The India-Nepal Partnership: Building Cross-Border Collaboration in Areas of Affinity

At least a thousand Nepalese trucks were lined up at Birgunj, the checkpost city on the Nepal-India border where the trucks' cargo is unloaded and reloaded onto Indian trucks. For Bhim, a seasoned Nepalese truck driver, this could mean days of waiting.

Away from the comforts and emotional support of home, Bhim was contemplating going to a sex worker for a few moments of pleasure when a stranger approached him. The stranger introduced himself as Kumar Das Manandar, a social worker from General Welfare Pratisthan, a local nongovernmental organization (NGO). Kumar's friendly approach persuaded Bhim to hear what he had to say about HIV/AIDS.

Bhim had heard about AIDS but had not considered himself vulnerable. After Kumar explained that HIV is transmitted mainly through sexual intercourse and that the risk of transmission is greatly increased with multipartner sex, particularly if either of the partners has a sexually transmitted disease (STD), Bhim became worried and asked Kumar for advice. He was promptly referred to the STD clinic run by the Bhoruka AIDS Prevention (BAP) Project in Raxaul, a checkpost city on the Indian side of the border. Without wasting any time, Bhim walked across the border to the BAP clinic.

At the BAP clinic two doctors -- one male and one female -- provide general medical services to truck drivers and others in the community, with an emphasis on STD treatment and HIV testing and counseling. Three social workers serve as outreach educators for truck drivers waiting at Raxaul and also offer counseling in the privacy and comfort of the clinic. Dr. Asha Rao, director of the BAP Project, monitors clinic activities from Calcutta.

As chief of the Transport Corporation of India (TCI) blood banking service, Dr. Rao saw the "storm" coming before most others. In a seroprevalence (point prevalence) study conducted over eight weeks (October to December 1993) at a clinic in Ulubaria, West Bengal, 7 percent of the truck drivers tested positive for HIV. Further enquiry revealed that 25 percent of these truck drivers had no knowledge about condoms, 68 percent never used condoms, 94 percent sought sex from commercial sources when away from home and 84 percent reported histories of STD symptoms.

With these alarming statistics in hand, Dr. Rao convinced the management of TCI to offer voluntary HIV testing and counseling at an STD treatment center at the Ulubaria checkpost, a major intersection for trucks traveling from Calcutta to Nepal and Bangladesh. The client response was encouraging: Data collected at regular intervals during the first year of the intervention showed that the number of people seeking counseling and HIV testing increased from 136 to 2,431 and the number of condoms distributed upon request rose from 630 to 26,290.

Across Borders

The BAP Project in Raxaul is the result of a collaboration between the AIDS Control and Prevention (AIDSCAP) Project and Dr. Rao to expand TCI's initiative into a cross-border intervention. Research by AIDSCAP -- one of a series of studies of "areas of affinity" for HIV/AIDS prevention in Asia -- had identified the trucking routes between Calcutta and Kathmandu as an important locus of high-risk sexual behavior.

In Asia, AIDSCAP has studied five areas of affinity that share common cultural, economic, demographic or epidemiologic characteristics. Most are linked by trucking routes, border zones or port cities with high concentrations of transport workers, business travelers, commercial sex workers, migrant laborers and other groups who may be at higher risk of acquiring HIV than more stable populations. Recognizing that the potentially deadly combination of mobile populations and a thriving sex industry drives transmission of HIV across national boundaries throughout the region, AIDSCAP and the Asia Bureau of the U.S. Agency for International Development (USAID) are encouraging development of interventions that also cross borders.

On the Indian subcontinent, a natural place to reach mobile populations at risk of HIV are the "zero points" where a number of highways converge. An average of 2,000 trucks pass through these points every day, and truck drivers stop briefly for rest and refreshments.

A zero point for the National Highway 28 in India, Raxaul is the most important entry point into Nepal from India because it connects with Birgunj, the zero point for the Prithvi Highway in Nepal. Both Raxaul and Birgunj are big, sprawling cities, separated from each other by a few hundred meters. Traffic between the two cities is continuous, and visas are not required to go from one country to another.

Raxaul was chosen as the most appropriate site for the cross-border intervention because it serves as a funnel for the trucks that transport goods between Nepal and India and because of its proximity to Birgunj, which is also one of the sites of an AIDSCAP-supported project implemented by General Welfare Pratisthan (GWP) in Nepal. The concept of linking two complementary prevention projects on opposite sides of the border was born.

Dr. Rao agreed to be director of the cross-border project at Raxaul in addition to her duties as manager of the Bhoruka Blood Bank, the leading blood screening, testing and storing facility in India. The Bhoruka Group is a subsidiary of TCI, the largest transport company on the subcontinent, with 1,500 trucks covering all of India. The Bhoruka Public Welfare Trust runs 15 dispensaries for truck drivers in various parts of the country.

Since Nepal's GWP had no Indian counterpart in Raxaul, the BAP Project could not build on existing local services. The Bhoruka Public Welfare Trust opened a new clinic in Raxaul and, with some difficulty, recruited medical staff and outreach workers who were willing to work in the remote checkpost town.

The BAP Project's clinic at Raxaul is the latest addition to the Bhoruka chain of clinics. AIDSCAP's role is to build capacity within the Bhoruka Group to develop, implement and monitor effective HIV prevention activities at Raxaul that can be replicated in Bhoruka clinics across India and to encourage collaboration between other HIV/AIDS prevention projects across the India-Nepal and India-Bangladesh borders.

Building a Partnership

To prevent the spread of HIV among the truck drivers and their assistants who regularly cross the India-Nepal border, the BAP Project collaborates with AIDSCAP's partners in Nepal. At every stage of the project -- planning, message and material design, training of field personnel and monitoring -- the Indian and Nepali staff of the two projects work together to ensure consistency of project goals, evaluation indicators, strategies, messages and services on both sides of the border.

This consistency was an important factor in facilitating collaboration at the field level. Outreach workers from India and Nepal readily accepted each other as partners and found it easy to coordinate their activities because the projects had adopted similar approaches.

During the early stages of project start-up, BAP's project director met with AIDSCAP/Nepal's field staff to identify common areas of interest. Communication strategies, materials, training curricula and condom social marketing approaches developed for the Nepal program were reviewed jointly by staff from BAP, GWP and AIDSCAP/Nepal for applicability to the Indian setting. BAP followed Nepal's lead in designing STD training based on the syndromic approach recommended by the World Health Organization.

In the Field

Collaboration in the field began with the launch of the BAP Project. On September 11, 1995, the project organized an advocacy meeting at Raxaul to create awareness among various sectors of the community, including truck drivers, about HIV/AIDS. This meeting was planned jointly by field staff of the two projects, and resources from Nepal were shared with the Indian partners.

A crowd of about 1,000, including truckers, their assistants, local community leaders and schoolchildren, gathered in a cleared truck parking area for this inaugural advocacy meeting. The minister of health of Bihar state, the AIDSCAP director, and USAID representatives from Washington and Kathmandu participated to endorse project goals and objectives.

Following this meeting, the two teams jointly implemented a number of events. On December 1, 1995 -- World AIDS Day -- a rally was arranged by inviting participation from both sides of the border and involving local political leaders from Nepal. The Nepal Contraceptive Retail Sales (CRS) Company, which implements the condom social marketing project of AIDSCAP's program in Nepal, organized street theater and video presentations.

Before each collaborative event, GWP sends its Birgunj outreach team to plan and coordinate field activities with BAP staff. The Birgunj team and BAP Project staff visit each other regularly, and BAP personnel participate in staff training activities at GWP's Hetauda field office, just an hour's drive north of the border.

The most important part of the ongoing collaboration are the referrals from Nepal to India. Because STD services are not accessible in the Birgunj area, GWP staff refer men and women in need of STD services over the border to the BAP clinic, where STD diagnosis, treatment and counseling are available six days a week. GWP outreach educators provide dual-language referral slips to direct clients to the BAP clinic for an STD consultation and HIV/AIDS prevention education. Just three months after the clinic opened, it was receiving approximately 35 visitors a day.

Expanding the Model

This collaboration between HIV/AIDS prevention projects on both sides of the India-Nepal border is already attracting attention from policy makers concerned about the spread of HIV/AIDS among and by mobile populations. At a December 1995 meeting, the U.S. ambassador to Nepal, the chief of USAID's Office of Health and Family Planning in Nepal, AIDSCAP/Nepal's resident advisor, the director of the BAP Project and the communication officer from AIDSCAP's Asia Regional Office determined that the Raxaul-Birgunj collaboration should be expanded into a regional initiative.

As a result, AIDSCAP organized a three-day seminar on "Sharing Tripartite Experiences" from India, Nepal and Bangladesh. Held in Calcutta April 22-24, 1996, the seminar gave participants from government agencies, NGOs and the private sector in the three countries an opportunity to discuss the lessons learned from the Raxaul-Birgunj experience and to strengthen collaboration among USAID-supported HIV/AIDS prevention projects in the border zones.

Some of the key lessons identified during the seminar are as follows:

• HIV/AIDS prevention messages for people traveling across borders must be consistent.
• Interventions on both sides of the border gain credibility and community support collaboration between field staff from the neighboring countries is observable at the field level.
• Collaboration between two neighboring projects is possible only if there is consistency in the strategic approach.

Seminar participants agreed on the need for complementary interventions to reach mobile populations on both sides of their borders. Building on the progress made during the tripartite meeting, AIDSCAP will continue to work with donors and NGOs to replicate the intervention in Raxaul and Birgunj, starting with the cross-border zone of Petrapol and Benapol on the India-Bangladesh border.

-- Mrudula Amin

Mrudula Amin, MA, of the Program for Appropriate Technology in Health, serves as the communication officer in AIDSCAP's Asia Regional Office in Bangkok, Thailand.