Two years ago, I left McKinsey & Company to head Avahan-the India aids initiative of the Bill & Melinda Gates Foundation-and stepped into another world. From serving India's business chieftains, my clients were now sex workers-female, male and transgender-and drug users. From an India challenging the world, I encountered an India of desperate poverty, and cruelly marginalised populations. I saw places as disparate as Bishnupur in Manipur to Kolar in Karanataka, and the devastation the aids virus was already wreaking.

Writing then in BT's anniversary issue, I described aids in India as the "elephant in our midst"-because what struck me was how enormous the problem was, but how few people even recognised it. It's probably fair to say Indian business also does not sense the elephant. While many companies pay lip service to the importance of tackling aids, the fact is that few do much about it. It's a tragedy, because business skills and assets can be the most potent weapon in the war against aids. This article describes why, and proposes a framework for Indian business to make a huge difference.

With a national prevalence of 0.9 per cent, India seems at an early stage of an HIV/AIDS epidemic. However, this statistic belies the multiple sub-national epidemics where it has already spread rapidly. Moreover, the complexity of India's epidemic is fuelled by three main factors that pose a unique challenge to prevention.

Diverse contexts: With India's population of more than one billion, and large high-risk groups such as commercial sex workers, men who have sex with men, intravenous drug users, and migrant labour found in many local contexts, it is impossible to define India's aids epidemic as a single epidemic. In the six high prevalence states of Tamil Nadu, Maharashtra, Karnataka, Andhra Pradesh, Manipur and Nagaland, with prevalence rates around 2 per cent, the combination of forces shaping the epidemic vary not only across regions, but even between districts within a state.

Dispersion: Driven by economic vulnerability and responsive to transitory economic opportunities, high-risk groups like commercial sex workers and their clients are both hidden and highly mobile, making focussed prevention a moving target. In addition, surveillance data points to a changing face of the epidemic as the epidemic increasingly shifts from urban to rural areas.

Disabling environment: The stigma of HIV/AIDS in India, at every level of society, casts a pall and makes HIV prevention efforts an uphill battle. Apathy and denial have sidelined a much-needed national HIV/AIDS dialogue that could shatter myths and stem the tide of discrimination spread across the country.

The world has probably never seen an HIV epidemic like India's. The combination of diversity, the hidden and dispersed nature of sex work, and the sheer scale and high levels of stigma make for a complex epidemic, posing a major challenge to prevention work.

Despite these challenges, there is a silver lining. India is still at an early stage of the epidemic, and an investment in prevention today can avert a socio-economic crisis in the future. Avahan's main objective is to reach the high-risk behaviour groups most vulnerable to HIV, with behaviour changing communications, condom promotion and access, and treatment of the sexually transmitted infection that fuel HIV. In addition to these targeted interventions, we put effort into advocacy for a more enabling prevention environment. At every stage, we have found the parallels with best practices from the world of business striking.

Execution focus: In business, competition is intense and sound strategy must be backed by executional ability. In tackling an epidemic, execution is obviously critical. NGOs and local communities often lack the mindset and the managerial skills that are central to good execution. We place high emphasis on creating that war-room atmosphere and in building managerial capacity with our partners.

Scale: Businesses constantly strive to expand their markets, using many techniques to rapidly scale up. Avahan spans six states with a collective population of more than 300 million. To build scale, we forge strategic alliances to share the solution-such as the partnership between India's largest trucking company and petroleum retailer in our highways programme. We standardise service delivery where possible to speed rollout, as in our franchised STI (sexually transmitted infections) treatment service for men. Finally, we reach scale by intervening at the structural level-working on the root causes of vulnerability that lead to risky behaviours.

Focus: A large business with diverse markets must understand its key battlegrounds-the consumer segments and territories where winning is a must. Similarly in Avahan, we search relentlessly for the greatest points of leverage for systemwide impact. This has led us to what we believe are the few most critical geographical clusters and sub-populations in terms of the transmission dynamics. As businesses can do, we try to maximise impact by concentrating effort.

Community driven: A business listens to its consumer and designs its delivery systems accordingly. The community of sex workers is our respected consumer and we ask the community to define its needs. We then involve community members in local programme design, service delivery in structural intervention. At the end of the day, we hope to build better quality solutions, more rapid scale-up and sustainability by keeping the consumer in the driver's seat.

Measurement: A business has to meet its numbers, and good businesses invest in quality management information systems as well as longer term assessment. In the public health programmes we reviewed, careful measurement-near- and long-term-seemed the exception, rather than the rule. Avahan tries to measure impact at every level, from the effectiveness of advocacy outreach to the impact of a small town intervention. Our MIS provides detailed data from over 500 intervention sites. Mathematical modelling and specialised studies facilitate evaluation across the board.

"Don't make the same mistakes in India we made in South Africa-we saw this coming, but the first reaction of business was that it wasn't threatening us now, that we'd let the government sort it out". Now, 25 per cent of Anglo's employees are infected with HIV/AIDS and the disease has begun to affect corporate profits, productivity and morale..." Brian Bank Medical Director for the South African mining gaint, Anglo-American

Flexibility: Market situations are constantly evolving, and lasting businesses are those that continuously adapt and evolve. With Avahan, we are trying many things for the first time-placing many big and small bets in prevention. We trust our judgment, take reasonable risks, check results and make required programme shifts that are technically appropriate. Avahan is about focussed strategy, careful market segmentation, brand marketing and franchising. It is about strategic alliances, managing logistics, ruthless execution and measuring results. Avahan is about adapting classic business principles to a specific public health context. Sound business thinking and management practices are probably the most needed skill in HIV/AIDS, if not in public health in India, today.

My team of 10 is largely made up of people with business backgrounds - consumer marketing, banking, information technology and management consulting. All of us feel very much at home in the world of HIV/AIDS because we have found that management is the premium skill in public health.

Business skills, infrastructure and thinking can be potent weapons in the war against aids. Yet, barring a few exceptions, Indian business has been slow to step up and contribute. AIDS in India is far too complex, and the public health system much too fragile, for the task to be left to government alone. Business must step up to this challenge, not just because it is in a position to make a big difference, but because defeating aids surely is also good business.

So how can corporates contribute to the campaign against aids? We would suggest the following framework for action, with initiatives arrayed in roughly increasing order of impact:

Workplace programmes: The minimum contribution any business should make is to have a compelling workplace programme for HIV prevention, education and awareness. Such a progamme should be part of an overarching policy of non-discrimination towards employees who may become HIV-positive. In addition to HIV prevention activities, workplace programmes should include basic care and access to treatment services. A sound HIV workplace programme is a must for every business in India, but few have it.

Community extension: Businesses should extend the same workplace efforts to their larger business communities-the suppliers, dealers, distributors and local populations of their townships. By so doing, they could greatly enhance the scale of their impact.

Providing infrastructure and access: Businesses with large supply chains can allow these to be leveraged for the supply of prevention services (e.g., condom rural distribution; awareness messaging). An example in our programme is Indian Oil Corporation, which has agreed to provide access to some 4,000 highway petrol pumps that can serve as information and service points to thousands of truckers vulnerable to HIV.

Lending business skills: Every HIV prevention programme can benefit from business expertise in distribution, marketing, communications and/or project management. Businesses can provide these scarce skills through short-term training programmes, or consultancies. Employee secondment to programmes like ours will be particularly effective-with the added advantage that the employee will probably return a much better manager!

Advocacy: Business leaders in India have greater societal influence than their counterparts in most countries. Business leaders must speak out to dispel stigma, combat discrimination, defeat apathy, and to promote prevention and treatment access. The impact will be huge-whether it is done by a nationally revered HIV or by a local businessman in the small town in Guntur district.

Businesses can contribute through workplace programmes, community extension, lending business skills, leveraging their infrastructure or through advocacy. Rather than hope that HIV/AIDS does not affect your business, think about how your business can affect the outcome of HIV/AIDS in India.

The author is Director of Avahan, Bill & Melinda Gates Foundation India AIDS Initiative