PSI Swaziland is in year four of a five year grant for strengthening the provision of high quality HIV testing and counseling (HTC) services. Its mandate in Swaziland has focused on client initiated counseling and testing and corresponding prevention services; but, as of COP 09 also included support for the national male circumcision (MC) scale up policy. With COP 10, PSI will continue to advance HTC in Swaziland but will see a diminished amount of MC funds due to a new Swaziland MC specific implementing mechanism that is being issued as part of the 2010 COP.

The Partnership Framework (PF) aims at increasing the number of sites offering HTC. PSI will establish new pockets of service delivery in communities guided by the Service Availability Mapping (SAM). Where stationery sites are not feasible, regular sites will be established using local structures like churches and schools. This will contribute to PF objective of increasing the percentage of the population knowing their HIV status.

In 2005, when USG funded HTC activities started, the cost to the organization for one test was $399. In 2009 this number has been reduced to $20.20 (calculated as total budget divided by the number of tests for that fiscal year; this includes budgets allocated for ABC. Without ABC the cost per test in 2009 was $12.62). The marketing communication premium included in this cost was $2.90 per test in 2009 compared to $21.50 in 2005 (this also includes all IPC related costs).

Human resources for health is a cross-cutting budget attribution in this activity for the salary support of ten community-based HTC counselors. Increasing gender equity in HIV/AIDS activities and services, addressing male norms and behaviors, end of program evaluation, mobile populations, military populations and workplace programs are addressed as cross cutting key issues in this activity.

In conjunction with implementing activities funded by the Royal Netherlands Government, PSI will attempt repositioning female condoms in the broader context of gender dynamics in Southern Africa. These activities will also build upon concurrency related work already. PSI will also address gender perceptions and role distribution through its HTC campaigns focusing on men, as well as activities related to male circumcision.

Entering the final year of this five year program, a national, cross sectional survey to assess the impact of HTC and condom programming will be conducted. This will be the third survey (the first conducted in 2006 and the second in 2008) and results will be compared across the three years.

PSI will give increased focus to increasing accessibility and utilization of condoms and HIV counseling and testing services among mobile populations. Activities with mobile populations will address sex workers, men who have sex with men as well as uniformed services.

A percentage of support will go towards PSI's Corporate AIDS Program, which works closely with employers to develop workplace HIV policies and conduct HIV prevention education among employees.

PSI employs an M&E Manager, two coordinators and a MIS Officer to manage qualitative pre-testing initiatives, quantitative monitoring and evaluation, and community/ site level activities. MC Coordinator and HTC Network Coordinator work closely with SNAP and WHO to provide support for quality assurance across the sector.

M&E Activities

- Quarterly site assessments for network sites/ public sites in collaboration with SNAP to ensure adherence to national standards & harmonize data collection tools;

- Forums to promote information use for decision making;

- With SNAP, WHO and JHPIEGO, support regular quality assurance assessments and MC site visits;

- Client exit forms will administered to every 10th HTC client to track satisfaction levels;

- New health services MIS database allows for live client feed of intake forms in both HTC and MC at sites and centralized to an integrated database. It also allows more complex analysis, done monthly;

- Continue to collaborate with National Referral Laboratory for quality assurance of testing at both HTC and MC sites;

- Support for the development and review of standards, protocols and operating procedures for HTC and MC;

Operations Research Activities:

- National, cross-sectional survey to evaluate program impact and allow identification of relevant behavioral determinants.

- National mapping survey to assess accessibility and availability of services and outlets, using geographic information systems to map delivery locations & sales points.

- Raw data for both above surveys stored in encrypted files will be analyzed and disseminated in report to donors, MOH, partners and other key stakeholders.

Given the complexity of the epidemic in Swaziland and the behaviors that drive the virus, integration of different HIV prevention strategies is essential (ABC + HTC + MC). HTC is used as a platform for prevention messaging, and prevention channels are used to promote testing and/ or MC; in this context the community-based agents play a crucial role in promoting these health behaviors.

Using funds dispersed in the past PSI has built an implementation infrastructure that relies on an integrated approach and has yielded impressive results. The most significant element of this infrastructure is the extensive network of 110 community based agents that support PSIs core program teams with activities that vary from mobilizing communities to inter-personal communication. It is with the support of these agents that they are able to maintain credibility in rural communities, react quickly if need be and reach the communication targets set on an annual basis. In 2009, the IPC related premium/ test was estimated $0.66. HTC specific activities proposed for COP10 include:

The overall goal for HTC in Swaziland is to increase the number of people knowing their status to 50% for men and 40% for women in for the period 2006-2013 (= 198,000 people). In 2010 focus will be on national coverage and service provision will target 54000 of the population aged 15-49. Services supported by PEPFARPSI will be offered according to the national HTC guidelines, including youth friendly services. This will be achieved by:

1. Providing high quality HTC services in PSI managed free standing sites

2. Providing CIHTC technical support to other sites

3. Addressing domestic violence related to HTC through post-disclosure counseling Contributing to the development of a national HTC BCC strategy. Campaigns will be targeted at couples and men (with additional linkages to MC);

4. Continuing MARP HTC interventions (prisoners, CSW's, MSM and mobile populations). These will be supported by IPC through the network of community based agents. Activities will be expanded to all prisons and referrals/mobile HTC will be conducted among CSW and MSM supported by peer education efforts. PSI will also increase HTC access among mobile and seasonal workers (with IOM)and provide support to the military to scale up HTC;

5. Door to door counseling offered by community based lay counselors & advocacy for policy shift to allow lay cadres to provide HTC;

6. Expanding the corporate HIV prevention program to focus on national systems strengthening and closer public private partnerships (PPP's).CAP services will be repositioned to target high volume/ high risk industries. .

7. Strengthening linkages to prevention, treatment, care and support; improve follow up to ensure access to care to include community support services;

8. Training of counselors in CIHTC and facilitate pre-service curricula integration. SWAGAA will support integration of gender based violence and counseling for victims of sexual violence. Pre service curriculum integration with certification of providers on HTC service provision will be done to equip providers and reduce time and costs associated with in-service training;

9. Integrating HIV prevention activities into HTC; adoption of risk reduction strategies with knowledge of HIV status. Follow up counseling will be done for clients who test HIV negative and discordant couples and monitor their sero status.

10. Partnering with churches to reach targets. .

11. Social mobilization through IPC agents based in communities and conducting activities addressing HTC, MC, abstinence, being faithful, concurrent partnerships and condom use.

12. Increasing coordination to support underserved pockets and avoid duplication.

13. Continue diversifying outreach models (60% of the total HTC clients in 2009) and reviewing CIHTC service delivery to integrate SRH services to increase the number of walk-in clients.

PSI has been a lead partner for the national MC scale up plans, but due to the national importance of the MC initiative it is imperative for PEPFAR Swaziland's strategic vision to initiate a Swazi-MC focused mechanism with COP10 funds. This will allow the PEPFAR Swaziland team to more fully oversee the development of this PF pillar. Funds in PSI's COP10 submission will ensure that services are not interrupted before the new award can be issued. The focus of this funding will be on service delivery at the Litsemba Letfu clinic and at three GKOS public facilities. At the GKOS sites PSI will work with the Ministry of Health to integrate circumcision services into the public sector facilities and will support their supply, equipment, training and QA needs.

HTC is a gateway to prevention, treatment, care and support and cannot be a standalone intervention. HVOP funds will support communications and other outreach efforts to support HTC. Efforts to maximize HTC for HIV prevention will be intensified through the following approaches:

1. Scale up access to HTC services among most at risk populations including prisoners, CSWs, MSM, seasonal workers and mobile populations. Peer educators will receive additional training and be given coupons to distribute during education sessions. Where possible mobile and on-site HTC services will be provided to these populations.

2. The IPC agents based in all Tinkhundlas, will receive partial continued support for social mobilization activities including door-to-door HIV prevention educational activities. The agents convene small community activities and will integrate messages on condoms, HTC, MC and concurrent sexual partnerships. Stipends for peer educators and IPC agents will be supported and cost shared across MC, HTC and condom budgets. Bus rank promotions and information desks will be also be staged on a monthly basis to increase access to HIV prevention messages and information