This implementing mechanism is unchanged from last year.

National Center for HIV/AIDS, Dermatology, and STDs (NCHADS)

The National Center for HIV/AIDS, Dermatology, and STDs (NCHADS) is the focal point within Cambodia's Ministry of Health for developing and implementing Cambodia's HIV prevention, care, and treatment services. Under NCHADS's guidance and leadership, a continuum of care for persons living with HIV has been developed that has expanded from an initial pilot in one operational district in 2003 to 51 HIV clinics in 20 of Cambodia's 24 provinces and 39 of Cambodia's 76 operational districts by the end of 2008. VCCT sites have been expanded from 12 in the entire country in 2000 to 216 at present. NCHADS is responsible for the training of physicians and associated staff, the procurement of HIV test kits, drugs, and supplies, the strengthening of laboratories and hospitals to diagnose opportunistic infections and monitor response to HIV treatment, and the development of information systems to monitor the success of the program. As of June 30, 2009, 72% of Cambodia's estimated HIV-infected adults were under care, and over 92% of estimated adults eligible for antiretroviral therapy were receiving it. In addition to scaling up diagnostic and treatment services, NCHADS has implemented a successful prevention program centered on a brothel based 100% condom use initiative and expanding recently to focus on prevention services for other MARP groups. It has also conducted a number of HIV and STI surveys that have been critical to understanding Cambodia's epidemic.

NCHADS receives support from GFATM Rounds 2, 4, 5, and 7, and both financial and technical assistance from WHO, World Bank, Clinton Foundation, and USG. NCHADS's 2008 expenditures were $8.5 million dollars. The NCHADS Cooperative Agreement Implementing Mechanism, while funding only a portion of NCHADS's activities, has had a major impact, particularly in support of national surveillance activities, strengthening of laboratories, and improving HIV clinical services, the three core focus areas of US CDC GAP. The Cooperative Agreement has enabled US CDC GAP to provide technical assistance at the national level and "on the ground" assistance to NCHADS in four focus provinces in northwest Cambodia, Banteay Meanchey, Battambang, Pursat, and Pailin, where 16% of Cambodia's population resides and 17% of Cambodia's HIV patients enrolled at government HIV clinics receive their care. In those provinces, the NCHADS Cooperative Agreement has contributed to the expansion of VCCT services, improved PMTCT services, implemented Continuous Quality Improvement activities at HIV treatment sites, remodeled and upgraded laboratories, provided a regional laboratory analyst to help strengthen referral hospital laboratory capacity, improved testing rates of TB patients for HIV and strengthened capacity of HIV clinicians and TB clinicians to diagnose TB in HIV-infected patients.

In FY2010, the NCHADS Cooperative Agreement Implementing Mechanism will continue to support PMTCT, Adult Treatment, Pediatric Treatment, Laboratory Infrastructure, TB/HIV, and Strategic Information at funding levels similar to those provided in FY2009. In addition, two new budget codes will be added, Adult Care and Support and Pediatric Care and Support. Adult Care and Support is being added to strengthen Prevention with Positive activities (PwP)at HIV clinics. Pediatric Care and Support is being added to improve follow-up of HIV exposed infants to Pediatric HIV Clinics for PCR testing at six weeks and at six weeks post-weaning. This activity, an expansion in geographic coverage of PDTX Budget Code in COP09, will improve our ability to assess the impact of the PMTCT program and assure that HIV-infected infants are provided early care and treatment.

We hope that the addition of these two budget codes to the NCHADS Cooperative Agreement implementing mechanism will produce cost savings over time. If strengthening PwP activities works, infections will be averted, and money for care and treatment saved. Strengthening PwP services also is likely to encourage volunteer activities among PLHA, who will be the country's best ambassadors for behavior change among at-risk groups. Improving testing rates of HIV-exposed infants, while resulting in a cost, will also save the lives of infants who would otherwise have gone undiagnosed, and will also give NCHADS an improved monitoring tool to assess the impact of PMTCT services and adjust those services as needed. We anticipate that the exposed-infant visit at six weeks will be used to counsel mothers regarding optimal feeding practices, which may result in reduction in breast feeding-associated HIV transmission.

This is a new activity. The NCHADS Cooperative Agreement contributes to adult care and support through support of five care and treatment facilities in two northwest provinces of Cambodia (Banteay Meanchey and Pursat). The target is the HIV-infected population in the two provinces and their families. The strategy of Cambodia's Ministry of Health is to organize HIV care and treatment at the operational district level around a Continuum of Care (CoC) in which the VCCT serves as the entry point, the OI/ART clinic serves as the focal point for facility based care, and home based care team is focal point for community based services. Referral between services (VCCT, OI/ART clinic, STD, FP, TB, PMTCT, home based care, in-patient care, and peer support groups) is supported through standard operating procedures, use of referral forms, and regularly scheduled CoC meetings. A patient booklet containing critical information including drugs and quantity prescribed and next visit date is given to every patient registered at the OI/ART clinic. This booklet is a communication tool that allows home based care teams to monitor adherence and remind patients about follow-up appointments and assist with transportation when needed. The NCHADS Cooperative Agreement provides the funds through which critical components of the Continuum of Care are implemented and strengthened in the HHS/CDC focus provinces. In addition, funds are reserved for use centrally by NCHADS to cover monitoring and evaluation and supervision visits by NCHADS.

The Adult Care and Support portion of the NCHADS Cooperative Agreement for FY2010 will fund positive prevention activities at the five focus care and treatment facilities. Specifically, adherence counselors will receive training in incorporating responsible sexuality messages into their routine counseling sessions including impact of alcohol on practice of safe sex; they will also be responsible for determining whether patient has disclosed his/her HIV status to spouse or primary partner and if not, assisting in disclosure. Condoms will be made available for all adult patients receiving care at OI/ART clinics, and pharmacists will be instructed to offer a supply of condoms with every refill of medication. Clinicians will record whether spouse or primary partner has been tested for HIV, and records will be modified so that this can be easily monitored; partners of unknown status and children of female patients will be strongly encouraged to undergo HIV testing. Finally, there will be a focus on prevention of unplanned pregnancies; clinicians will be responsible for referring all women patients of child bearing age to family planning services for birth spacing counseling and supplies, and are to incorporate monitoring of family planning choices as a routine component of every visit.

Positive Prevention will be added to the agenda of regularly scheduled clinical care meetings, during which time staff can discuss problem patientspatients who feel unable to disclose status to primary partner, or patients known to be engaged in risky sexual behavior. This will provide both an opportunity for sharing opinions about how best to deal with these challenging patients as well as keep positive prevention as a major focus of the staff. Meetings can also be used to consider new approaches to positive prevention that the staff may wish to adopt. Monitoring tools will be developed to evaluate positive prevention activities, which will help inform national policy.

This activity is unchanged from last year

This is a new activity. Until 2008, diagnosis of HIV in children could not be reliably determined until 18 months of age. This delay in diagnosis of infants known to be exposed, and the relative ineffectiveness of the PMTCT program in identifying the majority of HIV-exposed infants resulted in very few HIV-infected children under two years of age receiving care and treatment at Pediatric AIDS Clinics in Cambodia. The result is that many infants probably died of HIV-related opportunistic infections without ever being tested for HIV. COP09 described activities intended to strengthen links between PMTCT and Pediatric AIDS care sites to assure close infant follow-up of HIV-exposed infants so that treatment can be initiated as soon as the diagnosis is established.

In FY10, the NCHADS Cooperative Agreement implementing mechanism will fund measures to assure infant follow-up of 80% of exposed infants identified during antenatal care in seven operational districts in three provinces (Banteay Meanchey , Battambang, and Pursat). This will require strengthening the capacity of the Operational District (OD) Maternal Child Health (MCH) Supervisor to monitor the cohort of HIV-infected pregnant women identified during antenatal care or during labor to make sure each infant is followed by home based care, that home based care teams successfully refer these infants for PCR testing at six weeks and at six weeks post-weaning, and that all infants with positive PCR test are registered for OI/ART care at the Pediatric OI/ART Clinic. This will be facilitated by introduction of a cohort-based register organized around expected date of delivery, which will allow the OD MCH supervisor to track all HIV-exposed infants as they are identified during ANC or at delivery, and anticipate dates of expected six week and post-weaning visits so that active steps can be taken to prevent patients being lost to follow-up.

In a related activity, the NCHADS Cooperative Agreement will fund Continuous Quality Improvement activity at the Pediatric OI/ART Clinic to assure that all HIV-exposed infants registered at the clinic are started on Cotrimoxazole Preventive Therapy at six weeks and maintained on it consistently until HIV is definitively ruled out six weeks post-weaning, or maintained on it indefinitely if infant is diagnosed with HIV.

The target population for these activities are: HIV-exposed infants and HIV-infected children in Banteay Meanchey Province, one operational district of Pursat Province, and two operational districts of Battambang Province.

This activity is unchanged from last year.

This activity is unchanged from last year.

This activity is unchanged from last year.

This activity is unchanged from last year.

This activity is unchanged from last year.