FHI has been implementing HIV/AIDS programming in southern China since 2003 with the support of USAID. The primary of focus of USAID-supported programming has been to establish a Comprehensive Prevention Package (CPP) model focusing limited resources on the provision of comprehensive prevention services (behavioral change, VCT, STI, condom promotion and linkages to care and services) plus supportive interventions for those most at risk of being infected or transmitting HIV, in order to avert as many new infections as possible. This approach has been employed in eight "hot spots" in Yunnan and Guangxi provinces selected for their high HIV prevalence among specific MARPs: female sex workers (FSW), injecting drug users (IDU), and men who have sex with men (MSM). The hotspots include Kunming, Gejiu, Mengzi and Kaiyuan in Yunnan Province; and Nanning, Pingxiang, Ningming and Luzhai in Guangxi Province.

The goals of the project are to reduce the incidence and prevalence of HIV/AIDS and mitigate its impact on PLHA and their families. To achieve these goals, FHI focuses on five major programming components: comprehensive prevention interventions for MARPs; strategic information; increased access to care, support and treatment for PLHA and their families; strengthening the enabling environment; and enhancing the effectiveness of USG-supported programs by leveraging other donor resources.

Under the task order, FHI:

1. Provides HIV technical assistance (TA) to community and local partners receiving USAID support through other implementing agencies and stakeholders;

2. Provides sub-grants and TA to government and other partners; and

3. Provides TA for scaling up of the CPP model by the GoC, GFATM, and other donors.

As part of an overall strategy to shift away from direct implementation support to provision of TA for model replication and scale up, with FY10 funding, FHI will continue to strengthen prevention intervention models in potential centers of excellence, including an FSW project in Kunming, an IDU project in Gejiu, and MSM projects in Kunming and Nanning. In addition, FHI will continue to develop and strengthen Continuum of Prevention to Care and Treatment (CoPCT) programs for IDU and FSW in Luzhai to strengthen linkages between outreach and drop-in centers to uptake of VCT, STI, care and treatment services. These centers will function as model sites for replication by other government- and GFATM-supported projects. In FY10 FHI will develop and distribute model documentation and lessons learned for program replication and provide funding support for study tours or participation in internship courses provided through the model sites.

While strengthening projects at these hot spots to serve as model intervention sites, FHI will continue to build the institutional capacity of local health systems through the provision of ongoing TA and training as well as the development and distribution of standard operating procedures and training manuals for MARP interventions, counseling and testing, STI management, and clinical and home-based care and treatment services. FHI will also continue to improve referral linkages between disparate providers within the existing health system, and will support comprehensive HIV quality assurance and quality improvement (QA/QI) systems in Yunnan and Guangxi, which will help ensure the institutionalization of not only specific health systems improvements but also of the systems strengthening process in these provinces.

FHI will also continue to leverage funding from the GoC and other donors, including support for project offices and selected staff and cost-sharing for TA and training for GoC and GFATM project staff. Services will continue to be coordinated with existing providers, such as testing and treatment, needle and syringe exchange, and methadone treatment services provided by the GoC, in order to encourage cost-effectiveness and sustainability.

In prior years, FHI developed a performance monitoring system to track program outputs and achievements for implementing agencies, shared standardized operational definitions of monitoring indicators and measurement tools, and provided training in their use to implementing agencies and other USAID cooperating agencies. FHI also helped develop monitoring systems for selected GFATM and China Cares project sites in Yunnan. With FY10 funding, FHI will continue to provide technical support to enhance monitoring systems and will collaborate with other partners to conduct outcome monitoring and/or outcome evaluations, as appropriate, for prevention programs targeting MARPs in FHI-supported sites in Yunnan and Guangxi.

GHCS (USAID) = $134,000

GHCS (State) = $66,000

The GoC has proposed Luzhai in Guangxi province as a "Center of Excellence" for ART care and treatment. In FY 2010, FHI will conduct an assessment in Luzhai, in collaboration with GoC to identify gaps in clinical care and to target technical assistance in order to strengthen the linkages between prevention, care, treatment and support for PLHA (principally IDUs) as part of a Continuum of Prevention to Care and Treatment model. Depending on the outcome of the assessment, TA may consist of support for protocol and standard operating procedure development, and training of staff in order to enhance delivery of ART and other clinical services. FHI will also work with supporting the site in utilizing the Patient Management Information System to track clinical outcomes, including mortality, evaluate ART adherence and improve quality of service delivery. FHI will provide funding support to fill implementation gaps and will strengthen coordination and linkages, including referral to programming for ART adherence support activities being implemented by International HIV/AIDS Alliance (Alliance) in partnership with AIDS Care China.

GHCS (USAID) = $143,000

GHCS (State) = $71,000

HIV counseling and testing is not only a vital entry point to provision of care and treatment for PLHA, but also an important component of a comprehensive prevention program. Surveys have indicated that up to 90% of PLHA are unaware of their serostatus despite GoC expansion of free voluntary counseling and testing (VCT) service centers. Reasons for poor uptake of HIV testing include a lack of awareness of the benefits of testing, concerns about privacy and fears of discrimination by health care staff. In addition, some government policies including a local regulation requiring identification for confirmatory testing have limited access to counseling and testing, especially among MARPs.

Under FY10 COP, promotion of accessible, high-quality, non-stigmatizing VCT will be continued as a key component of all FHI-supported prevention projects for FSW, MSM and IDUs in Kunming, Nanning, Gejiu and Luzhai. Provision of HIV counseling and rapid testing at these drop-in centers will ensure accessible services for MARPs. Through VCT promotion during outreach activities, staff will refer to wellness/drop-in center-based pre- and post-test counseling and blood-based rapid testing using a nationally recognized test kit. As MARPs show less concern about stigma and discrimination when services are provided through non-government, non-clinic service centers, rapid testing can provide timely results and post-test counseling.

In line with the national testing algorithm, positive results on rapid testing will be referred to CDC for ELISA screening and confirmatory testing. Individuals confirmed positive are referred directly into the GoC care and treatment system, as well as to home-based care, psychosocial support and other PLHA-specific services supported by FHI and other USAID CAs.

FHI will continue providing comprehensive VCT training to testing counselors to build their capacity to work with marginalized, stigmatized populations. FHI will continue to provide QA/QI using checklists and client satisfaction surveys. Additionally, FHI will continue to build capacity and provide technical assistance for other VCT providers upon request and share VCT QA/QI tools to strengthen VCT quality and systems in Yunnan and Guangxi.

GHCS (USAID) = $41,000

GHCS (State) = $20,000

FHI will develop standardized prevention monitoring tools for MARPs, and provide M&E TA for local implementing agencies (IAs), the RCC Global Fund, and GoC.

As a part of the CPP Model for MARPs in Guangxi and Yunnan provinces, USAID will support the development of standardized prevention monitoring tools for future replication by the GFATM RCC or other donors. Beginning in FY 2010 and continuing into FY 2011, FHI will coordinate this activity across partners to address the following objectives:

Reach consensus among implementing partners on key prevention indicators for prevention programs for FSW, IDU, and MSM relevant to the China context and include standardized operational definitions.

Document best practices on program monitoring forms including examples that can be easily adopted by local partners.

Develop data quality assessment (DQA) procedures including checklists that local organizations can apply as part of their project management.

Develop a basic data use section on how to use monitoring data for improving program performance.

USAID partners will share their prevention monitoring tools, indicators, and operational definitions. FHI will coordinate and organize a series of consultants and meetings to identify lists of key indicators and standardized operational definitions, examples of data collection forms, and promising practices on data collection, data quality analysis (DQA) procedures, and data use. FHI will train local IAs and other USAID cooperating agencies (CAs) on implementing the tools. FHI and its partners will jointly conduct a DQA on a bi-annual basis to ensure the quality of project data and program implementation.

To better target intervention activities and provide reliable estimates on target population size, all IAs conducting outreach to MARPs will update their mapping of MARP sites and service platforms. In FY 2011, FHI will collaborate with other USAID partners to develop coverage and behavioral outcome monitoring tools for MARPs and an outcome evaluation of the IDU CPP model. FHI will provide TA and training on developing monitoring systems for selected Global Fund and GoC project sites in China, and provide TA in surveillance to local Chinese CDCs.

GHCS (USAID) = $61,000

GHCS (State) = $30,000

FHI will continue on-going efforts to strengthen the capacity of implementing agencies in the areas of data use and dissemination, advocacy and program/financial management. FHI will also continue to provide institutional capacity building to strengthen the management systems for the 19 demonstration counties in Yunnan as well as to selected GFATM sites as requested.

As in the past, FHI will continue to support stigma reduction activities through events such as World AIDS Day and through community-based stigma reduction activities conducted by HIV-positive and HIV-negative MARPs. Stigma reduction will also be addressed through regular meetings between service providers and members of target communities, and through sensitization trainings for healthcare providers conducted by FHI country and regional technical staff.

Finally, FHI will continue working to strengthen overall health systems by leveraging prevention, care, treatment and support services provided through USAID CAs, other nongovernmental organizations, the GoC, GFATM, local civil society and the private sector in order to provide MARPs and PLHA with a truly comprehensive set of services as envisioned in USAID's CPP model. A major role for FHI in this process will be continuing to help strengthen coordination and build effective referral networks between disparate providers.

GHCS (USAID) = $450,000

GHCS (State) = $224,000

In recent years, sexual transmission of HIV has outpaced injecting drug use as the primary route for new HIV infections. The FHI model for sexual prevention uses trained and salaried peer educators to target MARPs (FSW and MSM) with messages promoting correct and consistent condom use and mutually faithful, non-concurrent sexual relationships. This is combined with support for wellness/drop-in centers where MARPs can access high-quality, user friendly services to manage and treat sexually transmitted infections (STI) and provide HIV counseling and rapid testing as applicable. Condom use is promoted during outreach activities and supported by local Family Planning (FP) clinics and condom social marketing is provided by PSI.

Under COP FY10, FHI will continue to strengthen HIV prevention interventions for MARPs in three hot spots in Yunnan and Guangxi:

FSW projects in Kunming and Luzhai will target women at greatest risk due to lower transactional fees and higher numbers of clients and will link FSW to wellness/drop-in centers and local FP clinics.

Most traditional MSM venues are covered by existing interventions in Kunming and Nanning. FHI will increase health education through Internet-based outreach and SMS text messaging to reach those who do not frequent public venues.

The hot spots described above will also serve as learning centers for model scale-up by government and GFATM-supported projects, with on-going technical assistance by FHI to strengthen strategic behavior communications, MARP-friendly STI diagnosis and treatment, counseling and testing services, M&E, and linkages to clinical care and support including supportive interventions.

FHI technical staff and partners will ensure service quality through regular monitoring and use of QA/QI checklists and regular client satisfaction surveys. FHI has also designed a performance monitoring system to routinely track outputs and achievements.

Finally, the projects will leverage existing platforms to offer more comprehensive and sustainable services by linking to providers including GoC-funded STI and VCT clinics, PLHA care and treatment organizations, and income generation services and training provided by USAID partners and other organizations.

GHCS (USAID) = $174,000

GHCS (State) = $86,000

The HIV epidemic in China initially emerged among IDU in the southwest border region and continues to account for the largest number of infected individuals. Prevalence among IDUs in Yunnan has ranged from 40% to 80%. Up to 22% of male IDU and 21% of female IDU have reported engaging in commercial sex. Only a minority report having used condoms at last commercial sex. The situation is complicated by incarceration in "rehabilitation centers" where needle-sharing is believed to be common; upon release many former IDU return to communities where pressure and distrust contribute to high rates of relapse. USG supports the development of a comprehensive package of prevention, care and treatment services for IDU.

FHI will strengthen this package of services by delivering HIV prevention interventions for IDU in Gejiu City. Trained and salaried outreach workers and/or peer educators will reach IDU in their communities and will disseminate messages encouraging IDU to stop injecting drugs or to minimize sharing needles and other injecting equipment. FHI will continue to support a drop-in center where IDU can access HIV counseling and rapid testing, be treated for abscesses and opportunistic infections, and receive community and family support to quit and/or stay off drugs. The project will provide home-based care and support to PLHA/IDU.

FHI will leverage other service providers through linkages with existing services including MMT and NSP that are supported by the GFATM and the GoC. FHI will refer clients for care and treatment (provided by the GoC) and STI services as needed.

FHI will continue to strengthen Gejiu as a "center of excellence" for community-based IDU interventions. This project will serve as a model site to promote scale-up by other GoC and GFATM-supported projects. FHI technical staff and local partners will ensure quality through regular monitoring using QA/QI checklists, regular client satisfaction surveys, and a routine performance monitoring system. FHI will document the outcomes of this project. FHI will continue providing TA and support to the IDU project in Luzhai to increase staff capacity and effective linkages between services.