This activity focuses on 3 main objectives in support of the program area strategy: to plan and implement

expansion of the national PMTCT strategy, to generate demand and increase antenatal care (ANC)

attendance through working with the exisiting community volunteer structure and health facilities, and to

develop and implement training curricula for health care providers.

Building upon activities in 2007, CARE will continue to work with the rollout of the national PMTCT strategy

covering 100% of Koh Kong province, which includes 135 villages, 13 health centers (HC) and 2 referral

hospitals. This acivity will specifically address the emphasis areas of local organization/capacity building

and gender.

CARE will facilitate the National Maternal and Child Health Center (NMCHC) PMTCT assessments by

working with health care staff, in a mentoring and coaching role, providing technical support and training.

Regular meetings of the health center staff will be supported (logistics and transport costs) to faciliate

organizational learning across the facilities. CARE will continue to work with community volunteer

structures to create demand for PMTCT services, particularly the Home Based Care (HBC) group, who will

factor strongly in surveillance and monitoring of HIV positive mothers.

Using the platform of joint planning activities encouraged by CARE between the provincial health

departments, operational districts and Commune Councils, PMTCT will be included in the annual operating

plan of all administrative avenues funding health activities, ensuring ownership and shared responsibility

across the structures.

CARE will continue to work with Pagodas, not only to provide spiritual support to HIV positive mothers, but

also to provide transitional housing for mothers and children. CARE will also continue faciliatating

communication channels between health facilities and Pagodas.

CARE will facilitate futher strengthening of the Continuum of Care (CoC) framework in Koh Kong, promoting

further coverage and utilization of voluntary counseling and testing (VCT) and PMTCT services as sites

both for delivery of prevention messages and counseling and also an entry point to a CoC incorporating

prophylaxis/treatment for opportunistic infections (OIs), anti-retroviral therapy (ART), PLHA support groups

named Friends Help Friends (Mondul Mith Chuoy Mith - MMM), and community and home-based care

(CB/HBC).

To strengthen the quality of CoC services and referral practices between services, CARE will continue to

work with NCHADS and provincial AIDS office (PAO) to strengthen the Provincial CoC Technical Support

Team and operational district (OD) CoC coordination committees.

CARE will support staff training in PMTCT (midwives/doctors, counselors and laboratory staff) through

provision of logistic and transport costs to meetings and training.

CARE will continue to advocate for inclusion of at least partial PMTCT (counseling, testing, or referral) in all

HCs as a routine part of ANC through provider initiative testing and counseling (PITC). This will be achieved

using a two pronged approach: though building on relationships already established with the Provincial

authorities and Commune Councils and through participating in technical working groups (TWGs) at the

national level to feed into national protocols and policies. If this is approved, as a new activity in 2008,

CARE will conduct the necessary training of HC midwives where other donor support is not available. In the

interim, CARE will work with the PMTCT sites and HCs to develop convenient and cost-effective means of

referral of ANC clients for VCT.

CARE will enhance accessibility, quality and confidentiality of PMTCT services through mentoring and

facilitative supervision to ensure that HCs offer PMTCT directly or through referral to all ANC clients, and

that VCT sites provide family planning (FP) and PMTCT counseling to all HIV positive women. Particular

attention will be given to ensuring that VCT sites have special facilities for pregnant women and that ANC

sites are able to provide an appropriate room for confidential counseling. In addition community mobilization

for PMTCT will continue using the trust already gained by working for years at the community level.

CARE will train 6 new PMTCT counselors to provide couples counseling and referral of male partners for

VCT at ANC and delivery rooms. This training will be complemented by the community activities of the

'Couples in the Know' program, which uses peer education strategies to work with newlyweds in every

village.

Community awareness of the importance of PMTCT services will continue to be promoted through

information educaton and communication (IEC) material and referral by village volunteers and peer

educators as well as by HBC teams in 135 villages.

All HBC teams (one per village) will receive refresher training to support pregnant women to adhere to their

anti-retroviral (ARV) treatment or prophylaxis regimen. In locations where there is no equity fund (a support

fund for the poor to access health services) in place, CARE will continue to support transportation costs for

HIV positive women to deliver at referral hospitals with PMTCT and opportunistic infection/ anti retroviral

treatment (OI/ART) services and follow up care for patners and children. In addition, all HBC teams will be

trained to provide counseling on the feeding practice of the woman's choice with special emphasis on

discouraging mixed feeding and ensuring that infants get regular check-ups with particular attention to

growth monitoring and the incidence of diarrhea.

These organizational and capacity building activities will result in 6 newly trained midwives in the provision

of PMTCT services in line with national guidelines and protocols, provide a complete course of ARV in a

PMTCT setting to 30 pregnant women, provide VCT and follow up testing to 700 pregnant women and

increase the number of service outlets providing the minimum package of PMTCT services by three.

In FY 08, CARE will continue to work with high risk groups namely beer promotion girls, garment factory

workers, youth out of school, young urban males (YUM), and married women in rural areas. Building on

work in 2007 and initiating new innovations in 2008, key condom use and social marketing messages will

be packaged as part of a gender based approach to HIV prevention, which addresses cultural sexual norms

that put both men and women at risk for HIV.

CARE predominately implements through local partner NGOs, and monitors, facilitates and provides

technical assistance to them. The NGOs then work in the factories or other targeted sites delivering the

activities outlined below. In FY 08, CARE will work with 8 NGO partners.

The delivery of condom and other prevention messages is made possible through strong partnerships with

private industries and volunteers. Direct targets number 38,500. FY 08 activities will specifically address

the emphasis areas of gender, capacity building, and workplace programs.

In FY 08, CARE will focus on incorporating life skills, HIV/AIDS awareness and prevention, and reproductive

and sexual health messages into the training of dedicated peer educators for each nominated high risk

group. CARE will train 200 peer educators (PE) for YUM, 2,400 PE working in 40 garment factories, and

120 beer promotion peer facilitators. Target groups are identified through workplace and employers groups

in the case of the women, and for YUM in outreach promotions such as universities, nightclubs, and bars.

Peer educators receive three days of intensive training using curricula and materials developed and

supplied by CARE. Refresher trainings/meetings including peer educators sharing experiences, in addition

to monitoring and tracking peer educators is implemented on a monthly basis by each individual NGO

partner and organization.

In Koh Kong province, CARE will train and support PEs among the following vulnerable groups: fishermen,

migrant male workers (mototaxi drivers, laborers, cross-border traders), and women who are especially

vulnerable to engaging in transactional sex such as employees in massage parlors and karaoke bars.

In Phnom Penh, CARE will support PEs who work in garment factories and will train new PEs to work with

YUM. Among women, PEs will give special emphasis to skills in negotiating condom use, matched by

advocacy with gatekeepers to support women's rights to refuse coerced sex, to insist on condom use, and

to be safe from the threat of gender based violence (GBV). Among men, PEs will emphasize the dangers

associated with transactional and unprotected sex and reinforce that even healthy-looking ‘sweethearts'

may carry HIV. PEs will stress the need for correct and consistent condom use by people in non-

monogamous relationships. CARE will enable Vulnerable Group (VG) PEs to socially market condoms

procured with non-USAID funds.

With all VGs, CARE will promote prompt treatment of STIs and reproductive tract infections (RTIs). VG PEs

will provide IEC on the signs and symptoms of STIs/RTIs and location and cost of available services. CARE

will also train and support both workplace-based and public health providers in STI diagnosis, treatment,

contact tracing and follow up. This training will emphasize confidentiality and respectful provider demeanor

so that clients feel comfortable accessing the services. Building on the Provider Behavior Change

Intervention (PBCI), which provides a good foundation in terms of basic empathy and provider ethics, CARE

will conduct sessions with providers to sensitize them to the special needs of vulnerable populations and

provide them with skills in breaking down real and perceived barriers. Lastly, CARE's assistance for rape

survivors will promote HIV prevention through counseling of the survivor and family to reduce the

stigmatization of survivors that may result in extreme vulnerability to exploitation.

In FY 08, CARE will continue to work with the model of home based care (HBC) that is implemented jointly

between CARE, Health Center (HC) staff, community volunteers and Buddhist monks. This activity

specifically addresses the emphasis areas of HIV/AIDS, gender equity, increasing women's access to

income and productive resources, increasing women's legal protection; local organization capacity building;

wraparound programs in TB and child survival; wraparound programs in economic strengthening, food

security, and education; training - in-service and pre-service.

In FY 08, in Koh Kong province, CARE will continue to financially, logistically and technically support the

‘Mondol Mith Chuey Mith' (MMM) centers headed by PLHA volunteers that host self-help groups for PLHA,

providing essential psychosocial support as well as information on self-care, treatment issues and service

availability. MMMs will be supported in all locations where HBC teams work.

In FY 08, CARE will promote community involvement and contribution to the care of PLHA via such

mechanisms as pagoda/mosque/church donations and donations by farmers of rice after the harvest. This

will ensure that communities have the means to care for their most vulnerable members. CARE will

implement interventions to build community resources and resilience in villages with above average poverty

and a high concentration of PLHA and orphans and vulnerable children (OVC). These will include initiatives

such as the formation of savings groups and rice banks, technical assistance and small inputs in improving

agricultural productivity and animal husbandry, and improvements to water and sanitation. Such assistance

will be predicated upon a contractual agreement with the community to provide material assistance to

PLHA, their families and children, and represents a small but important step towards making PLHA/OVC

care sustainable in Cambodia.

CARE has supported Smach Meanchey Reproductive Health (RH) to provide opportunistic infection (OI)

prophylaxis and treatment at OI/ART service and is in the process of establishing the OI care service at Sre

Ambel RH. CARE will continue to facilitate quality improvement of OI care servcies through supporting MoH

health care workers (clinicians, nurse counselors, laboratory staff) to attend National Training Courses and

OI/ART team to conduct regular team meetings with participation of the provincial AIDS office (PAO) and

CARE clinical mentor.

CARE community based volunteers will also promote TB screening for PLHA.

CARE will support HBC teams in provision of physical and psychosocial support to PLHA and their families,

including OVC, following NCHADS Standard Operating Procedures for HBC provision. It is estimated that

more than half of all PLHA are presently reached by HBC teams in Smach Meanchey and Sre Ambel

Operational Districts (OD), but lack of a denominator makes such estimates only approximate, and may

hinder expansion. Village leaders and Village Health Support Groups (VHSGs) will be trained and assisted

in listing all persons with a chronic illness and OVC in each village, thereby allowing a more accurate

assessment of coverage and identification of missed beneficiaries. Further beneficiaries will be identified

through referral from VCT and AIDS treatment facilities. HBC teams will consist of CARE or sub-grantee

staff, HC counterparts who join the teams after normal HC hours, PLHA support group members, Village

Care Givers (VCGs) and religious leaders. They will be trained and supported in psychosocial/spiritual

support, OI prevention, early recognition and referral of OIs for treatment, adherence support for ART and

ARV prophylaxis (for PMTCT), education in coping with ART side-effects, Family Planning (FP) and PMTCT

counseling/referral, infant feeding education, and follow-up of HIV-exposed infants. Self-care information,

education and communication (IEC) materials, including nutritional guidance, hygiene, and recognition of

signs and symptoms of OIs will be disseminated to PLHA and caretakers. In collaboration with the National

Center for HIV/AIDS, Dermatology and STDs (NCHADS) and Douleur Sans Frontières, CARE will assist in

training facility-based providers and HBC teams in pain management care. CARE will address the problem

of homeless or abandoned PLHA through development of, and referral to, community-managed hospices as

a locally sustainable solution. CARE has already supported the establishment of a hospice at a Buddhist

pagoda in Smach Meanchey OD; other hospices will be established following this model as necessary.

In Koh Kong province, this work links with GF Round 4 funding for ART and care.

The New Hope for Cambodian Children's Transitional house in Phnom Penh provides a place where very

sick children who need intensive care that their families can not provide can come and be restored to

health. When they have better health, these children return to their families.

In FY 08, the CARE home based care (HBC) teams will be responsible for monitoring and assisting

households with OVC and assisting families with succession planning for child care when necessary.

Adequate parenting by biological parents or an extended family member will be facilitated where possible

and placement with appropriate non-related caretakers where not. This will be accomplished through

advocacy with village leaders, religious leaders, and the Ministry of Social Affairs, Veterans and Youth

Rehabilitation (MoSALVY) to involve village Child Protection Networks (CPNs) in child placement. CARE

will train local leaders in the new adoption law and related procedures, and assist in establishing and

supporting community-based mechanisms to evaluate and select OVC family placements, assist adoptive

families in securing legal status, and provide follow up support.

CARE will also provide subgrants to support group homes for OVC who cannot be placed in a family, and

will monitor the care they provide. In FY 07, CARE served over 1,680 children in the proposed project area

who are either orphaned due to HIV/AIDS or unusually vulnerable due to chronic illness in the family,

physical or mental disability, physical psychological or economic abuse/exploitation, and/or extreme

poverty.

In FY 08, CARE will ensure strong linkages between the program activities and its literacy, life skills and

livelihoods program in Koh Kong province, integrating vocational training and/or scholarship support for

young people identified through the OVC support activities. This will be operationalized through partnership

with Pagodas and other existing youth groups.

HBC teams will advocate for and mobilize community support to OVC households and CARE will implement

interventions to enhance community resources in villages with a high concentration of PLHA/OVC. CARE

will encourage communities to establish play activities, such as painting, for OVC and non-OVC in the same

village, enabling them to interact with each other positively and form friendships. This model has proven

highly successful in breaking down social barriers and improving the psychosocial well-being of previously

marginalized children. In communities with several OVC, CARE will facilitate meetings of caretaker support

groups.

In Phnom Penh, The Early Childhood Development Center provides day care and support ensuring that

PLHA will not have to abandon their children in order to work. In FY 08, the center will continue to provide a

safe place for working mothers and fathers to leave their children while they work.

In FY 08, CARE will continue to integrate VCT into its larger ABC prevention activities. Using the same

platforms that are outlined in the activity narratives of AB and Condoms and other prevention, CARE will

work in Koh Kong province and Phnom Penh with high risk populations including beer promotion girls,

garment factory workers, youth out of school, young urban males and married couples in rural areas.

Building on FY 07 activities, and initiating new innovations in FY 08 VCT health promotion messages will be

packaged as part of a gender based approach to HIV prevention, which addresses cultural sexual norms

that put both men and women at risk for HIV.

Building on the sound relationship already established in 2007, CARE will particularly target newly married

couples, through a peer educator approach, termed Couples in the Know (CITK). Youth will also be targeted

through a peer educator approach. VCT referral will be supported, by providing training and incentives to

Village Health Volunteers for referral. 1600 people will be tested at 2 VCT centers.

In the urban areas, CARE predominately implements through local partner NGOs, which work in factories or

other targeted sites delivering the activities outlined below. In FY 08, CARE will work with 8 NGO partners.

VCT messages are delivered using small and large health promotion activities based on strong partnerships

with private industries and volunteers.

In FY 08, CARE will specifically address the areas of gender, capacity building and workplace programs.

Peer education for youth and adults will enhance lifeskills and empower young people not to engage in high

risk behavior. Life skills, HIV/AIDS awareness and prevention, reproductive and sexual health messages,

and the benefits of being tested are incorporated into the training of peer educators for each nominated high

risk group. In the the urban areas there are 200 peer educators (PE) for young urban males, 2,400 PE

working in 40 garment factories, and 120 beer promotion peer facilitators. Target groups are identified

through workplace and employers groups in the case of the women, and for Young Urban Males (YUM) in

outreach promotions such as universities, nightclubs and bars. Peer educators receive three days of

intensive training using curricula and materials developed and supplied by CARE. Refresher trainings and

monitoring and tracking of peer educators is followed on a monthly basis by each individual NGO partner

and organisation learning is shared at a monthly meeting of all partners.

CARE will assist in raising awareness of the benefits of VCT through its network of PEs, who will be trained

and supported in actively promoting the benefits of VCT and publicizing the locations of MoH approved VCT

centers. They will stress the importance of being tested only at an MoH approved site, as there are many

unregulated private testing services.

In Koh Kong province, CARE will train and support PE who are "model" couples, one per 30 families in the

village. These Couples in the Know (CITK) are the focal points for queries or referral to VCT. CARE staff

will train the CITK for three days, then monitor activities on a monthly basis. CARE will support monthly

meetings of CITK where experiences, successes, and obstacles are exchanged. In previous years this

approach has proven successful in generating demand for VCT, particularly when the CITK peer educators

are highly respected in the village.

With all activities and target groups CARE will promote VCT by providing health promotion materials

showing the location and cost of available services. CARE will also train and support both workplace-based

and public health providers in VCT. This training will emphasize confidentiality and respectful provider

demeanor so that clients feel comfortable accessing the services. CARE will conduct sessions with

providers to sensitize them to the special needs of vulnerable populations and provide them with skills in

breaking down real and perceived barriers.

In FY 08, CARE will also conduct small and large scale target group mobilization and health promotions,

with a focus on the benefits VCT. These will be conducted at participating employer facilities, universities,

nightclubs, at health facilities, with youth groups, as well as at the village level with local authority

participation. The messages will be delivered using media, IEC material, interactive games, and other

participatory activities.

For youth, who are often hesitant to seek testing, the location of ‘youth friendly' VCT will be specifically

publicized, e.g., the RHAC clinics and ‘youth-friendly' Health Centers (HC). VCT education and information

materials will include information on HIV care and treatment to assure people that services are available if

they test positive. CARE will support the National Center for HIV/AIDS and Dermatology (NCHADS) training

of people living with HIV/AIDS (PLHA) as VCT counselors and strengthen referrals from VCT to HIV/AIDS

care and treatment through provincial Continuum of Care (CoC) technical support teams and the

Operational District (OD) CoC coordination mechanism.

In FY 08, in Phnom Penh CARE will continue to advocate and facilitate the provision of VCT referral

network by the garment factory and beer distributors management for their staff. This will be done through

the employers association channels that have been established by CARE with the private institutions in FY

06 and FY 07. CARE facilitates and provides logistics support to participating referral clinics to meet

regularly to discuss operating issues and responsibilities. Referral data is collated monthly and reported to

CARE quarterly. The exisiting referral network will be accessed by the YUM target group through a

confidential counseling function in the CARE youth center.

In FY 08 CARE will pilot a mobile VCT van, which arrives in villages following promotion messages through

the volunteers, and encourages testing on the spot. Activities around the arrival of the van will include

theater and music messages, as well as formal welcoming by village leaders and volunteers. The VCT will

be done by health staff from the VCT facility. Follow up and tracking will be done through the exisiting

channels already established in the VCT facility.

CARE will continue to strongly advocate that employers take responsibility for their staff in the areas of

reproductive and sexual health with key HIV/AIDS prevention and VCT focus. Activities include logistics

and technical support to employers groups and associations, development and refinement of good

corporate citizen code of conduct with emplyees and leveraging the power of the private organizations to

advocate for safe and healthy work practices at the national level.

Activity Narrative: CARE will continue to participate in HIV/AIDS TWG at national level feeding into national policy, guidelines,

and protocol refinement.

CARE will collaborate with the National Center for HIV/AIDS, Dermatology and STDs (NCHADS) and the

Koh Kong Provincial AIDS Office (PAO) to establish a satellite anti-retroviral therapy (ART) site in Sre

Ambel. During the period, CARE will continue to support ART services in Smach Meanchey and Sre

Ambel, with an emphasis on improving quality while promoting universal access to treatment for eligible

PLHAs. CARE will support access to NCHADS training and refresher courses by MOH clinicians,

counselors, and pharmacists in opportunistic infection (OI)/ART team, and facilitate onging quality

improvement through in-service training by NCHADS-approved trainers, supportive supervision, case

conferences, telemedicine, regular participatory problem-solving sessions, workshops, and regional

conferences. CARE will also support NCHADS to establish a regional/ provincial network of OI/ART

clinicians and conselors and help organize their semi-annual meetings.

In both full and satellite ART locations, CARE will provide technical and financial support to establish

minimum adequate levels of physical infrastructure and materials for ART services, and provide expertise in

data management for patient and program monitoring. Since CD4 values are sensitive to specimen

collection and transportation practices, CARE will continue to support quality control of CD4 counts in the

field in collaboration with the National Institute of Public Health and CDC, and to support specimen

transportation costs. CARE will continue to support institutional pediatric ART via sub grants to New Hope

for Cambodian Children which will provide transitional homes to enable children to be stabilized on ART and

train hospital staff in pediatric AIDS care; quality improvements mentioned above; and coordinating special

laboratory requirements, for Smach Meanchey pediatric ART program. CARE will also train home-based

care teams in follow-up of children on ART and adherence support.

CARE will support transportation costs to OI/ART facilities for indigent PLHA to ensure uninterrupted

therapy, and train home based care teams, PLHA support group leaders, and family members to serve as

adherence supporters. CARE is now developing curriculum to promote ARV treatment literacy, and it is

expected that 30 PLHA support group members will be trained using this curriculum by mid-2008. In

addition, CARE will strengthen supply management of ARV and related medical supplies at facility and

provincial level to avert potential stock outs.

HIV/AIDS care and treatment is heavily dependent upon the willingness of providers to treat PLHA and their

ability to do so in an empathetic and non-discriminatory manner. CARE will provide training to providers on

HIV transmission which stresses an accurate understanding of risks associated with occupational exposure,

the protection afforded by universal precautions (UP), and the availability and efficacy of post-exposure

prophylaxis (PEP). CARE will assist SMC and SA hospitals in establishing a system to monitor UP practices

and to promote readiness to repond and report accidental occupational exposure.

Strengthening of clinical service provision will be closely coordinated with activities funded under GFATM

Round 4 in Koh Kong province.

In FY 08, CARE will continue to build upon strong partnerships formed in FY 06 and FY 07 with local and

national authorities and ministries; District, provincial and national level health teams; private providers and

industry representatives; community and youth based volunteer networks; and local NGO partners. In FY

08, activities will emphasize gender, capacity building and workplace programs.

In FY 06 and FY 07, CARE initiated several influential partnerships in the private industry to support HIV in

the workplace and increase HIV prevention education. Industry based associations have been formed that

meet directly with factory and distribution owners and managers. Industry codes of conduct will continued

to be refined, and monitored by CARE, leveraging the power of private organizations and the data collected

on the improved situation of workers, particularly women, to inform national policy.

Cross cutting activities relating to gender and right to health will continue in 2008. This includes advocacy

through national and more local campaigns to various ministries including health, womens affairs, education

and labor. CARE will provide a voice for the high risk populations that it works directly with to advocate for

access to the Continuum of Care (CoC).

In FY 08, CARE will build upon FY 07 pilot activities in Koh Kong in the area of post partum care. An

inportant part of the post partum package is the identification and referral of HIV/AIDS positive mothers into

the PMTCT program.

In FY 08, CARE will carry out surveys in both Koh Kong and Phnom Penh. All survey results will be shared

with appropriate national organizations, as well as with other USG partners. Through consultancy technical

support, the technical capacity of CARE M&E staff and local partners will be strengthened. Survey results

will be diseminated at District level, helping to measure performance against baseline surveys taken in

2007/2008.