Integrating TB/HIV screening and services into TB Program.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18434

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

18434 18434.08 U.S. Agency for Tuberculosis 12086 12086.08 TB- CAP $256,000

International Control Assistance

Development Project

Program Budget Code: 13 - HKID Care: OVC

Total Planned Funding for Program Budget Code: $350,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

13-HKID Care: OVC

Note: Due to late initiation of the new USAID contract with AED, FY07 USG funds were partially used to extend the CONECTA

project one more year so that the two projects would overlap and the transition to the USG HIV/AIDS program to Region V and

the border areas would be smoother. CDC and DOD also experienced delays in starting implementation. Therefore, FY09 is the

first year for the majority of USG support to be concentrated in Region V and the border areas. The border areas lack the basic

infrastructure needed to support a comprehensive HIV/AIDS program, and hence FY08-09 funding will focus on improving

infrastructure and strengthening NGOs.

Program Area Context/Services

DR does not have reliable data on the numbers of orphans and vulnerable children in the country and estimates about their

numbers vary widely. The 2007 DHS estimates that there are 120,000 orphans under age 15 in the DR and 439,650 other

children who do not live with either of their parents but with relatives or other caregivers. Approximately 58,000 of these children

have been identified as orphaned, or at risk of becoming orphaned, due to AIDS ("Vulnerable Children at Risk of being Orphaned

and Displaced by AIDS in the Dominican Republic," USAID/PROMUNDO, 2002). Of these, 6,425 children have mothers with

AIDS, while 48,684 children have HIV+ mothers who have not yet acquired AIDS. The PROMUNDO study also reported that sixty

percent, or 12,316, of children orphaned or at risk of being orphaned live in Santo Domingo. Estimates of the number of children

living with HIV/AIDs show considerable differences. For example, CDC estimates that there are approximately 11,000 children

living with HIV/AIDS in the DR, while the 2007 National Estimates suggest that 2,719 children are living with HIV. The 2007

PAHO/UNICEF evaluation estimated that approximately 800-2007 children per year were not protected due to the weak PMTCT

services that only provided complete Nevirapine prophylaxis to 12% of HIV+ pregnant women who delivered in the public sector.

Little is known about the status of these children, their caretakers, their welfare or their quality of life. There is no current system in

the DR for tracking orphans to ensure a continuum of welfare and other services. One of every 47 women nationally may be

burdened by the additional responsibilities and costs of caring for orphaned children. In 2007, The National Council for Children

(CONANI), UNICEF and COPRESIDA developed a policy to protect children (including those who are HIV+ or at risk of being

orphaned because of AIDS) and their caretakers. Although COPRESIDA finances some community-level activities for these

children with GF money, to date no programs based on this policy have been implemented at the national level.

Many children in the DR are vulnerable to HIV/AIDS. According to the 2007 DHS report, 15 percent of females and 24 percent of

males initiated sex before age 15. Young women engaging in early sex are generally those with no or little schooling and in the

lowest wealth quintile. Some young adolescents initiate sexual intercourse as early as 12 years of age in the bateyes (sugar

plantations), and even younger than 10 years of age in areas along the border with Haiti. Such early sexual debut is a

characteristic of sexual abuse (not generally detected or considered, much less punished, in the DR), informal transactional sex

and/or cross-generational sex, all of which put young people (especially young women) at a greater risk of HIV/AIDS. Fully 23%

of women 15-49 years old reported having had sex with partners at least ten years or more older than themselves, including 29%

of women in the lowest economic quintile and over 30 per cent of women living in Health Regions IV and VII. Having a partner ten

or more years older than oneself is a major risk factor for HIV/AIDS among young women.

Through March 30, 2008, via the CONECTA project, USG/USAID supported 18 NGOs/FBOs that ran 20 OVC programs in 87

communities. These organizations provided direct care and support services to 8,837 OVC and trained 139 providers and

caregivers to care for OVC. In addition, 467 OVC were reached through the USAID/AED bridge grants. USG-supported OVC

services include providing health supplies and care, emotional and psychological counseling, educational assistance (including

tuition), economic support for clothing, food and nutritional support, referral to health services for immunizations, support for

caregivers and communities, legal services to secure birth registration, and training caregivers on providing a better health and

nutritional environment for their charges. Some NGOs provide small loans to families affected by AIDS to develop income-

generating activities. In FY09 we expect a temporary decrease in OVCs receiving USG support due to the conclusion of USG-

supported OVC services in areas outside Region V and the Haiti-DR border areas, and the need for time to start up OVC support

activities in the geographic focus areas. Although USG is concluding support for OVC services outside the focus regions with

FY07-08 funding, we are committed to continuity of OVC services in these areas and will work to ensure that these services

continue with support from non-USG sources. We expect the same level of OVC services will continue, but without USG support.

In the future, OVCs receiving such services will not be counted in the USG-supported indicators.

Leveraging/Linkages

USG will continue to coordinate with the Ministry of Education to ensure orphans and vulnerable children are enrolled in and

attend school. Work with adolescent OVC includes ensuring that they continue in school or are referred to technical training

programs offered by the Instituto de Formación Técnica (INFOTEP), a technical GODR institution supported by the German

Development Bank (KfW). USG/USAID will work closely with NGOs and MOH service providers to provide health care to these

OVC, and USG will continue to work closely with NGOs and hospitals in Region V and the border areas to develop and strengthen

VCT programs for at-risk adolescents. Linkages are promoted between OVC and other interventions, such as ICUs, pediatric

services, PMTCT and income-generating activities. USG will work closely with USAID's Rule of Law activities to increase attention

to OVC issues through human rights work. As a wrap-around activity, USAID's democracy and governance program will support

the training of prosecutors and judges to integrate knowledge and enforcement of child protection legislation developed with USG

support (see below). Given that OVC are included in the new National Strategic Plan, USG and its partners are advocating with

COPRESIDA to ensure that GF monies provide support to NGOs working with OVC and their caretakers. Additionally, USG will

promote linkages between DR-side services and NGOs working with OVC in Haiti, including distribution of referral materials in

Creole. Legal services are provided to OVC, their families and caretakers by specialized legal groups, including JSI/Promundo,

with JICA funds, Spanish Cooperation, the Jesuits and other FBOs. This is especially important given that UNICEF reports that 26

percent of the poorest children in the DR do not have birth certificates, something required to get into school. These organizations

also provide selected other services for OVC, their families and caregivers.

FY09 USG Support

Much of the USG's FY09 OVC resources will be concentrated in Region V and the DR-Haitian border area where OVC services

are currently extremely limited. USG support will initially be used to identify and train NGOs/ FBOs willing to work with OVCs in

the focus areas and to develop and implement plans of action for that OVC work. The NGOs/FBOs, in turn, will identify HIV+

children and OVC in the target areas and apply the USG program-developed OVC model of care which follows PEPFAR OVC

guidance. It includes: ensuring a complete basic well-child package of care, supplemental feeding for those with poor nutritional

status, sports and other activities, and referrals for pediatric care. School-age children receive basic school uniforms and supplies.

Adolescent OVC are helped to continue in school or technical training programs, educated in HIV/AIDS prevention and, if sexually

active, referred for CT, family planning and other health services, as needed. Child advocates will be trained to support these

activities and ensure OVC receive the services and supplies meant for them. Support will also be provided to families caring for

OVC including, if appropriate, training in income-generating activities. Legal services are provided by NGOs that specialize in

legal issue. USG will also develop NGO capacity to build and strengthen community support networks for OVC. USG, the Clinton

Foundation (through its pediatric AIDS initiative), COPRESIDA and Columbia University are implementing a pediatric AIDS pilot

project to provide early diagnosis, care and treatment to children born to HIV+ mothers. See Pediatric Care and Support for more

information.

In FY09, USG will conduct surveillance activities targeted at out-of-school youth, including OVC, particularly in the border regions,

to assess current risk behaviors, access to prevention and care services and to estimate the HIV prevalence in this population.

This activity will be conducted with CDC, local MOH, and NGO participation. Monitoring and evaluation of USG-supported OVC

activities will be carried out by the Measure Project and by AED via its support to USG-supported NGOs. CDC will conduct M&E

on the CDC-led activities.

Currently the system for supporting child victims of sexual abuse is weak and in many cases sexual abuse goes undetected. In

FY09, USG/USAID will work with GODR and CONANI to develop and implement a plan of action to support victims of sexual

abuse. USAID's democracy and governance program will support the training of prosecutors and judges to enforce child

protection legislation. NGOs/FBOs will be trained to inform communities about sexual abuse and how to denounce it. Further,

information and materials on sexual abuse will be provided to teachers and school administrators as part of the education

program to be implemented by the MOE and the MOH. Age-appropriate sexual abuse awareness information will be included in

the learning materials.

Sustainability

Community activities supporting OVC are not sustainable alone. Direct support from international donors is required, as OVC are

generally unable to advocate for their own needs. Therefore, sustainability of this program will be measured by the involvement of

local and international donors. Continuing with advances made in FY08, USG will focus on increasing the capacity of indigenous

organizations to deliver these services independently of continued external support. Private sector support for OVC programming

will be fostered by promoting social responsibility in the DR. Religious organizations may play a key role in supporting OVC

programs, as demonstrated by the vigorous response and participation of FBOs in an OVC pilot project with PROMUNDO. USG

will work with GODR's social cabinet and CONANI to develop a social responsibility agenda for OVC.

Enforcement of existing child protection legislation is inconsistent and the current AIDS law does not address children's issues.

CONANI focuses on supporting orphanages rather than helping children remain with their families or a formal foster care program.

Under the leadership of PLH NGOs, USG and other stakeholders are currently discussing changes to the law to include orphans

and children who are vulnerable due to HIV/AIDS. It is anticipated that this will contribute to greater stability for the child, move

away from institutional care, and ensure greater sustainability of OVC programs.

Table 3.3.13: