This mechanism supports CARs PEPFAR Strategy Objectives 1, 2 and 3.

The Quality Health Care Projects overall goal is to support increased use of effective HIV and TB public health services, by vulnerable groups in CAR. The project focuses on improving the continuum of care for MARPs by strengthening the enabling environment, with a focus on building policy environments that support the delivery of care to MARPs and addressing policy and legal barriers that constrain MARP access to health services; governance of GFATM grants and governance of national HIV programs; and capacity of health providers and NGOs to plan, deliver and manage improved services for MARPs.

The project will work closely with the Health Policy Improvement Project in conducting a rapid review of policy assessments and developing and implementing a policy advocacy strategy and interventions. Quality will build on the work of GMS in implementing capacity strengthening activities for country CCMs and regional coordinating bodies. Quality will work with AIDSTAR II to conduct diagnostic assessments of NGOs and develop and implement capacity building strategies to strengthen the role and capacity of NGOs in supporting national AIDS responses.

FY12 activities will be focused in KZ, KG and TJ. Previous year funds will be used in TK and UZ. Target populations are MARPs, health providers, MOHs, NGOs, civil society, and policymakers. All activities will be closely coordinated with the GFATM, MOHs and other USG partners to leverage resources and build ownership and sustainability of project interventions. Baseline assessments are conducted for each intervention, tracking progress during and after the completed intervention. The project provides on-going mentoring and support

Global Fund / Programmatic Engagement Questions

1. Is the Prime Partner of this mechanism also a Global Fund principal or sub-recipient, and/or does this mechanism support Global Fund grant implementation? No

This mechanism will support the CAR PEPFAR Strategic Objective 3: Strengthen the capacity of public and private sectors to collect, analyze, manage and utilize data for evidence-based planning and policy making at all levels particularly sub-objective 3.1 health information systems. This activity is linked to HVSI BCN of Columbia University-ICAP SUPPORT Project, IM # 12027 and HVSI BCN of the Regional Technical Support project IM #13975. Multiple partners are currently collecting data on MARP populations in KZ, TJ and KG. NGOs collect information on MARP outreach, coverage and behaviors. Republican AIDS Centers conduct MARP size estimation studies, annual sentinel surveillance surveys, among other studies. Health facilities collect data for patients. Donors and development partners conduct surveys and assessment. In order to support one M&E system for Central Asian countries, NGO and AIDS Center data need to be consolidated and standardized. By determining ways to share and use data from the community, facility and national level, countries will have a better understanding of the HIV epidemic and will be more effective in programming limited resources.

The Quality Project will leverage broad project resources and experience and use limited funds to improve the use of data for decision making. Specifically, the project will support streamlining data on MARPs services from the community/NGO level to feed into the national M&E system.In Kyrgyzstan, the Quality Project will build on recent commitment from the government sector, within the scope of the national health sector strategy (Den Sooluk) to create a system by which NGOs report MARPs data to the Republican AIDS Center. This merging of information systems between governmental and non-governmental groups will contribute significantly to clarifying currently unreliable coverage statistics, and should ultimately feed into more accurate population size estimations; it is expected that the dynamic between the governmental and non-governmental sectors will also allow the two groups to hold each other more accountable for accuracy of data. When this system is successfully implemented in Kyrgyzstan, the Quality Project will explore opportunities to introduce a similar system in Tajikistan. The project will work very closely with USG partners, MOHs, development partners, and GFATM Principal Recipients to ensure that these activities support one monitoring and evaluation system for Kyrgyzstan and Tajikistan.

This mechanism supports CAR PEPFAR Strategy Objective 1 and 2 & is linked to OHSS BCN/IM #13974& IM#13977. The HIV epidemic in CAR is affected by many health systems challenges such as stigma, discrimination, legal and policy barriers to accessing services, lack of coordination between NGOs and the health care system, insufficient program oversight and human resources, and non-coordinated systems of care. These challenges need to be addressed as a coordinated approach with other stakeholders at the national and service delivery levels. In previous ROPs, the Quality Project focused its activities on service delivery and supporting NGO capacity building. In FY12, the project will re-focus on broader policy and governance issues to build sustainability of national HIV programs. The Quality Health Care Project will focus on Health System Strengthening activities to improve four sub-objectives: Policy Environment: the project will support development and implementation of national health and HIV strategies in KZ, KG, TJ to include more equitable and gender-sensitive services for MARPs. Using results from the barrier analysis, the project will provide TA to support country partners to improve the legal and policy framework, such as improved documentation services for released prisoners. It will also support approaches such as the strengthening of local coordinating councils and the formation of community advisory boards at the National AIDS and Narcology Centers and local levels to strengthen the role of MARPs in shaping health services. Governance: The project will build management capacity of the CCMs and of regional coordinating bodies in KZ, KG and TJ. The project will strengthen national systems that affect efficiency of GFATM grant implementation such as TA to improve procurement and supply management in TJ and KG. It will assist CCMs in KZ, KG, and TJ to use the dashboard data for decision-making. The project will also provide targeted TA and support as identified by the GMS led diagnostic and CCM capacity development framework. The project will continue to support CCM mechanisms (i.e. technical working groups, oversight teams) that bring together NGOs and health providers to strengthen their partnership. Capacity: In collaboration with CDC partners, the project will support USG efforts to strengthen capacity of health providers in primary health care facilities. Activities may include reviewing and updating in-service curricula, rollout of in-service HIV communication skills training (i.e stigma reduction), and applying new training and mentoring models. The project will strengthen counseling and social work skills for in-service professionals. Integration, collaboration and sustainability: The project will provide targeted technical and management TA to address needs identified by the NGO capacity assessment. The project will also support the essential role of NGOs by advocating for introducing a government financing mechanism for NGOs i.e. social contracting in KG and TJ and for expanding KZs current government NGO financing program, as well as provide TA to develop key aspects of social contracting. Many project activities will be shaped by the results from the reviews of CCM capacity, NGO capacity and stigma and discrimination. The project will work very closely with USG partners, MOHs, development partners and GFATM PRs to ensure that recommended activities from these reviews are implemented and coordinated.

This mechanism supports CAR PEPFAR Strategy Objective 1 and is linked to (1) HVCT BCN/IM #12859; (2) IM #12872; (3)IM #12889; (4) IM #13217; and (5) IM #12812. The numerous policy and legal barriers for expanded rapid testing for MARPs contribute to very low levels of MARPs who know their HIV status. Most counseling and testing is only available at national AIDS centers, which are difficult for MARPs to access due to fear, stigma and lack of legal documents or registration. The quality of counseling and loss to follow up also limits MARP access to quality counseling and testing services. One solution is to expand access to rapid testing for MARPs in a variety of settings and to accompany these tests with high quality pre- and post-test counseling.

The Quality Health Care Project will support two PEPFAR sub-objectives of improving access to rapid HTC in KZ, KG and TJ, and improving the policy and legislative environment for HTC. To improve access, the project will coordinate closely with CDC implementing partners and GFATM to expand access to HTC for MARPs, by instituting the pilot use of rapid tests in six target primary health care facilities in KZ, KG and TJ, and expanding use to outreach workers in the field. In close collaboration with CDC implementing partners, the project will establish appropriate rapid testing protocols, including follow-up testing links for those with positive rapid tests in a non-medical setting. The project will continue to train primary health care workers and facility providers in interpersonal communications skills necessary for accurate risk assessment and provider-initiated counseling and testing. Ongoing mentoring will enable health providers to continually increase their responsiveness to both MARPs referred for HTC and MARPs presenting for other health needs. Continuous Quality Improvement processes as well as on-going monitoring and evaluation will measure HTC quality as well will be used to assess the success of these models.

Using data from the secondary review of policy issues related to MARPs as well as experience from successful models of rapid testing, the project will work with USG, government and development partner stakeholders to further policy changes that promote implementation and institutionalization of rapid testing in different settings. The Quality Project will also work with host country partners to update relevant policies and laws to ensure sustainability of the new testing algorithms.

In KZ, the project will work closely with other USG partners and the Almaty City AIDS Center to examine appropriate rapid testing protocols. The project will also explore funding mechanisms within the state budget to assure that purchase of rapid tests is scaled-up in future years. In KG and TJ, the project will work closely with other USG, outreach partners and GFATM PRs to assure that a strategic plan is in place for rolling out rapid testing to reach more MARPs, and appropriate protocols exist for both rapid testing and follow-up for those who test positive.

The project will coordinate closely with MOHs, other USG partners, GFATM and other donors on policy activities, on efforts to expand coverage of HTC services as well as on identifying models and best practices that can be scaled up and sustained.

This mechanism supports CAR Regional PEPFAR Strategy Objectives 1 and 2 and is linked to: (1) IDUP BCN/IM #12859; (2) IM#12872;(3) IM #12889; (4) IM #13217; (5) IM# 12812; (6) IM #13969; (7) IM# 12772; and (8) IM#13973. The HIV epidemic in Central Asia continues to be primarily driven by injection drug use, with most HIV cases registered among young, unemployed males. The proportion of HIV infection attributed to PWID was around 53% in KZ, 55% in TJ, and 64% in KG. Of CAR's estimated 263,000 PWID, only 1,225 (in KZ, KG, and TJ) are receiving MAT. High levels of stigma and discrimination, a restrictive policy environment, and vertical systems of care for most at risk populations are among the many barriers that prevent access to HIV prevention, treatment and care services.

The primary focus of Quality's work will be in the areas of policy advocacy and capacity strengthening of HIV/AIDS national and regional governance structures, NGOs implementing HIV/AIDS and health providers in targeted primary health care facilities.

Taking recommendations from the Health Policy Project-led rapid review of policy assessments conducted to date, including harm reduction and stigma and discrimination policy reviews, the Quality Project will implement policy change advocacy activities to increase access to PWID services (i.e. expand MAT) and reduce stigma and discrimination at the national and service delivery levels. Among other areas of policy focus, the project will work with other development partners to develop and implement recommended actions to improve the legal and political framework for the expansion of MAT, including assisting in preparation of key policies and protocols, and prikazes and algorithms to implement and expand these services. The project will develop and advocate for adoption of drug treatment legislation that assures right to MAT for treatment of opioid dependence.

In close collaboration with CDC implementing partners, the project will help build the capacity of providers within targeted primary health care facilities to improve and scale-up HIV programs related to drug dependency, including, as available, MAT for PWID. The project will work to improve the capacity of health care workers to address the needs of PWID and improve interpersonal communications skills; follow-up mentoring will be provided and quality of care for PWID will be measured through patient satisfaction surveys and focus groups.

The project will work closely with targeted primary health care facilities to develop and implement service referral systems to promote models of integrated care for MARPs. Attention will be paid to increasing access to these services for women. Quality will also conduct trainings for NGOs and health care workers on family centered approaches for treating females who use injecting drugs.

The project will continue to coordinate with MOHs, other USG and development partners and GFATM grants to ensure coordinated approaches to policy and advocacy and capacity building for health providers can be scaled up and sustained.