This ongoing cooperative agreement supports the CAR PEPFAR Strategy Objectives 1, 2 and 3. The overarching goal is to provide TA to and build the capacity of the Ministries of Health in CAR so that care, treatment, laboratory, and MARPs prevention services for people at risk for, and living with, HIV/AIDS in CAR will be provided according to accepted international standards, and adapted to the local context. These activities will take place primarily in Kazakhstan, Kyrgyzstan, Tajikistan, and to a lesser extent, Uzbekistan.The TA is primarily targeted to most-at-risk-populations, people living with HIV/AIDS, their health care and other service providers, and Ministry of Health staff. This mechanisms strategy to become more efficient over time is by developing standard operating procedures, guidelines, and quality management systems, in partnership with CAR Ministries of Health, which will be institutionalized and incorporated into CAR governmental prikaz (orders of the MOHs) to be implemented nationwide, after appropriate USG-supported training of relevant staff. The SUPPORT Project will closely coordinate its efforts with other PEPFAR-supported programs and the GFATM and other development partners to leverage limited resources and avoid duplication of efforts.USG will monitor the activities funded through this cooperative agreement through regular, ongoing site visits, meetings, and monthly reports. In addition, the implementing indicators included in the monitoring and evaluation plan will be regularly monitored by USG.

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? Yes2. Is this partner also a Global Fund principal or sub-recipient? Neither3. What activities does this partner undertake to support global fund implementation or governance?

Budget Code Recipient(s) of Support Approximate Budget Brief Description of ActivitiesHTXS Republican and oblast AIDS centers (PRs and SRs) 261000 training of staff on ART, review of treatment protocols and guidelines, supervisory visits to GFATM-supported treatment sites in KZ, KG and TJHVCT Republican and oblast AIDS Centers (PR and SRs) 42000 VCT assessment to identify gaps and obstacles to HIV testing among MARPs in KZ, KG and TJ. In KG - also supporting revision of HIV testing algorithims and validation of rapid tests procured by the GFATMIDUP GFATM subrecipients -- Narcology Dispensaries 285000 Training of MAT staff and development of MAT M&E systems in KZ, KG, and TJ. TA to GFATM/PEPFAR supported trust points

This mechanism supports CAR PEPFAR Strategy Objective 1. This activity is linked to HBHC BCN PSI/IM #12859. The goal is to build individual, institutional and organizational capacity in Kazakhstan, Kyrgyzstan, and Tajikistan to provide high-quality facility-based and home/community-based care activities for HIV-infected adults and their families.In FY 11, The Columbia Universitys SUPPORT Project completed comprehensive assessments of C&T services in KZ and KG and TJ. In FY12, the project will complete a similar assessment in Uzbekistan, and will then develop recommendations based on the results. The SUPPORT Project will assist the MOHs to develop clinical guidelines on palliative care for PLWHA and organize a CAR Conference on Palliative Care for PLWHA. The project will also provide in-service trainings for AIDS-centers staff (physicians, nurses, physiologists, gynecologists and epidemiologists) on HIV-related care as part of a pilot C&T model that will be implemented by six selected AIDS Centers (two each in KZ, KG, and TJ). As part of the model, the SUPPORT Project will facilitate bi-directional referral systems with other USG partners programs, including those implemented through NGOs and will work with the AIDS centers to integrate provision of clinical care, nutrition assessment, counseling, support and palliative care (pain and symptom relief) and positive prevention services into their routine medical HIV care. Most of the services will be facility-based, but if needed, home-based care will be provided through the existing Visiting Nurse program of the AIDS Centers. Couples-based counseling and gender-based approaches will be introduced to ensure effective positive prevention. It is expected that model implementation will result in higher retention rates, improved quality of life and treatment outcomes among PLWHA. All models will include rigorous M&E, including a standard set of indicators, a client data management system (client contact forms and an electronic database), supervisory visits, mid-term and end-line evaluation of results, patient exit interviews and focus group discussions with PLWHA groups (NGO-based and independent). The results of performance measurement data will be used to refine model activities. Upon completion, successful models will be recommended for national rollout using GFATM funds in Kyrgyzstan and Tajikistan and state/local health care funds in Kazakhstan. If accepted, the revised procedures and the extended package of care services will be included into the SOPs to be developed for the HIV clinical departments of the AIDS Centers during FY13.

This mechanism supports the CAR Regional PEPFAR Strategy Objective 1. This activity is linked to: (1) HLAB ASCP/ IM #12026 and (2) CLSI,/IM#13970. The primary goal is to support the MOHs in Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan, to enhance laboratory capacity to provide HIV-related diagnostic and monitoring tests according to international laboratory competency standards. The current HIV testing algorithms in CAR require an excessive number of tests for confirmation of results; existing procedures contribute to delays and difficulties for individuals to obtain their results of laboratory examinations. The SUPPORT Project will provide TA to help MOHs strengthen referral and communication links between laboratories and medical providers, and provide TA to MOHs to examine different HIV screening and diagnostic algorithms, including the incorporation of rapid testing, and the addition of quality assurance procedures.The lack of effective and accessible laboratory monitoring for PLWHA seriously hinders effective clinical management of patients. The SUPPORT Project will provide training on proper use of laboratory equipment needed for monitoring of people on ART. Currently, CD4 and viral load testing is being performed primarily at the national level, and in a few regional (oblast) level laboratories. Due to this centralized laboratory structure, high cost and irregular delivery of kits and necessary supplies, and lack of trained personnel, only a fraction of people on ART are being properly monitored. The SUPPORT Project will work closely with all Republican (national) AIDS Centers in KZ, KG, TJ and UZ, as well as with selected regional AIDS Center laboratories, to develop and implement laboratory Quality Management System (QMS), QA/QC procedures, protocols, and SOPs for HIV testing and laboratory monitoring of PLWHA. The project will continue supporting MOH TWGs in CAR to develop and implement SOPs for viral load and CD4 testing, including on-site training and mentoring as well as national workshops for laboratory technicians on a variety of topics. Technical assistance will also be provided for strengthening referral linkages and networking between clinical and regional and national reference laboratories. The SUPPORT Project will work with the MOH in KZ, KG and TJ to plan and implement validation of test-kits adapted to dry-blood spot (DBS) elutes and saliva-based and blood-based rapid tests officially registered in each of the countries. Results of validation will allow improving QA/QC procedures and improve implementation of IBBS and rapid HIV testing. The SUPPORT Project will work with the Laboratory Coalition partners to address remaining gaps and issues on HIV quality testing. The SUPPORT Project TA will include assisting the MOHs develop and implement an effective system of forecasting and planning for laboratory supplies, including training of laboratorians and related staff on how to use the newly developed systems.

This mechanism supports the CAR Regional PEPFAR Strategy Objective 1. This activity is linked to: (1) HVCT BCN RAC-KZ/ IM #12889; (2) RNC-KG/ IM #12812; (3) RAC-KG/ IM #13217; (4) PSI /IM #12859; and (5) Abt Associates/IM # 12746. The primary goal is to support the MOHs in Kazakhstan, Kyrgyzstan, Tajikistan to scale up counseling and testing activities to ensure that PWID, their sex partners and other MARPs receive access to high-quality and accurate HTC services.According to IBBS data, HIV prevalence among female SW in 2010 was 1.5% in Kazakhstan, 2.7% in Tajikistan and 1.6% in Kyrgyzstan. The percentage of SW who were tested for HIV and knew their results ranged from 44% in Tajikistan to 80% in Kazakhstan. The prevalence of HIV among PWID was 2.8% in Kazakhstan, 14% in Kyrgyzstan and 17.6% in Tajikistan, while HIV testing knowledge was 61% in Kazakhstan, 38% in Kyrgyzstan and 27% in Tajikistan. The percentage of MSM tested for HIV who knew the results of their test was 60% in 2010. Based on IBBS assessments results we know that IBBS prevalence data is most likely underestimated, while HIV testing indicators are overestimated, and the actual level of HIV testing among MARPs is very low. Official HIV testing statistics shows that HIV tests among MARPs represent less than 2% of the overall number of tests performed in the regionIn FY12, the SUPPORT Projects TA will include activities in which both HTC are provided through provider-initiated and client-initiated approaches in government-run health-facilities, including MAT distribution sites, stationary and mobile Trust points (sites offering specialized prevention services for PWID) and outpatient departments of the AIDS centers (friendly clinics) in KZ, KG, and TJ. At least 30 medical specialists, counselors, outreach workers, and social workers will be trained on motivational interviewing techniques to increase utilization of HTC by MARPs, including couples-based counseling and gender-based counseling.The SUPPORT Project will also support strengthening of peer-driven interventions to motivate PWID, their sex partners, and SW to increase HIV testing rates. Quality assurance systems for both testing and counseling will be developed and piloted in USG-funded HIV prevention sites. Activities to track enrollment of HIV-positive people into care will be ensured, including voucher-based referral and monitoring systems and case management activities.The SUPPORT project will closely collaborate with other PEPFAR-funded programs as well as with GFATM and other development partners to leverage resources and avoid duplication of efforts.The project will support the MOHs in CAR to evaluate the existing HIV rapid test systems and make recommendations that would allow integration of rapid HIV testing into the national HVCT algorithm.

This project supports CAR's PEPFAR Strategy Objective 1. This activity is linked to HVOP BCN PSI /IM #12859.In Central Asia, HIV is most commonly transmitted through injecting drug use. However, heterosexual transmission has been increasing, with the proportion of newly registered cases reporting this mode of transmission rising between 2006 and 2010 from 20% to 43% in Kazakhstan, 17% to 27% in Tajikistan and from 30% to 33% in Kyrgyzstan. HIV transmission from PWID to their sex partners is believed to be the key factor for the increasing number of heterosexually transmitted HIV infections.Rates of male-to-male sexual transmission are largely unknown. According to the KZ RAC the estimated number of MSM in 2010 was 37,500 in Kazakhstan, however other yet unpublished study indicates that the estimated number of MSM in 4 major cities is 60,000. According to the RAC (2010), the estimated number of MSM is 3,700 in KG: and is 30,000 in TJ. There are currently no good estimates for the size of MSM population in Tajikistan, Kyrgyzstan and Uzbekistan.In Kazakhstan, the percent of officially registered HIV cases with male-to-male sexual transmission increased from 0.5% of all registered cases in 2006 to 1% in 2010. In Tajikistan 0.03% (4 cases) of registered HIV cases were among MSM. In Kyrgyzstan, official statistics do not separate sexual transmission by heterosexual and male-to-male. Annual IBBS among MSM conducted in 8 sites in Kazakhstan estimated 1% HIV prevalence among MSM, however these figures are underestimated. Results of one study conducted in Almaty showed that HIV prevalence among MSM in Almaty can be as high as 20.2%. According to the IBBS data, 60% of MSM were tested for HIV and know their results.With funds available from previous years, the SUPPORT project will work with the Ministries of Health of Kyrgyzstan and Tajikistan and local MSM NGOs to develop a protocol and conduct a survey to estimate the size of the MSM population and identify key barriers and opportunities for HIV prevention among this group. Based on existing evidence, the SUPPORT Project will provide TA to the MOH in Kazakhstan to pilot MSM-friendly HIV services in four sites based at GFATM/Government supported friendly clinics. Technical assistance will include formulation of approaches and implementation, on-site training and mentorship, including technical competence to initiate and provide quality counseling related to sexual practices and ability to monitor and evaluate services provided. Technical assistance will focus on incorporating evidence-based behavioral and combination strategies to daily work, including motivational counseling and couple-counseling.

This activity is linked to: (1) IM #12889; (2) IM #13217; (3) IM #12812; (4) IM #13969; (5) IM #12799; (6) IM #12772; (7) IM#13973, (8) IM #12859; and (9) IM #12746. This Project supports CAR Strategy Objectives 1 and 2. HIV in CAR is mainly transmitted through unsafe injecting practices. In 2010, the proportion of PWID among officially registered HIV cases was 53% in KZ, 55% in TJ, and 64% in KG. There are about 263,000 PWID in CAR; HIV infection rates range from 3% in KZ to 17% in TJ. The majority of PWID are young, unemployed males. IBBS results for PWID show high frequency of sharing injecting equipment and low levels of condom use. Transmission of HIV from PWID to their sex partners is believed to be a key factor for increasing sexual transmission of HIV in CAR.In FY12, the project will disseminate results of geographical mapping of HIV services for PWID in KZ, KG and TJ to increase service provider and PWID awareness of service availability and also provide evidence-based recommendations for improving HIV prevention programs. The project will continue to build MOHs capacity to routinely update maps of HIV/AIDS health services. The project will work with local partners to develop a system to collect program data from all partners working with PWID.The project will provide TA to the MOHs of KZ, KG and TJ to implement HIV prevention services for PWID and their sex partners through mobile Trust Points & a client-friendly drop in center. The project will support the introduction of evidence-based and effective approaches, promotion of peer-driven interventions, development of guidelines, counseling training & mentoring of staff (including gender-based counseling and couples-counseling); motivational counseling for HIV testing; introduction of rapid tests; positive prevention; ART support for PWID/PLWHA; case management and referral to TB diagnoses and treatment; referral for other medical services, peer support and psychosocial care. TA for M&E will include elaboration of indicators, data collection forms and reporting tools, training of staff and supervisory monitoring visits and establishment of quality assurance systems at the central and service delivery levels.In close collaboration with USG, GFATM and other partners, this project will organize a Regional Harm Reduction Conference to share best practices and lessons learned in Harm Reduction, including MAT and other evidence-based interventions across Central Asia and the rest of the world.In FY12, the project will disseminate results of comprehensive assessments of the GFATM-funded MAT programs in KZ, KG, and TJ and work with the MOHs and international partners to improve the quality of MAT implementation by training MAT staff and improving M&E of MAT programs. To further improve understanding of MAT among existing and potential clients, SUPPORT will help MAT sites to develop information education materials for clients and their family members. By disseminating lessons learned and organization of regional meetings, the project will support regional exchange fostering collaboration and knowledge transfer among service providers working on HIV prevention for PWID.

This cooperative agreement (CoAg) supports the CARs PEPFAR Strategy Objective 1. The goal is to build individual, institutional and organizational capacity in Kazakhstan, Kyrgyzstan, and Tajikistan to provide high-quality comprehensive C&T packages, including ARV, cotrimoxazole prophylaxis and TB screening. The MOHs in these countries have identified a great need in improving their capacity in ARV treatment, and The SUPPORT Project will be the primary provider of rigorous TA to the AIDS Centers in HIV treatment.In FY11-12, the project completed a comprehensive baseline evaluation of the HIV C&T Services in KZ, KG, and TJ. The key results show poor levels of knowledge and understanding among clinicians of existing ARV recommendations, low prescription of preventive cotrimoxazole treatment and TB screening, poor efforts to implement positive prevention, absence of a multi-disciplinary approach to patient management, low patient retention, low adherence to treatment, and lack of comprehensive treatment services at the ARV treatment sites. The project will conduct in-service trainings for medical staff on ARVs, treatment schemes, and adherence. On-site supervisory visits will follow to ensure proper use of skills and knowledge obtained during trainings. The project will support national ARV conferences to inform clinicians about new ARVs, results of the latest studies and recommendations for ARV usage, and assist the MOHs develop ARV forecasts for 2012-2015. In order to make the ARV forecasting and planning process data driven, transparent, and sustainable, the SUPPORT Project will incorporate an ARV forecasting module into the Electronic HIV Case Management System (EHCMS) that is now being rolled out to the local AIDS Centers in CAR. This will allow automated calculation of ARV needs, based on the current ARV demand and predicted enrollment of new clients. Furthermore, the project will provide TA to the MOHs in implementing the EHCMS entry of clinical data, and will support two AIDS Centers each in KZ, KG and TJ (six total) to pilot comprehensive patient-centered C&T service-delivery models. These pilots will seek to improve patient retention and adherence to ARVs, cotrimoxazole prophylaxis, and TB screening by working closely with other PEPFAR-funded programs. Implementation of the models will involve in-service trainings, task shifting, and development of standard operating procedures. The SUPPORT Project will conduct on-site supervisory visits, and develop M&E systems to track evaluation of outcomes using data from the EHCMS and client interviews. Adherence obstacles will be addressed using gender-based approaches, and will be closely linked with PLWHA support groups. Couples-based counseling and involvement of treatment supporters will be introduced to improve patient retention. Performance measurement data from the EHCMS will be closely monitored and used to refine model activities. Project activities will primarily target MOH medical clinic staff (clinicians, epidemiologist, and data management specialists). Through the provision of TA, in-service trainings, and development, dissemination and implementation of standard operating procedures and other documents, knowledge and skills will be transferred to the host MOHs to assure sustainability of ARV service delivery.