In FY 2012, CDCs Global AIDS Program (GAP) will enter the second year of its third five-year CoAg with MoPH. Specific objectives of the CoAg are to support Thailands national HIV/AIDS strategy by:

1) Supporting replicable models for prevention, care, and treatment;

2) Improving the quality of prevention, care and treatment programs;

3) Increasing the collection and use of SI;

4) Sharing successful models by providing TA to other PEPFAR countries.

Expected outcomes include:

1) Strengthening health systems, human capacity, guidelines and protocols, and QA/QI systems to best enable the RTG to finance and manage programs;

2) Supporting replicable and scalable models for interventions;

3) Improving prevention, care and treatment programs;

4) Increasing collection and use of SI;

5) Sharing successful models with other PEPFAR countries.

This approach follows GHI principles, including promoting the development of sustainable, country-owned programs, prioritizing M&E, and fostering research and innovation. All USG technical support is for programs that are, or will be, fully integrated into routine, MoPH-managed public health programs.

CoAg activities have a national scope. Target populations include MARPs (FSW, IDU, MSM, and prisoners); pregnant women (PMTCT); children (early diagnosis); and efforts that strengthen capacity overall (HCT systems; HIV care; laboratory systems, PwP; and SI).

As a TA-based CoAg, costs continue to be low for this implementing mechanism. Model development and evaluation are supported for a time-limited period, and then other donor or government funding is leveraged for program expansion and integration. This CoAg may be a model for countries transitioning to PEPFAR 2 and GHI approaches to the HIV/AIDS epidemic.

Strengthening the Quality Improvement of HIV Treatment and Care Programs (nationwide program)

In 2010 in Thailand, an estimated 480,000 people were living with HIV/AIDs and 280,000 were receiving ART. The national ART program was started in 2000 and fully scaled up in 2004, with over 1,000 hospitals currently providing HIV care and treatment. Of these, nearly 900 are government hospitals, located in all provinces and districts in Thailand. Ensuring quality of HIV care in these hospitals is highly needed as the number of HIV patients in Thailand increases.

The HIVQUAL model was developed in 2003 and scaled up with funding from the National Health Security Office (NHSO) in 2007, which has fully supported all operational costs since 2010. The Department of Disease Control within MoPH provides national program management, and GAP Thailand provides TA on developing tools, materials, and training curriculum, and on program monitoring.

This program is focused on capacity building for healthcare workers and public health officers at national, regional, provincial, and hospital levels to conduct performance measurement to develop quality improvement activities/projects (related to HIV monitoring, ART, disease screening, OI prophylaxis, and/or positive health promotion); strengthen local HIV care networks, and develop QI coaching systems. For long term sustainability of the QI program, integration of the HIV QI into Thailands existing hospital quality management and hospital accreditation systems is planned.

In FY 2013, GAP Thailand will focus on TA to enhance capacity building, strengthen regional QI coaching systems, and support program monitoring. A program evaluation plan will be developed to assess program achievement and effectiveness.

Strengthening the Quality Improvement of STI Programs (12 provinces in 12 regions)

Thailands STI program was reformed in 2001, with most services integrated into outpatient care, leading to weaknesses in STI prevention and control. GAP Thailand began developing programs to strengthen the STI program in 2002 in 3 provinces (not including Bangkok) and 4 institutes. Since then, 4 provinces were added (during the second Co-Ag) to maintain STI management services and regular STI screening for FSWs. GAP Thailand efforts have since been redirected to provide TA to improve the quality of services at clinics receiving GFATM Round 8 funding for HIV prevention among MARPs in 44 provinces.

GAP Thailand TA builds the capacity of health facilities to provide high-quality STI services for MARPs, especially FSW and MSM. A QI model was developed and piloted in 2009-2011 in 20 provinces. The model strengthens STI diagnosis and management, promotes interventions to modify behavioral risks and condom use, encourages regular HIV testing and referral to HIV care and treatment among HIV-infected persons, and improves STI SI collection and use.

In FY 2013, the STI program plans to expand to more provinces by developing a training-of-trainers program for QI in 12 regions in Thailand, continuing to monitor program expansion, and conducting program evaluations in existing implemented areas.

New Models and Innovations for TB Control: EQA

GAP Thailand, in collaboration with the Thai MoPH, has evaluated and improved TB diagnosis through laboratory strengthening and the development, improvement and evaluation of new and existing diagnostic tools and methods. Sputum smear microscopy remains the cornerstone of TB diagnosis in Thailand, but access to culture and newer rapid methods is increasing. GAP will support an in-country AFB EQA program to increase coverage by strengthening regional (sub-national) reference laboratories as a TB laboratory network with the national TB reference laboratory; in FY13, QA systems for culture methods will be developed. GAP will support capacity building of regional reference laboratory staff on requirements for EQA providers and knowledge about quality systems. GAP staff will support the TB reference laboratory to pilot, monitor and evaluate project implementation.

Two projects are funded under this budget code, as follows:

Pediatric Care Network

While adult HIV care and treatment has been decentralized, most pediatric HIV care and treatment occurs at tertiary care hospitals due to the complexity of pediatric HIV care and lack of knowledge and skills of health care workers (HCWs) and multi-disciplinary care teams in community hospitals.

In Chiang Rai province, a network of community hospitals has successfully implemented a holistic approach for pediatric HIV care. This model involved building a multi-disciplinary team, including people living with HIV (PLHA), that provides holistic care to HIV-infected children and adolescents, and strengthens referrals and networking between tertiary and community providers. This model has been scaled up to 30 provinces with funding from GFATM and NHSO.

In FY 2013, GAP Thailand will provide TA to support continued expansion of the pediatric HIV network model by developing four regional training centers for provinces adopting the network model. The training centers will provide technical support and coaching to provincial teams in their geographic area.

Of note, performance measurement and QI using Pediatric HIVQUAL-T is part of the QI program in these networks. In FY 2013, 60 of 76 provinces, covering at least 60% of children living with HIV/AIDS, will be participating in Pediatric HIVQUAL-T.

Comprehensive Positive Youth Model in Health Care Setting

Approximately 10,000 HIV-infected children are receiving HIV care under the national program. Perinatally infected youth are at risk for mental health and behavioral difficulties. Most perinatally HIV-infected adolescents have been taking ARV medications for most of their lives, and some may have developed resistance. As youths become sexually active, transmission of resistant strains is possible.

Since 2009, GAP Thailand has supported three institutions to develop a clinic-based intervention for HIV-positive youth aware of their status. This model educates HIV-positive youth on reproductive health, STIs, and adherence, promotes self-esteem, self-discipline and problem solving skills, and provides skills for reducing risks of disease acquisition and transmission. The model will be evaluated by the end of 2011. If shown to be successful, it will be scaled up to other provinces with funding from NHSO.

Another challenge confronting healthcare providers working in pediatric HIV care is transferring care of older HIV-positive youth to adult HIV clinics. Some HIV-positive youth referred to adult clinics have been dissatisfied with their new clinics due to confusion in navigating busy clinics with unfamiliar environments.

Developing a model to assist with that transition will be part of a comprehensive model, to include other aspects of preparing youth and their caretakers for adult clinics and preparing youth for adulthood. Key strategies promote involvement of youth and their caretakers to build connections between pediatric HIV care and adult HIV care to ensure successful transition for HIV-positive youth.

By 2013, if the transition model from pediatric HIV care to adult HIV care developed during 2012 has been proven successful at pilot sites, the package of PwP youth model will be scaled up to other provinces through the pediatric HIV care quality network.

Strengthening the Quality of HIV/AIDS Testing Laboratories of Thailand

Through MoPH, GAP Thailand will help implement and evaluate a new EQA program for HIV rapid testing using dried tubes specimen (DTS) in remote areas and in MARP-focused (MSM and FSW) VCT clinics in Thailand. The DTS sample panels can be stored and transported at room temperature, and can be used as an alternative EQA/IQC program to conventional EQA/IQC panels that require controlled temperature conditions to monitor the quality of HIV rapid testing in some remote sites. This will complement the national plan to promote HIV VCT in MARPS to increase access to testing and care especially at peripheral or community sites for hard-to-reach populations.

Quality Systems in Hospital Laboratories Saraburi

To support implementation of practical and sustainable quality management systems through the Thailand laboratory accreditation program, GAP Thailand has supported a laboratory network to strengthen and improve the quality of laboratory testing within the network. GAP Thailand will support the Saraburi laboratory network by providing training on QMS and assisting with a laboratory internal assessment according to Thai Medical Technology standards. GAP funds will be used to leverage government funds that are available for system quality and accreditation processes.

Strengthening Surveillance, Management Information System and Human Resource Capacity on Utilization of SI to Promote Effective HIV/AIDS Program Management, Thailand

The Government of Thailand is committed to reduction of new HIV infections by preventing the spread of HIV/AIDS, eliminating AIDS-related deaths, and eliminating discrimination in society. In order to guide the development of effective strategies and operational plans, evidence about the status of the HIV/ AIDS epidemic and the ongoing response is needed.

In the past, GAP Thailand provided TA to MoPH to strengthen the existing national surveillance and monitoring systems through innovative epidemiological and informatics approaches. However, challenges remain, including limited number of human resources, especially at provincial levels, with the epidemiological knowledge and informatics skills to use SI for policy and program planning. Hence, GAP Thailand will provide TA to MoPH to strengthen national and provincial capacity on utilization of HIV SI to promote the effective implementation of the 2012-2016 National AIDS Plan, focusing on a better understanding of the HIV epidemics and intervention responses at the national level and in 12 sentinel provinces. In FY 2013, GAP Thailand plans to undertake the following activities:

1. Scale up nationally an innovative model of integrated behavioral surveillance and biological markers (IBBS) among non-venue-based FSW.

2. Ensure the quality implementation of IBBS among venue-based FSW, MSM, IDU and male military conscripts, focusing on standardization of data collection and analysis methods and staff training.

3. Strengthen sero-incidence surveillance using BED-CEIA, considering the lessons learned from evaluating a new laboratory approach (Limiting antigen avidity assay) and the adjustment of False Recent Rate conducted in FY 2012.

4. Develop and implement HIV drug resistance surveillance, using experiences learned from pilot models.

5. Implement HMIS to monitor the facility-based harm reduction program for IDU and assess feasibility of integrating key monitoring data with the monitoring systems for outreach interventions, counseling and testing, care and treatment, and sero-surveillance.

6. Strengthen HMIS to use NAP data for ART program monitoring, PMTCT outcome monitoring and case reporting surveillance.

7. Develop and implement guidelines on synthesis and triangulation of SI for situation analysis, monitoring of program implementation, MARP population size estimation, and estimation and projection for key parameters for policy decision making and program planning at national and provincial levels.

8. Increase capacity of human resources at national and provincial levels through workshop trainings and field supervisions. Expected outputs include capacity to 1) synthesize and use SI to describe HIV epidemics and responses; 2) synthesize SI to develop policy and projections to guide decision-making; and 3) develop communication skills to engage policy-makers to promote improvements in evidence-based programs.

9. Set up web-based information bank to enable linking relevant SI to support the description of HIV epidemics and responses (key indicators for program outputs, outcomes and impacts).

CDC and MOPH support Thailands highly trained scientists and public health officials to share their knowledge and experience and provide technical assistance to countries within and beyond the region to promote and support development of high-quality HIV care and treatment and sustainable laboratory capacities, among others. Activities will be provided up on request and the need of countries. Projects focus on building the capacity of the MOPH staff to improve work performance via sponsoring staff to attend conferences and workshops in-country and international trainings, meetings, conferences and workshops. As GAP projects in Thailand focus on model development, and regional and global technical assistance, strong human resources capacity is needed for better programs. Projects include PMTCT services, quality of HIV care and treatment, HIV counseling and testing (including couples counseling at antenatal care centers), STD diagnosis and treatment including MARP-friendly services, and collection, interpretation, and use of strategic information. Others will develop training material for Global Technical Assistance for laboratory activities that improve the quality of all HIV related testing as well as the quality of laboratory systems and laboratory training, meetings, and workshops for activities in Thailand, and internationally. Reliability of laboratory results are fundamental to supporting HIV prevention, care and treatment. A sample project would be providing support to MOH of Vietnam, in collaboration with the U.S. CDC and GAP in Vietnam, to work to improve the quality of laboratory testing; as Vietnam has limited human capacity and infrastructure to support these activities. Therefore, highly experienced Thai staff and experts in laboratory fields will assist the Vietnam MOH in providing technical assistance in the areas of quality management systems and HIV and HIV related test quality assurance according to the needs and requests from Vietnam.

Strengthening the Quality Improvement of HIV Counseling and Testing Programs (5 provinces)

HIV counseling and testing (HCT) coverage among the Thai general population is very low (< 1%) and less than 60% in all MARPs except in pregnant women (> 90%). Although HCT services are available in more than 1,000 hospitals all over the country, HCT services are variably structured and independently managed among hospitals. No concrete national program exists to promote HCT for all groups, except pregnant women seeking ANC, TB-infected persons, and MARPs served by clinics funded by GFATM with Round 8 funding. HCT approaches also differ, with PICT for TB patients, persons with HIV/AIDS symptoms, pregnant women, and persons with STIs. However, outreach/mobile-based VCT and special events or campaigns to promote VCT are conducted only in small areas and at demonstration sites. In addition, M&E and QA systems for HCT in general, and VCT in particular, are not well formed.

Since 2010, GAP Thailand has promoted HCT among MSM and FSW in four and five provinces, respectively. PICT and VCT with same day results are conducted under the program. A testing algorithm using rapid tests was defined by following the national guideline with EQA and IQC development. Persons diagnosed with HIV infection are referred to care, with M&E of that referral system. For MSM, HIV uptakes in FY 2011 in four provinces were 840 cases, of which 759 (90%) opted for rapid testing.

A QI model of HIV counseling was piloted in three MoPH hospitals during 2010-2011, and will be expanded to five hospitals in FY 2012. The target population includes all persons receiving HIV testing in hospitals. Quality of pre- and post-test counseling, follow up among window period cases, psychosocial counseling and referral of positive cases are key services which are assessed and targeted with QI efforts. Client and counselor surveys are conducted annually to assist with QA and QI efforts.

In FY 2013, HCT with same day results among MSM and FSW will be conducted in targeted areas, and a program evaluation is planned. Additionally, QI of HCT will be expanded to more hospitals, with development of a training-of-trainers for QI, continuation of program monitoring, and evaluation of existing program areas to help develop a plan for program expansion.

Capacity Building and System Strengthening for Health Care Personnel on Access to HIV Prevention and Care Among Key Affected Populations -- MSM (5 sites) and FSW (2 sites)

GAP Thailand will collaborate with MoPH to strengthen HIV intervention activities among MSM and FSW in major affected areas, including Bangkok and southern, eastern, and northeastern provinces where HIV prevalence among MARPS is high.

MSM. Since 2004, with technical and financial assistance from GAP Thailand, MoPH has supported provincial health offices in key provinces to implement a MSM HIV intervention program that includes peer outreach activities, capacity building and sensitivity training for healthcare providers, and monitoring and evaluation (M&E). After piloting in four sites, the program has expanded to over 30 provinces in Thailand with GFATM support.

A health promotion model program for MSM living with HIV/AIDS was introduced in 2009. CBOs help promote access to treatment and care services among MSM living with HIV/AIDS and promote risk reduction behaviors, both in terms of preventing onward transmission of HIV and preventing acquisition of STIs. It is expected that more than 6,500 MSM will reached by peer outreach in FY 2012, at a cost of approximately $175,000.

FSW. A RDS survey conducted by GAP Thailand in 2007 among FSW found an unexpectedly high HIV prevalence 20%. Prevalence was particularly high among non-venue based sex workers. Current GFATM support for HIV interventions among FSW in Thailand does not focus on non-venue based workers.

Linking community-based outreach to VCT and STI services, and MSM or FSW diagnosed with HIV infection to care and treatment services, are key strategies in Thailands draft national HIV/AIDS strategy (2012-2016) Getting to Zero. In FY 2013, together with other USG agencies, GAP Thailand will collaborate with MoPH to strengthen the quality of peer outreach activities, promote and create strategies to link key affected populations (MSM and FSW) to VCT and STI services, help ensure linkages of HIV-positive MSM and FSW to HIV care and treatment, and promote quality-of-life and risk reduction among MSM and FSW living with HIV/AIDS. Based on number of non-venue FSW recruited in RDS surveys, peer educators expect to reach over 840 of them through 3 demonstration sites in FY 2012. The proposed budget for the project is $96,000.

In FY 2013, a program evaluation of HIV-positive MSM will be conducted, with the aim of national expansion, if the program is shown to be successful. Part of this strategy will be to support capacity building of community-based MSM and FSW peer groups and of healthcare providers at the national and regional level to ensure quality implementation of HIV prevention and care programs, along with strengthening strategic information (SI) to help guide HIV/AIDS program planning.

For correctional settings, in FY 2013, USG will support the scale up of HIV peer education and the VCT monitoring system. USG, in line with the national M&E plan, will support capacity building for prison and health care staff on use of data for program improvement.

Strengthening Couples HIV Counseling and Testing in Antenatal Care Settings

Approximately 800,000 pregnant women deliver in Thailand each year. More than 95% of pregnant women receive ANC at health facilities. Data show a high uptake of HIV testing among pregnant women; 99% of all pregnant women received HIV testing in 2007. However, only 15% of pregnant women received couples counseling, and 30-50% of new cases of HIV infection in Thailand occur among discordant couples.

The high discordant rate among HIV-infected persons highlights the need for couples HIV counseling and testing (CHCT) for pregnant women and their partners. Following a successful pilot project conducted collaboratively by MoPH and GAP Thailand, routine CHCT for women in ANC settings and their male partners was instituted as new MoPH policy in October 2011. A training-of-trainers program will be conducted in late 2011.

In FY 2012-2013, GAP Thailand will provide TA to MoPH and regional trainers to support the continued roll-out of CHCT. Supervisory follow-up visits to regional offices or hospitals will be conducted to further coach trainers and providers. CHCT indicators will be integrated into the national PMTCT monitoring system (PHIMS v3) to determine uptake and identify implementation barriers. The goal is that, by 2013, at least 60 of 76 provinces will have established CHCT in routine ANC services, and 40% of male partners of pregnant women will be receiving HCT as part of CHCT.

Development of Thailand National PMTCT Monitoring System with Integrated Data Utilization System of the Goals of Elimination of MTCT

Thailands draft national HIV/AIDS strategy for 2012-16 (Getting to Zero) aims that by 2016, the mother-to-child transmission (MTCT) rate will be lower than 1% and the mortality of HIV-positive mothers and their exposed infants will decrease by 75%. (Those percentages might change as the strategy is finalized.) This project will support the national PMTCT program by strengthening the national PMTCT M&E system (PHIMS v3) and promoting data utilization for program improvement. GAP Thailand will pilot the revised PHIMS web-based program to capture current national PMTCT guidelines and develop a system for PMTCT data utilization.

By 2013, the goal is to scale up PHIMS nationally, including PHIMS web-based process monitoring, outcome monitoring (using the National AIDS Program [NAP] database), and systems for data utilization (regular data review, monitoring and supervision, and quality improvement planning and implementation). TA will be provided through MoPH and 12 Regional Offices to monitor and provide technical and management support to provinces and hospitals in their administration. The website for dissemination of monitoring data and PMTCT information will be maintained and regularly updated by the central MoPH team.