This ongoing cooperative agreement supports the Central Asia Region (CAR)s PEPFAR Strategy Objectives 1, 2 and 3. The goal is to provide TA to the Republican AIDS Center, Ministry of Health (MOH), of Kazakhstan to provide an expanded and high quality minimum package of essential HIV prevention services for MARPS, particularly people who inject drugs (PWID). The target population is the MOH in KZ, MARPS, especially PWID, and their service providers. Through this project, TA and support will be provided to enhance access to and increase the quality of HIV prevention services to PWID, through rapid HIV testing in mobile units, and additional activities to foster a friendly environment for PWID. These programs will be developed to maximize efficiency and cost effectiveness. Activities are designed to work with the MOH to develop policies and protocols that will be adopted by the KZ government when the project ends. All activities are coordinated with the GFATM, and other USG partners to leverage resources and build ownership and sustainability of project interventions. Monitoring and evaluation plans will be developed for all project activities, which will allow MOH staff to monitor and improve the quality and efficiency of their HIV prevention services. These reports will be monitored by USG staff during regular site visits, meetings, and review of monthly activity reports.

This activity supports CAR's PEPFAR Strategy Objective 3: Strengthen the capacity of public and private sectors to collect, analyze, manage and utilize data for evidence-based planning and policymaking at all levels. This activity is linked to: (1) HVSI BCN Columbia /IM # 12027; (2)the Abt Associates /IM # 12746; and (3) the Regional Technical Support project/ IM #13975. Since 2003, USG helped to launch regular Integrated Biological and Behavioral Surveillance (IBBS) among MARPs that became a routine practice implemented nationwide in Kazakhstan. In FY 11, the USG team conducted an assessment of IBBS. The results of the assessment revealed the need to improve IBBS practices to ensure its effective implementation. ROP12 funds will be used in FY12 to support a nationwide IBBS conference to present and discuss the HIV epidemiologic situation in Kazakhstan. The Project will also closely coordinate its efforts with other PEPFAR-funded programs, GFATM and other international partners to ensure leverage of efforts and avoid duplication.

This supports Central Asia Region (CAR)'s Strategy Objective 1 and 2. This activity is linked to HVCT BCNs (1)Columbia/IM #12872; and (2) Abt Associates/IM # 12746. The predominant mode of HIV transmission in Kazakhstan (KZ) is unsafe injecting practices. As of January 2011, there were an estimated 119,000 PWID in Kazakhstan, of which approximately 17,000 reside in Almaty. Sentinel Surveillance indicates an HIV prevalence among PWID of 3%, accounting for 53% of all registered HIV cases in Kazakhstan in 2010. Only 23% of PWID have been reached by existing, fixed-location HIV prevention services (Trust Points or TP), which are primarily located in medical facilities. Poor coverage of PWID by these Trust Points is attributed to lack of transportation, fear of medical institutions and legal authorities, and a perceived hostile or unfriendly environment. It is expected that a mobile outreach program would significantly expand services to PWID in underserved areas of Almaty. Kazakhstan does not use rapid HIV tests in their national testing algorithm. Through this program, USG will provide TA to the Kazakh Ministry of Health (MOH) to pilot the use of rapid HIV testing as part of the HIV testing and counseling in the mobile outreach station proposed for Almaty. Rapid testing will be used for screening, and in the event of a positive screening result, venous blood will be collected and sent for confirmatory Western Blot testing at the National Reference Laboratory. In these instances, persons will receive appropriate post-test counseling, and will receive instructions for returning to receive their confirmatory result. For persons testing HIV positive, appropriate medical and social service referrals will be made. To insure quality assurance of counseling, intensive training will be conducted for counselors and laboratory specialists on use of the rapid HIV test kits, and QA/QC. The target for the number of PWID who undergo rapid HIV testing in the mobile unit setting is 950 for this budget period. The project indicators will the number of PWID, their sex partners, and other MARPs who are tested at the mobile unit, the number who were informed of their HIV test result, the number referred for additional testing, counseling, and treatment services, and the number of persons trained in both the laboratory and counseling aspects of rapid HIV testing. Only FDA approved rapid HIV tests will be purchased. PEPFAR funds will be used to purchase rapid HIV tests for the pilot project. Once the use of rapid tests is incorporated into the national algorithm, Government of Kazakhstan will support the use of rapid tests in the country. Random sample verification will monitor the quality of the rapid test results. The Project will also closely coordinate its efforts with other PEPFAR-funded programs, GFATM and other international partners to leverage funds. These activities will be included into Kazakhstan's National HIV Strategic Plan to eliminate duplication and complement existing services for MARPs. NGOs working with PWID and other MARPs in Almaty will be involved to disseminate information about the availability of the mobile unit and rapid HIV testing for PWID.

This project supports the Central Asia Region (CAR)'s PEPFAR Strategy Objective 1. This activity is linked to IDUP BCNs of: (1) PSI/ IM #12859; (2) Columbia/IM #12872; (3) UNODC IM #12772; and (4) Health Policy Project, IM #13973. The predominant mode of HIV transmission in Kazakhstan is unsafe injecting practices. However, the proportion of registered cases reporting injecting drug use as the method of transmission decreased from 66% in 2006 to 52%% in 2010. As of January 2011, there were an estimated 119,000 people who inject drugs (PWID) in Kazakhstan, of which approximately 17,000 reside in Almaty. In 2010, Almaty city had the largest number of HIV registered cases (3,204). Almaty city also has the highest HIV prevalence rates with 203.4 HIV cases per 100,000 people. HIV prevention services for PWID are implemented through a network of government and donor supported sites called Trust Points (TP). There are 168 TP in the country, but only 23% of PWID have been reached by existing, fixed-location TPs, which are primarily located in medical facilities. Poor coverage of PWID by these TP is attributed to lack of transportation, fear of medical institutions and legal authorities, and a perceived hostile or unfriendly environment at the TPs themselves. Under this cooperative agreement, USG will provide TA to the Republican AIDS Center (RAC) to establish a Drop-in-Center (DIC) in the city of Almaty, in an area with a high prevalence of drug users and high HIV prevalence. The DIC will provide a comprehensive package of HIV prevention services, including dissemination of individual protection items, educational materials, social support, and referrals to medical services (HIV counseling and testing, narcologist, TB and STI clinics and surgeon). The project will be implemented in collaboration with other USG funded organizations. Data shows the coverage of PWID with mobile teams remains low. USG will also provide TA to RAC on how best to operate mobile units (bringing best practices, developing guidelines, developing messages to PWID, creating schedules, provide trainings for mobile teams). It is expected that establishment of a DIC for PWID and enhancing mobile outreach would significantly expand services to PWID in underserved areas of Almaty. The main purpose of these activities is to set up models that can be demonstrated and replicated in the future with support of the Government of Kazakhstan. A vigorous M&E system will be set up to evaluate implementation and results of the models. The program will monitor indicators, including number of people served; number of referrals made; number of people tested and who received results; and the number of people trained, using electronic databases and internal registration forms. After the 12 month implementation phase, if successful, these models will be included into the KZ national plan and activities will be supported by the local government budget (it may take another 12 months to approve the support from local budgets. The Project will also closely coordinate its efforts with other PEPFAR-funded programs, GFATM and international partners to ensure leverage funds and avoid duplication of activities. In light of recent Congressional directives on NSPs, PEPFAR CAR will eliminate direct USG support for NSPs and instead leverage GFATM resources and networks for NSP procurement and distribution with USG-funded MARP outreach and peer education efforts.