Social network strategy: an innovative approach to reach hard-to-reach people who inject drugs in northeast states in India

BACKGROUND: India has a concentrated HIV epidemic, with an estimated 2.3 million people living with HIV (0.22% adult prevalence). Key populations (KPs) are disproportionately affected, with HIV prevalence among people who inject drugs (PWID) at 6.26%. High HIV prevalence in northeast states of Mizoram (2.3%), Nagaland (1.45%), and Manipur (1.18%) is driven by injecting drug-use behavior. Under the PEPFAR/CDC-supported Project Sunrise, FHI 360 implemented social network strategy (SNS), an innovative approach to provide HIV prevention, testing, and treatment services to hard-to-reach PWID in these three states from June 2019 to March 2020.
DESCRIPTION: Community-based organizations (CBOs) hired peers as seed participants and used a chain-referral recruitment strategy and social network connections to reach, test, link, and treat hard-to-reach PWID in six sites in the three states. Using 139 initial seed participants (14 HIV positive, 125 HIV negative), 3,495 PWID, injecting and sexual partners were recruited and tested for HIV. SNS participant characteristics included predominantly male (95%); young (44% less than 25 years); unmarried (59%); completed basic school (56%); and unemployed (55%). Three hundred (8.6%) tested HIV positive, of whom 208 (69%) were initiated on antiretroviral therapy. Nine hundred thirty (29%) HIV negative participants were linked to harm reduction programs. Twenty-one (7%) of the 300 HIV-positive clients were females. Nearly half (n=311) of the new HIV-positive PWID were identified in Aizawl, Mizoram, with a 19% case-finding rate.
LESSONS LEARNED: SNS can strengthen CBO networks' ability to penetrate hard-to-reach networks using minimal additional human resources. Early community involvement with SNS processes was critical to the strategy's effectiveness, including the discussion of incentives. Robust referral networks including network size, syringe services, and injection environment improved identification of undiagnosed PWID. Enrolment of spouse and sexual partners through SNS was challenging.
CONCLUSIONS: SNS implementation effectively reached unreached populations and provided communities with increased access to HIV services. Based on the results of SNS implementation, National AIDS Control Organization included SNS in expanded outreach interventions to reach new KP individuals. Such network-based referral strategies, including both SNS and index testing services, should be scaled up and integrated to increase case finding to accelerate progress toward achieving the UNAIDS 95-95-95 goals.

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