This project supports CAR PEPFAR strategy objectives 1 and 2.The goal of the USAID Dialogue on HIV and TB Project is to increase access to HIV and TB prevention and treatment services among most at risk populations (MARPs) through outreach, TA, and training. The project implements outreach programs in 16 sites in Kazakhstan, Kyrgyzstan, and Tajikistan focusing mainly on people who inject drugs and sex workers, people living with HIV/AIDS, men who have sex with men and migrants. Dialogue consortium member, AIDS Foundation East-West, will target prisoners in eight sites in the three countries. The project will fill the gap between services through direct outreach to MARPs, providing referrals to services throughout the HIV continuum of care, and escorting clients to needed services.

Gender will be addressed through targeted outreach activities, increasing equity in HIV activities, and addressing male norms and behaviors. Since this program is co-funded with TB funds, it will also address TB prevention, treatment and adherence.

During the last two years of the project, the project will reduce the number of sub-partners and key staff in the consortium to reduce program costs. The project will provide organizational capacity building to NGOs by training outreach workers and peer educators and through grants. By building organizational and financial management skills of NGOs, it is expected that they will be able to receive grants from other donors in the future. The project will advocate for innovative models such as multi-disciplinary teams (MDTs) to be institutionalized into the national level program.The project uses a rigorous monitoring and evaluation system which consists of on-going oversight and monitoring including financial audits and behavior change surveys.

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

The mechanism will support CAR Strategy Objectives 1 and 2. This activity is linked to HBHC BCN of Columbia University/IM #12872. In KZ, KG and TJ, there are approximately 35,000 PLWHA and slightly about 2,000 on ART. High levels of stigma and discrimination and other barriers prevent many PLWHA from accessing treatment and social support or PHDP services. The USAID Dialogue on HIV and TB Project will support two objectives. The first is to continue to provide high quality PHDP services to 1,250 PLWHA in KZ, KG, and TJ through five grants and TA to NGOs. The projects geographic area will be focused on PLWHA who are not covered by GFATM or other development partners. Activities will include: social support to encourage uptake and adherence of ART, counseling, referral and escort to medical services including TB, HTC, STI, and RH, comprehensive outreach services for PLWHA, and the formation of self-help groups. The project will mobilize PLWHA to take an active role in addressing stigma through support groups who will work closely with AIDS Centers to assist newly identified HIV positive people in coping with their status and provide coaching to reveal status to family and friends. The project may adjust its program based on the Health Policy Project rapid secondary review of analyses related to policy, regulatory and legal factors affecting MARPs access to care and associated policy advocacy strategy. The second objective is to continue to build the capacity of service providers through nine primary health care facility-based MDTs (3 each in KZ, KG, and TJ) and to advocate for institutionalization of a patient-centered approach into government structures. The project uses the Adherence to Treatment Triangle Model for PLWHA, a patient-centered approach that works in coordination with health services, including TB. The MDTs work with 3 points of support: medical, social work and peer support. Peer educators are trained to provide social support and case management for PLWHA and their families, and to build a stable home environment. Medical providers are receive technical training and supportive supervision. The project will continue to provide TA to the 9 MDTs to improve PLWHA recruitment into ART and provide social support while building approaches to assist governments to scale up this model as appropriate. MDTs at primary health care facilities refer and link PLWHA to community-based support groups, which involve PLWHA, family members and partners. Medical specialists provide counseling on ART and TB treatment and on HIV/TB co-infection and other health-related issues. In FY12, USG partners will assess the success of the MDT approach. If the results are favorable, Dialogue Project and partners will advocate for inclusion of MDTs or similar models into HIV National Programs in KZ, KG and TJ, to institutionalize this approach for providing care and support to PLWHA. Inclusion of MDTs at the national level will help ensure sustainability and take this approach to scale. The project will work with development partners to identify and support clinical and in-service training for AIDS Centers and other medical specialists on co-infection issues and treatment regimens. The project will also continue to coordinate with MOHs, other USG partners and GFATM to ensure adequate mapping and coverage of PHDP services

This mechanism supports CARs PEPFAR Strategy Objectives 1 and 2. This activity is linked to: (1) HVCT BCN Abt Associates /IM #12746; and (2) Columbia University/ IM #12872. Access to quality HTC services continues to be a constraint to MARPs knowledge of their HIV status. In Kyrgyzstan, only 10% of MARPs are estimated to have been tested. NGOs are not allowed to perform HIV tests in CAR so their role is restricted to pre- and post-test counseling and referrals to government-operated testing facilities. With no national standards, the quality of counseling for MARPs is irregular. There is significant loss to follow-up between pre-test counseling and testing and between testing and post-test counseling. HIV prevalence among PWID ranges from 3% in KZ to 18% in TJ and 14% in KG. HIV prevalence among inmates was 3% in KG, 3% in KZ, and 9% in TJ. Sexual transmission is reportedly growing with 43% of HIV infections attributed to sexual transmission in KZ. It is assumed, but not yet validated, that this is largely concentrated in bridge populations.

The USAID Dialogue on HIV and TB Project will support two objectives in KZ, KG and TJ. The first is to continue to link PWID and their sex partners, SWs, prisoners, MSM, and PLWHA to high quality HTC services through 27 grants to NGOs in KZ, KG and TJ. USG will support collaborative public sector-NGO activities to reach MARPs reluctant to seek HIV testing services in health care facilities. Approaches will build on HTC messages provided during outreach to undertake MARPs-friendly events where AIDS Centers' staff will provide HTC. The project will also provide escort and referrals to HIV stationary and mobile testing facilities and track the number of tests completed using their voucher system.

In program areas, the project will collaborate with AIDS Center mobile HTC units in KZ, KG, and TJ to increase reach to MARPs as well as provide pre- and post-test counseling for all MARPs while receiving a rapid HIV test. The project will bring mobile HTC services to edutainment and events targeting MARPs, where MARPs feel comfortable receiving services and have positive prevention messages reinforced by their peers. Where mobile HTC does not exist, the project will coordinate with other donors to expand their mobile HTC routes to reach additional sites convenient to MARPs, or advocate for establishment of additional mobile units. It is expected that approximately 5,000 MARPs will receive access to testing using mobile and stationary HTC and be provided with pre and post-test counseling by trained NGO staff.

The projects second objective is to continue to build capacity of NGO outreach workers and health personnel to provide quality counseling services. In collaboration with other USG partners, the project will support an HTC practicum to develop improved pre and post-test counseling skills for NGO outreach/social workers. Trainings will also be provided to participants from HIV testing sites and personnel from mobile HTC units where rapid tests are used and counseling is rare.

The project will continue to coordinate with MOHs, other USG partners and GFATM grants to ensure adequate mapping and coverage of HTC services, and to identify models and best practices that can be scaled up and sustained. The project may adjust/adapt its program based on the Health Policy Projects secondary review of analyses on policy, regulatory and legal factors affecting MARPs access to care.

This mechanism supports CAR's PEPFAR Strategy Objectives 1 and 2. This activity is linked to HBHC BCN of Columbia/IM #12872. Sexual HIV transmission in CAR is increasing. Recent data indicate a steady increase in the percentage of sexually transmitted HIV infections (from 20% in 2006 to 43% in 2009 in KZ, and from 30% in 2006 to 33% in 2010 in KG).HIV transmission among MSM has also increased, though data from different studies vary widely. Migrants are considered to be a risk group but little HIV prevalence data is available.This project will support two objectives in KZ, KG and TJ. The first objective is to continue to provide high quality HIV outreach services for SWs, MSM and migrants through 9 grants and TA to NGOs, and through direct outreach by outreach workers hired by the project. The projects geographic area is focused on areas with high densities of SWs, MSM, and migrants that are not covered by GFATM grants or other development partners.The project will implement a comprehensive package of HIV prevention outreach activities (information, counseling, condoms from the GFATM, negotiation skills, referral and escort to services) for street SWs and SWs in saunas and hotels in target sites through one-on-one sessions, group discussions, peer education and interactive events. Referral to friendly OB/GYNs & STI specialists will be supported through vouchers. Comprehensive outreach activities (IEC materials, condoms from the GFATM, referrals) for MSM will take place through direct outreach, group discussion, events, and through peers and doctors. Families of migrants will receive a targeted package of services (HIV, STI & TB prevention and treatment information) in light of growing indications that wives left behind when husbands migrate often turn to selling sex to support their families. These women will be referred to job skills development training and services to help them exit sex work.The projects second objective is to continue to build capacity of health providers and NGOs to provide quality services and outreach for SWs, MSM and migrants, address stigma and discrimination, and collect, monitor and use data on outreach in support of one M&E system for the national AIDS response. The project will promote MOH-NGO partnerships and pilot approaches through which NGOs will collaborate with MOHs to extend reach and expand coverage of MARPs who are reluctant to visit MOH facilities due to stigma and provider attitudes.Friendly OB/GYNs and STI specialists are included in Health Service Provider trainings to address stigma reduction towards MARPs, to orient providers to use the referral voucher system, and to provide these physicians with accurate information on HIV and HIV/TB co-infection. Trainings will sensitize and educate providers on how to communicate with MARPs and how to provide comprehensive, compassionate care , including STI diagnostics, treatment and RH services.Through the Gender Challenge Fund, the USG will pilot an activity to expand access by female sex workers and MSM to services and information on GBV.The project will continue to coordinate with MOHs, other USG partners and GFATM grants to ensure adequate mapping and coverage of outreach services, as well as to identify models and best practices that can be scaled up and sustained. The project may adjust/adapt its program based on the Health Policy Projects secondary review of policy, regulatory and legal factors related to MARPs access to care.

This mechanism supports CAR Strategy Objectives 1 and 2. This activity is linked to: (1) IDUP BCN Abt Associates/ IM # 12746; (2) Columbia/ IM #12872; (3) RAC-KZ/IM #12889; (4) RAC-KG/ IM #13217; (5) RNC-KG/IM #12812; (6) TBD Harm Reduction Center/IM #13969;(7) UNODC IM #12772; and (8) Health Policy Project/IM #13973. HIV infection attributed to PWID is around 53% in KZ, 55% in TJ, and 64% in KG. Estimated PWID numbers range from 119,000 in KZ to 26,000 in KG and 25,000 in TJ. At special risk are the sub-populations of drug-using SWs and prisoners. The project will support two objectives in KZ, KG and TJ. The first is to continue to provide high quality HIV outreach services for PWID and their partners, SWs and prisoners through 18 grants and TA to NGOs in KZ, KG and TJ. The project will focus in areas with high densities of MARPs who are not covered by GFATM grants or other development partners. NGOs through peer educators, will offer comprehensive outreach services for approximately 5,900 PWID (KZ, KG and TJ) on safer injection and safer sexual behaviors, skill development for refusing requests to assist new injectors to inject, overdose prevention and naloxone use and referrals to MAT if available. In coordination with GFATM and needle/syringe exchange points, the project will refer clients to NSP but per PEPFAR guidance will not engage in direct distribution of NSE. The project will provide information for PWID and their partners on HIV and TB prevention, safe sexual behavior, condoms from the GFATM, HIV counseling and couples counseling, and referral to HIV and TB testing. Edutainment events to attract SWs will provide training on bloodborne infections and sexual prevention of HIV, as well as on drug prevention and treatment. Outreach will cover about 5,000 prisoners many of whom are HIV positive and/or PWID who will soon be released. Social and medical workers and outreach staff in prisons will be trained to work with prisoners on issues related to HIV, TB, viral hepatitis, release preparation and skills development for reintegration into society. Escorts will guide PWID, SWs and prisoners throughout different levels of services- including HIV prevention, ART treatment and adherence, drug treatment, and treatment for TB/HIV co-infection. The project will use non-PEPFAR funds for TB activities. The projects second objective is to continue to build capacity of health providers and NGOs to provide quality services and outreach for PWID, address stigma and discrimination and collect, monitor and use data on outreach. The project will provide TA to support data collection and improve financial management. This data will also support and strengthen one M&E system for MOHs. Through convening technical working groups and national steering committees for project activities, the project will improve the quality and credibility of NGO services as key partners to MOHs for extending coverage and reaching MARPs who are reluctant to visit MOH facilities due to stigma and provider attitudes. Through the Gender Challenge Fund, the project will pilot activities to expand access by female PWID to gender based violence services, such as HIV/STI testing for sexual assault survivors, legal services through drop-in centers and psychosocial services. The project will coordinate with MOHs, other USG partners and GFATM grants to ensure adequate mapping and coverage of outreach services and to identify models and best practices for scale up.