On September 30, 2012 USAIDs contract with FHI 360 will end. A request for applications for a new flagship project focusing on prevention, care, treatment and capacity building will be issued in fiscal year 2012. The new project is outlined below.

Goal and objectives:

The project will enhance the impact and reduce the cost of the national response to HIV through investments in innovative service-delivery approaches and improved local capacity to deliver these services. The objectives of the project are to: 1) foster local capacity to design and implement innovative HIV interventions targeting most-at-risk populations and people living with HIV; and 2) to strengthen the organizational capacity of local partners.

Geographic coverage and target populations:

Project activities will target major urban and peri-urban centers in provinces with high HIV prevalence. Target groups include female entertainment workers and their male clients; men who have sex with men and transgendered persons; injecting drug users; and persons living with HIV.

Cost-efficiency:

The new project will develop innovative and targeted approaches to HIV prevention in an effort to provide and disseminate more effective and relevant services to underserved populations while reducing overall costs.

Monitoring and evaluation:

The new project will develop and execute a monitoring plan that will specify expected program results with indicators, mid-term milestones or benchmarks, and end-of-project results.

Vehicles:

We anticipate that at least one vehicle and several motorcycles will be procured with this project.

Target populations:

Target populations are people living with HIV and their affected family members.

Interventions:

The TBD partner will develop refined models to deliver community-based and family-focused HIV care in Cambodia. Programming priorities will include improved integration of services; the expanded use of quality assurance and quality improvement protocols; the early detection and referral of suspect cases of tuberculosis; improved monitoring of and support for antiretroviral treatment adherence; and the provision of positive prevention services including enhanced access to family planning services and couples HIV counseling for HIV-infected or affected individuals.

Key activities will include: 1) support for the implementation and evaluation of recently revised national standard operating procedures for HIV prevention activities for individuals infected or affected by HIV/AIDS; 2) the development of enhanced client referral systems to improve use of tuberculosis, family planning, sexually transmitted infection, and HIV care and treatment services among people living with HIV; 3) the piloting of new protocols to identify and reach HIV-infected individuals in their communities earlier in their disease progression; and 4) support for the revision of the national home-based care curriculum to improve the skill sets of care providers. In particular, the curriculum revisions will strive to improve the ability of care providers to provide positive prevention services, monitor for HIV treatment adherence and side effects, and refer clients to other relevant HIV, health and social services.

Target populations:

Target populations are children infected or affected by HIV and their caregivers.

Interventions:

Interventions for orphans and vulnerable children and home-based care are integrated in Cambodia to develop a more comprehensive child-centered and family-focused approach. The TBD partner will focus on strengthening the capacity of families, guardians and community members to care for and protect orphans and vulnerable children. Specifically the partner will provide training to home-care teams and caregivers on: counseling and palliative care; life skills; parenting skills; establishing linkages for medical, psychosocial, nutritional and economic support; and combating stigma and discrimination. This training will strive to introduce values and skills that strengthen the links between community-based interventions and those in health facilities to improve care for orphans and vulnerable children. By establishing working relationships with existing community development entities, such as local pagodas, and commune and village chiefs, the partner will also facilitate beneficiary access to a broader set of livelihoods, economic and social support services. At the national level, the TBD partner will work collaboratively with the National Task Force for Orphans and Vulnerable Children to revise and refine national policies for comprehensive and high-quality care for orphans and vulnerable children.

Target populations:

Target populations are people living with HIV, tuberculosis patients, and their affected family members.

Interventions: To improve access to HIV services among tuberculosis patients, and to reduce tuberculosis-associated morbidity and mortality among individuals infected with HIV, the TBD partner will focus on: 1) improving joint tuberculosis and HIV communications strategies; 2) strengthening referral systems between HIV and tuberculosis services; 3) increasing access to antiretroviral treatment for tuberculosis patients; 4) providing training on the clinical management of tuberculosis and HIV; and 5) developing strategies to improve tuberculosis infection control, access to isoniazid preventive therapy for people living with HIV, and intensified tuberculosis case-finding.

Specifically, the partner will train physicians to screen for and diagnose tuberculosis among HIV-infected individuals, and to routinely offer HIV testing to tuberculosis patients. Providers will also be trained to provide isoniazid preventive therapy to HIV-infected individuals without active tuberculosis on a routine basis according to national standard operating procedures. The partner will support the development and implementation of tuberculosis infection control strategies at HIV care and treatment sites. Training will be provided to Village Health Support Group volunteers to deliver tuberculosis and HIV prevention and care education, identify and refer suspect cases of tuberculosis through contract tracing, and monitor tuberculosis treatment adherence.

Target populations:

Target populations are children living with HIV and their caregivers.

Interventions:

Key priorities of the TBD partner will be increasing the coverage of care services among HIV-infected children, and reducing the loss of these children to follow-up in pediatric health facilities. Improved protocols to enhance communication and referrals across antenatal care, maternity, prevention of mother-to-child transmission and pediatric HIV care and treatment service-delivery sites are critical to achieve these objectives. The partner will work with relevant national technical working groups to develop appropriate guidelines and policies to strengthen pediatric HIV care and treatment services and improve information sharing and successful referrals across HIV and other health services at the clinical and community levels.

In addition, the partner will pilot referral mechanisms to improve follow-up of HIV-exposed children from delivery sites to HIV pediatric services. Greater emphasis will be placed on performing early infant diagnosis in collaboration with the National Institute for Public Health, UNICEF, and the Clinton Foundation. The partner will provide appropriate training for home-based care teams, health clinic staff, and pediatric HIV care providers.

At the facility level, the partner will improve cotrimoxazole opportunistic infection prophylaxis coverage among HIV-infected and HIV-exposed children. Home-based care teams will encourage mothers or guardians of HIV-infected children to have their children fully immunized. The partner will improve quality of pediatric HIV services through training, supervision, and mentoring activities to strengthen drug and commodity supply systems, case management, coordination structures, referral systems and monitoring systems. Targeted training through a combination of onsite mentoring and formal training will be provided to physicians. The partner will support regular meetings for infected children and their families at HIV care sites, and will use these to provide appropriate information and education on basic care, opportunistic infection prevention, nutrition, and social and psychological support.

Interventions:

The TBD partner will strengthen the dissemination and use of strategic information to improve the quality of programs and to inform rational resource allocation in the national HIV program. Through direct mentoring and supervision, as well as though the development and implementation of enhanced information systems in demonstration sites, the partner will build local capacity to use data to identify and address unmet service delivery needs, improve program quality and impact, and reduce program costs.

Anticipated results include: the conduct of more routine, integrated HIV behavioral and biological surveillance among most-at-risk populations; the conduct of routine censuses of most-at-risk populations to assess program coverage; improved use of routine program data to inform resource allocation; expanded use of quality assurance and quality improvement systems in service delivery; and the introduction of a confidential system that can track unique individuals use of a variety of HIV and other health services. Such a multi-faceted system is critical to monitor and improve successful provision of needed HIV prevention, care and treatment services to members of hard-to-reach and highly mobile at-risk groups.

In addition to building local capacity to gather and use strategic information, the new partner will provide program information to a third-party partner to facilitate the rigorous, independent evaluation of service-delivery innovations introduced under this implementing mechanism.

Interventions:

The TBD partner will play a key role in supporting the rational development of the annual operational work plans for the National Center of HIV/AIDS Dermatology and Sexually Transmitted Infections; the National Center for Maternal and Child Health; and provincial partners.

In addition, the partner will work with the Ministry of Health and other civil society partners to improve the appropriate, cost-effective integration of HIV and other health systems and services in clinical settings and in communities. In particular, activities will focus on: improving referrals across HIV other health service-delivery sites; developing systems to share patient information across facilities and providers; establishing protocols to improve access to HIV services among infected individuals hospitalized in departments that do not specialize in HIV; expanding the use of provider-initiated approaches to HIV testing and counseling in relevant clinical settings; developing protocols to improve access to family planning services in HIV care and treatment sites; and developing protocols to improve linkages between tuberculosis and HIV services. This work will include the provision of training to health facility staff to promote service integration and the integration of program and human resource management within the other functions of referral hospitals.

Target populations:

Target populations include female entertainment workers, their male clients, men who have sex with men, injecting drug users, and pregnant women.

Interventions:

The TBD partner will work in close collaboration with the National Center for HIV/AIDS, Dermatology, and Sexually Transmitted Infections to strengthen the quality and coverage of HIV testing and counseling services among most-at-risk populations in Cambodia. Activities will focus on the development and dissemination of innovative approaches to improve rates of HIV testing and counseling among most-at-risk populations in their communities, and in clinical settings likely to feature patients facing elevated HIV-infection risks. These approaches will include, but not be limited to: 1) the use of rapid HIV testing technologies to provide diagnostic services and clinical referrals to at-risk individuals on an outreach basis through lay counselors, and 2) the expansion of provider-initiated HIV testing and counseling in sexually transmitted infection clinics, tuberculosis clinics, antenatal care clinics, and on hospital inpatient wards.

The partner will provide technical assistance to the national HIV program in revising HIV testing and counseling guidelines and training curricula to incorporate the use of innovative technologies, improve client referrals to other relevant HIV prevention, care and treatment services, and foster rational service integration to improve quality and reduce costs. Specific emphasis will be placed on enhancing the quality of HIV counseling to prevent HIV transmission from HIV-infected individuals and in HIV serodiscordant couples, and to address unmet family planning and sexually transmitted infection treatment needs among HIV testing and counseling clients.

Target populations:

Target populations include female entertainment workers and their male clients; men who have sex with men and transgendered persons; injecting drug users; and people living with HIV.

Interventions:

Epidemiological evidence and resource constraints call for HIV prevention programming with an enhanced focus on populations facing the greatest HIV infection risks. The effectiveness and efficiency of programming depends on the routine involvement of beneficiaries in planning and implementation, and the constant adaptation of service delivery protocols to embrace emerging innovations and scientific breakthroughs. To address these challenges, the TBD partner will work with local implementing partners to create centers of excellence for the implementation, evaluation, and dissemination of innovative interventions to reduce the vulnerability of most-at-risk populations to HIV and sexually transmitted disease acquisition. The partner will promote preventive and health-seeking behavior among program beneficiaries, improve the quality and relevance of prevention services, and strengthen linkages between HIV prevention, care, and treatment services across clinical and community-based delivery sites.

The anticipated results under this project will include: 1) more impactful and cost-efficient national protocols for the delivery of HIV prevention services; 2) improved access to a comprehensive package of clinical and community HIV services for most-at-risk populations; 3) enhanced community participation in HIV prevention programming; and 4) the introduction and adoption of novel and more impactful approaches to HIV prevention nationwide. Project activities include: 1) delivery of a refined package of prevention services to most-at-risk populations, including peer education and counseling, condom and lubricant provision, and referrals to HIV and sexually transmitted infection care and treatment; 2) the delivery of HIV testing and counseling services to most-at-risk populations on an outreach basis using rapid HIV testing technologies; and 3) training and mentoring of government and civil society staff in the implementation of technical advances and innovations in HIV prevention.

Target populations:

Target populations include injecting drug users, female entertainment workers, and men who have sex with men.

Interventions:

The TBD partner will focus on the provision of technical assistance improve the quality and coverage of harm reduction programming, focusing on the use and abuse of alcohol, amphetamine-type substances and heroin among populations facing elevated HIV risks in Cambodia. The partner will help refine one-to-one or small group counseling interventions for drug users at high risk for HIV infection, and will pilot innovative contingency management approaches and other activities designed to improve the quality of existing programming for drug users. In collaboration with the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and AusAIDs HIV/AIDS Asia Regional Program, the partner will develop and implement a new assisted referral system to improve the utilization of methadone maintenance treatment and HIV care and treatment services among injecting drug users. These efforts will also improve access to needle and syringe programming and case management services for current and recovering drug users, and referrals to other relevant social services. To cultivate critical community support for the implementation of harm reduction activities for injecting drug users and other populations facing elevated HIV infection risks, the partner will also work closely with the National AIDS Authority, the National Center for HIV/AIDS Dermatology and Sexually Transmitted Diseases, the Ministry of Interior, UN Agencies, and other development partners to engage local leaders in HIV prevention activities.

Target populations:

Target populations include female entertainment workers, pregnant women, and people living with HIV.

Interventions: The TBD partner will provide technical support to the national HIV and maternal health programs to: develop refined prevention of mother-to-child transmission guidelines and policies; strengthen service delivery at the facility and community levels; and apply program data to improve the relevance and quality of programming. These efforts will result in more efficient service delivery protocols, improved curricula to train providers and enhanced access to prevention of mother-to-child transmission services among the beneficiary populations listed above. In particular, the partner will support integration of family planning and reproductive health education and services into HIV and maternal health delivery sites, and will work to improve linkages between clinical and community activities. To promote HIV testing among pregnant women, breastfeeding women, and postpartum women, the partner will train health center staff in provider-initiated HIV testing and counseling. The partner will conduct regular monthly supervision visits using quality assurance and improvement tools. The partner will improve rates of clinical follow-up among infants born to HIV-infected mothers by using community members to identify needs and to facilitate referrals. In addition, the partner will provide specialized training to traditional birth attendants on the prevention of mother-to-child transmission, and to home-based care teams on the use of checklists to improved follow-up of exposed infants and their mothers, promoting polymerase chain reaction testing for exposed infants at six weeks, appropriate prophylaxis and informed safe-infant feeding and immunization.

Target populations:

Target populations include people living with HIV.

Interventions:

Consistent with World Health Organization recommendations, Cambodia has issued revised treatment guidelines which call for the initiation of treatment among HIV-infected adults with a CD4 cell count of fewer than 350 cells/mm3. The TBD partner will strengthen the quality of HIV treatment services through training, mentorship and supervision to strengthen drug supply systems, clinical case management, coordination, and the introduction of enhanced referral and monitoring systems.

Specifically, the partner will: 1) expand the use of continuous quality improvement systems at HIV care and treatment sites; 2) support the revision and delivery of training curricula for providers to improve the quality of patient care; 3) develop and pilot innovative HIV treatment drug distribution systems through patient networks to eliminate unnecessary clinical visits and improve adherence; 4) provide direct in-service mentoring and support to HIV care and treatment providers; and 5) work with the national HIV program to develop revised, more impactful and cost efficient national HIV care and treatment guidelines.

Target populations:

Target populations are children infected with HIV.

Interventions:

There are currently 19 public sites that provide HIV care and treatment to children infected by HIV. Due to the increasing number of children on treatment, the TBD partner will support the National Center for HIV/AIDS, Dermatology, and Sexually Transmitted Infections in expanding the implementation of HIV care and treatment services for children to additional sites. Specifically the partner will provide in-service provider training through mentoring and formal workshops. The partner will also provide training in the use of relevant data collection and analysis approaches to enhance patient monitoring and follow up, and identify opportunities for program improvement. The partner will also provide training to volunteers at the community level to help identify HIV-exposed or infected infants and children and to ensure their referral to appropriate follow up services. Finally, the partner will support the development of revised, more impactful, and cost efficient national guidelines for pediatric HIV care and treatment.