Despite the scale-up of PMTCT sites to 77 centers with coverage including every province and 40 of

Cambodia's 69 operational districts (OD), less than 10% of Cambodia's pregnant women are getting tested

for HIV. The result is that most pregnant HIV positive women are unaware of their HIV status and thus miss

the opportunity to receive ARV and to prevent transmission to their child. Attempts to refer pregnant women

to HIV testing sites some distance away have had mixed but generally disappointing results. Recently the

National Center for HIV/AIDS, Dermatology, and STDs (NCHADS) eased its restriction on HIV testing

outside a VCT center for pregnant women. The Royal Government of Cambodia (RGC) will now allow

pregnant women to undergo HIV screening at an antenatal care (ANC) site performed by a midwife or other

health professional. Women testing positive shall require confirmatory testing and appropriate post-test

counseling at the nearest VCT. The change in testing strategy greatly increases access to HIV testing as at

ANC centers where testing is available on site, there has been wide acceptance of testing.

In an effort to rapidly scale up PMTCT testing in FY 08, NCHADS with support from the USG will provide

HIV-screening on site at 81 health centers in Battambang, Banteay Meanchey and Pursat Provinces and

Pailin City. NCHADS will also provide screening on-site at the seven PMTCT maternity sites in the above

four provinces to ensure that women with unknown HIV status presenting in labor have the opportunity to

receive effective prophylaxis. Cooperative agreement funds will cover training, supervision, and monitoring

and evaluation.

NCHADS, with support from the USG, will work with Provincial Health Departments' Maternal Child Health

coordinators and PMTCT supervisors to train staff in counseling and testing, utilizing training tools

developed by the USG. The USG will also collaborate with the National Maternal and Child Health Center

(NMCHC) and NCHADS to institute logistical and management procedures that will need to be in place in

order to replicate this model of scale-up in other provinces. NCHADS will also work with its partners in

promoting health messages in the region to build acceptance of the need for testing during pregnancy. This

should increase ANC participation and will also serve to heighten public awareness of the risk of HIV to

married women.

This undertaking is consistent with the USG 5-Year Strategy, which states that rapid expansion of PMTCT

services remains as an integral part of the USG Cambodia strategy.

NCHADS will provide feedback to the Secretaries of State for Health regarding the outcome of this project

and will utilize the annual PMTCT workshop, which it will continue to sponsor, to highlight this activity.

NCHADS will use FY 08 cooperative agreement funds to:

- Conduct annual PMTCT workshop in 2008;

- Participation of two PMTCT secretariat staff in one regional conference;

- Costs for provincial and OD PMTCT supervisor from each of four provinces to participate in quarterly

meeting with ANC staff of USG supported health centers to discuss HIV testing and counseling procedures,

record keeping, and referrals of positives;

- Transportation expenses to VCT for;

1. women who screen positive for HIV at an ANC site in Battambang, Pursat or Battambang Province

or Pailin City, where NCHADS is supporting on-site HIV screening and partner funds are not available; and

2. impoverished women who are referred from an ANC site in Battambang, Pursat, or Banteay

Meanchey Province, or Pailin City, that does not offer on-site HIV screening.

The National Center for HIV/AIDS and Dermatology STDs (NCHADS) and the USG have collaborated with

TB/HIV activities nationally and with Provincial Health Departments in three provinces. Nationally, they

have helped re-invigorate the TB-HIV working group as a forum where the national HIV and TB programs

with assistance and support from partners can jointly develop policies around shared themes. These

include roles and responsibilities in the diagnosis of TB among PLHAs and the screening for HIV among

patients with TB, agreeing on TB screening criteria, on M&E indicators, and on how to share data across

programs.

In FY 08, the NCHADS cooperative agreement and the USG will continue to work with national and

provincial government partners to make optimal care universally available to HIV-infected persons with TB

disease. It will add Pailin City to the locales it serves. Optimal care can be provided when both HIV

infection and TB disease are found in its early stages, so active case detection efforts will be expanded.

Optimal care can be provided only if available tests for diagnosing TB are of high quality. National TB

Program has identified inconsistent quality of diagnostic smear microscopy. The USG regional laboratory

analyst will work on site with TB laboratory staff, who do staining and microscopic exam, and health center

staff, who do smear preparation, to optimize smear microscopy diagnosis. The cooperative agreement will

also continue to provide funds to cover the cost of transport to VCT for impoverished TB patients without

NGO support for transport.

The cooperative agreement in conjunction with the USG will continue to support quarterly TB staff meetings

in the three focus provinces and will add Pailin as a fourth service area. It will provide mentoring of

provincial health department (PHD) personnel who coordinate TB/HIV activities in Battambang and Pailin to

improve their leadership in motivating TB staff to send their patients for HIV testing. With that intent, it will

fund participation in a regional TB/HIV conference for up to 8 provincial level staff (up to two from each

province and Pailin) showing exceptional leadership skills. With the recent opening of a USG office in

Battambang, staffed with a project development officer with a focus on TB/HIV, a program support assistant

charged with gathering performance indicator data and providing feedback to the PHD and clinical care

sites, and a regional laboratory analyst, the USG will have a more consistent presence and will be able to

provide regular feedback to health center staff regarding their success in referring TB patients for HIV

testing.

However, it is noted that even in Banteay Meanchey, where this approach has been in practice for three

years, 24% of TB patients with unknown HIV status are not receiving their test results. Recently, in

response to a USG supported evaluation of Cambodia's PMTCT program, NCHADS has modified its

position regarding HIV testing at primary care sites to allow screening with a single Determine rapid test to

be done at the health center level, with all positives referred to VCT or OI/ART clinic for confirmatory testing

and appropriate post-test counseling. NCHADS, the PHD, and the USG will identify selected health center

sites with high TB case load and will pilot on-site testing at those sites, using training tools developed by the

USG and translated into Khmer.

At the national level, CDC-GAP will continue to provide technical assistance by participating on TB-HIV

TWG. In addition if the training materials used to train HC staff in counseling and testing prove effective,

CDC-GAP will provide these materials to the NTP for use nationwide as it scales up on-site HIV screening

of TB patients.

Finally, CDC-GAP will support increased attention to infection control either by sponsoring an international

consultant to evaluate care sites in Cambodia or supporting two Cambodians, one from the TB program and

one from NCHADS, to get training in this area. Training would consist of attendance at international training

courses and mentorship under USG consultants. A field evaluation will also be supported to develop

recommendations regarding steps needed to minimize risk of TB transmission in HIV care facilities.

This activity is linked to the CDC-TBD request to develop a Quality Assurance/ Quality Improvement

program to be initiated at ten OI/ART sites in FY 08 in the provinces of Banteay Meanchey, Battambang,

and Pursat, and the City of Pailin. In FY 08, the National Center for HIV, AIDS, Dermatology, and STDs

(NCHADS), with technical assistance from the USG and its partners, will begin to implement the Quality

Assurance/Quality Improvement program which will include the following:

1) Development of a set of quality of care indicators by a team assembled by NCHADS and the USG. The

USG HIV clinical advisor will assist in the development of the indicators, and will work with NCHADS to

implement this activity in the three provinces and municipality.

2) Develop a tool that is compatible with the current data management system that with minimal investment

in additional data entry personnel can generate automatic site or provider specific reports, assessing quality

of care based on the selected indicators.

3) A core management committee consisting of Provincial Health Department (PHD) directors or deputy

directors and Provincial AIDS Office (PAO) managers that convenes quarterly to review quality of care

reports and gets feedback from PLHA representatives regarding their care from the patients' perspective.

4) A team of clinical mentors, one from each province, selected by their peers to be available for one week

assignments at a care site where quality indicators have identified a quality concern. The core

management team of the project will give no more than two such assignments per year to each mentor.

Mentors will submit reports to the core management team and to NCHADS regarding findings and

recommendations, and corrective actions would be initiated with follow-up of indicators to monitor for

improvement in performance. The USG HIV clinical advisor will monitor mentoring interventions and assess

whether mentoring led to improvements in performance quality indicators, and assess whether investment

in quality improvement program results in a demonstrable improvement in quality.

This new activity will require funds to be incorporated into a Cooperative Agreement with NCHADS to cover:

• Cost of one day quarterly meetings (per diems and travel expenses) of four PHD directors or deputy

directors and Provincial AIDS office managers plus NCHADS personnel in attendance;

• Cost of one day quarterly meetings (per diems and travel expenses and small stipend) for PLHA

representatives from each represented OI/ART site (10 sites);

• Stipend, per diem, and travel expenses for three clinicians for two one week assignments;

• Data entry, management, and analysis costs;

• Cost of two regional one day meetings, one to enlist responses and feedback from the providers and

managers from the sites where this will be implemented to assure a sense of ownership and so that

appropriate adjustments in the plan can be made prior to implementation, and a second implementation

meeting to review procedures that are to be followed.

In addition to this new activity, NCHADS, with technical assistance from the USG and its partners, will

continue to strengthen ARV services in Banteay Meanchey, Battambang, and Pursat Provinces (and will

add Pailin City) by:

o sponsoring two clinical case conferences/ clinical training workshops in the northwest Cambodia region.

The USG HIV clinical advisor will participate in these conferences;

o sponsoring two regional network meetings;

o providing funds for 3 providers from each province (and Pailin) to attend an appropriate regional

conference.

The USG cooperative agreement with NCHADS will continue to support laboratories in four focus areas:

the three provinces of Banteay Meanchey, Battambang, Pursat, and the municipality of Pailin. Onsite

technical assistance, to include review of laboratory methods, standard operating procedures, and quality

assurance, will be provided by the CDC laboratory analyst stationed in Battambang. Workshops on

laboratory techniques and quality assurance will be conducted in collaboration with the National Institute of

Public Health Laboratory. USG funds will be used to support laboratory equipment maintenance

agreements and purchase quality control reagents, as necessary. In addition, USG funds will be used to

purchase three new hemoanalyzers, needed for monitoring HIV patients receiving ARV treatment.

As described in separate PMTCT and TB/HIV activity narratives, the USG will support the purchase of HIV

test kits for screening TB patients and pregnant women at health centers in the four focus areas. HIV

screening of TB patients and pregnant women at health centers is a newly approved initiative. NCHADS,

with technical support from the USG and its partners, will train health center staff in HIV screening methods

and interpretation of test results. Although there are 164 health centers in the four focus areas screening

will be conducted initially in those health centers with sufficient staff and TB and antenatal care services,

and will be expanded to others when sufficient resources are available to ensure high-quality testing and

referral. Note that components of this activity are dually funded through both GHAI and CDC Base funds

through the NCHADS Cooperative agreement.

The National Center for HIV/AIDS, Dermatology and STDs (NCHADS) Surveillance Unit is responsible for

conducting routine sentinel surveillance and special surveys for prevalence of HIV, sexually transmitted

infections (STIs), and risk behaviors. Additionally, in collaboration with several partners, NCHADS is

responsible for developing estimates and projections of HIV prevalence, incidence, and mortality.

NCHADS Data Management Unit is responsible for managing all of NCHADS program data (voluntary

confidential counseling and testing (VCT), ARV, etc.) needed for monitoring care and treatment and

supporting the data management needs of the Surveillance Unit. In 2006, Data Management Teams were

placed in the Provincial AIDS Offices of 11 provinces. NCHADS plans to expand Data Management Team

coverage to 9 provinces by the end of 2009. Both Surveillance and Data Management Units work closely

with staff in Provincial AIDS Offices.

In FY 08, NCHADS, with USG support, will conduct an integrated biological-behavioral sentinel survey.

Until 2005, Cambodia's sentinel surveillance system had not included MSM as a sentinel population.

Prevalence of HIV, sexually transmitted infections (STI), and related risk behaviors among MSM had not

been routinely monitored. NCHADS included MSM in a cross-sectional integrated biological-behavioral

survey (IBBS) for the first time in 2005. In 2008, NCHADS will conduct a follow-up IBBS in 5 priority

provinces (Phnom Penh, Kampong Cham, Battambang, Sihanoukville, Banteay Meanchey) among three

target populations: female sex workers, clients of female sex workers, and men who have sex with men

(MSM). MSM will be tested for HIV as well as STIs. Technical assistance in protocol development and

data collection, analysis, and interpretation will be provided by Family Health International (FHI) and the

USG.

The USG will provide technical and financial support to conduct HIV Sentinel Surveillance (HSS) in 2009 in

22 provinces and municipalities. The ninth round of this national survey is projected to cost well over

$200,000 and USG will provide partial funding ($140,000). HIV prevalence will be measured among

pregnant women attending antenatal care clinics, female sex workers, and other at-risk populations. From

this data, national estimates and projections of HIV prevalence, incidence, and mortality will be derived.

The USG will also support NCHADS to develop population size estimates. Projects to estimate or improve

previous estimates of population (MSM, IDU, OVC) size will be conducted in Phnom Penh and several other

USG-supported provinces (to be determined). NCHADS will conduct the projects in collaboration with the

World Health Organization (WHO) and USG. USG will contribute $2,500 to support partial costs of in-

country training and data collection and provide technical assistance in project design and data collection,

analysis, interpretation, and reporting.

And finally, USG will provide $2,500 to support NCHADS data management and monitoring and evaluation

activities. NCHADS Data Management Unit will continue to collect program data needed to monitor VCT

and Continuum of Care programs as well as support surveillance data entry and management. The unit will

continue to be supported primarily by WHO with technical assistance provided by USG as requested. USG

funds will be used to provide computer equipment and support training on data collection, analysis, use, and

management in USG's four focus areas (Banteay Meanchey, Battambang, and Pursat province and Pailin

municipality).