envisaged. In October 2006, less than 3 years after the launch, the mid-term review had already recommended ‘exploring alternative posi- tions to align the organisation with changing priorities as the program managers scale down their implementor role and focus more on packaging the learnings from Avahan’.3 The success deﬁnition of Avahan therefore shifted only to demonstrate i7