Tuberculosis (TB) is the most common cause of death among HIV-infected persons, but diagnosis of TB in

these persons is difficult. In addition, the global burden of drug-resistant TB in HIV-infected persons is

increasing and can only be addressed through accurate diagnosis of drug-resistant TB. Improving the

diagnosis of TB in HIV-positive persons was one of Ethiopia's emphasis areas in FY07. Using plus-up

funding from 2007, the Ethiopian Health and Nutrition Research Institute (EHNRI) sought to increase TB

culture capacity in five regional laboratories through renovations of existing facilities, procurement of

appropriate supplies, training of regional staff, and ensuring quality assurance and control. In FY08, EHNRI

will build on that work by implementing liquid TB culture, which is the most rapid and sensitive method for

TB diagnosis, and drug-susceptibility testing at these five regional laboratories. This will maximize the

sensitivity and speed of TB diagnosis and the identification of drug-resistant TB.

EHNRI will work with the Federal Ministry of Health (MOH), regional health bureaus (RHB), and PEPFAR

partners to realize these activities. Activities will include:

1) Site assessments

2) Renovation of existing laboratory facilities for appropriate biosafety precautions

3) Procurement of equipment and reagents

4) Training of regional staff

5) Implementation of liquid-culture diagnosis

6) Transport of specimens from health facilities to regional laboratories

7) Internal and external quality assurance

8) Provision of technical assistance

9) Appropriate monitoring and evaluation

In addition, the national reference laboratory needs support for its work with a network of regional

laboratories to enhance TB culture-capacity. To do this, an additional three staff members will need to be

hired by EHNRI, and their staff should be re-trained in liquid-culture techniques. A study tour that would

bring EHNRI staff to a laboratory with such activities is under consideration.

PARTNER: Ethiopian Health and Nutrition Research Institute

Project Description:

Even though there are not yet reports of extensively drug-resistant tuberculosis (XDR TB) in Ethiopia, it has

recently emerged as a global public health threat. In South Africa, XDR TB among HIV-infected persons

killed 52 of 53 persons diagnosed with the disease, many of whom were on antiretroviral therapy (ART).

The World Health Organization (WHO) recommends surveillance for XDR TB among high-risk patients,

which would include "retreatment patients," or those previously treated for tuberculosis.

EHNRI proposes to conduct XDR TB surveillance in collaboration with St. Peter's Specialized TB Hospital in

Addis Ababa, the largest TB hospital in the country. The hospital sees a large number of TB patients with a

previous history of TB treatment, many of whom have drug-resistant TB. All re-treatment patients have their

sputum sent to the national reference laboratory for first-line drug susceptibility testing.

Evaluation Question:

The evaluation question is whether XDR TB exists among HIV co-infected persons in Ethiopia.

Programmatic Importance:

The study is important to establish presence, or lack thereof, of XDR TB in Ethiopia and to develop local

capacity at EHNRI to screen for XDR TB.

Methods:

USG will support surveillance for second-line TB drug-resistance (and thus XDR TB) by having sputum

specimens for all re-treatment cases at St. Peter's for a 3-6 month interval sent to the national reference

laboratory as usual for first-line drug-susceptibility testing. All such specimens will be stored in a freezer at

EHNRI and then will be shipped in 1-3 batches to either one of the WHO International Union against

Tuberculosis and Lung Disease (IUATLD) Supranational Reference Laboratories (SRL) or to CDC-Atlanta

for second-line drug-susceptibility testing. To build the capacity of EHNRI, second-line testing will also be

done there.

Activities will include, purchase of second line testing reagents, training in second line testing for EHNRI

staff, shipment of specimens to supra national lab, supplying second line testing to a destination laboratory

(WHO IUATLD SRL). In addition, the EHNRI TB laboratory will be strengthened to be able do XDR TB

testing in future.

Information Dissemination Plan:

Stakeholders include the HIV-TB Technical Working Group members, selected TB diagnostic centers in

Ethiopia, the Federal Ministry of Health (MOH), Addis Ababa Regional Health Bureau, health care

providers, PEPFAR and other entities involved in HIV-TB care and support. Results will be disseminated in

a review meeting for the region and findings will be shared with PEPFAR partners.

Expansion of Laboratory Information System

Information, in the form of test results and clinical investigation, is the primary product of the clinical

laboratory. To meet the needs of the laboratory's consumers, it is essential that this information be

accurate, available, and timely. Laboratory Information System (LIS) supports workflow and information flow

in all steps of the laboratory testing process, including patient registration, test ordering, sample collection,

testing, and reporting. LIS enables laboratories to manage their data, to maintain quality, and to improve

efficiency. In developing countries, almost all laboratories meet these needs with a manual information

system, but the scale-up of ART and monitoring programs forces these laboratories to implement a

computer-based LIS to handle the ever-increasing volume of data that they receive and report out.

In FY06, Laboratory Information System (LIS) support was piloted at selected PEPFAR-supported hospitals

and regional laboratories with a laboratory Information Management System, computer hardware, and

accessories. In FY07, this activity was expanded to 26 sites to support operations and quality-assurance

activities at the Ethiopian Health and Nutrition Research Institute (EHNRI), regional laboratories, and

PEPFAR-supported ART hospital laboratories. LIS also enabled sites to have efficient data and report

exchanges. To achieve this, the following expansion work was accomplished: (1) procured an additional 78

LIS software site licenses for 26 sites; (2) procured 26 barcode printers, 78 barcode readers, and 52

barcode printer papers; (3) trained 52 laboratory technicians and 26 receptionists in LIS; (4) procured and

provided 78 computers and accessories; (5) designed and implemented peer-to-peer network for selected

regional and hospital laboratories; (6) installed and configured LIS in selected regional and hospital

laboratories and linked the hospital laboratories via dial-up with their respective regional laboratories, and

regional laboratories with the EHNRI reference laboratory; (7) installed telephone lines into regional and

hospital laboratories for successful implementation of LIS; (8) provided technical support to FY07 funded

LIS sites; and (9) local travel for technical support and international travel for experience sharing with

Association of Public Health Laboratories (APHL) facilities on LIS.

Strengthening and expansion of activities started in FYO7 will be continued in FY08 at EHNRI and other

facilities. The planned activities will include: strengthening of peer-to-peer networks for all hospital

laboratories selected; continuing to install and configure LIS in all hospital laboratories and link the hospital

laboratories via dial-up with their respective regional laboratories and regional laboratories with the EHNRI

reference laboratory; continuing to provide training for PEPFAR-supported hospitals and to provide

technical support to FY07 funded LIS sites.

Specimen Management and Transport Services

Because most health facilities in Ethiopia lack basic equipment, referral-testing services are extremely

important. In order to offer laboratory-monitoring services (CD4 and other basic tests) for people living with

HIV/AIDS (PLWH), including children and pregnant women, a sample referral system was established by

EHNRI in partnership with US university implementing partners. Clinical samples were transported from

outlying clinics to referral laboratories where equipment and human resources are available. To improve the

quality of care and treatment, standardized laboratory services must be provided to all patients at hospitals

and health centers. The quality of laboratory services rendered should also be maintained. To enroll

patients and monitor the efficacy of ART, basic and advanced laboratory tests are required: CD4,

biochemical and hematology profiles at specified period of time as per the guidelines for ARV use in

Ethiopia. However, most of the health centers and some peripheral hospitals involved in ART

implementation do not have a capacity to support laboratory services. For example, Flow Cytometry to

measure CD4 cell counts is beyond the scope of what can be implemented at health centers. In addition,

some clinics do not have the basic equipment for routine CBC, differential, and clinical chemistry tests.

In FY07, specimen transport and referral testing services were provided to peripheral hospitals and health

centers. The Ethiopian Health and Nutrition Research Institute (EHNRI), along with regional reference

laboratories, provided sample tansport and referrral testing servies. In addtion, EHNRI provided techncial

assistance to quantify and purchase laboratory supplies, including diagnosis and monitoring reagents, and

to distribute diagnostic and monitoring tests for referral and facility-based tests to laboratories.

In FY08, EHNRI will continue its FY07 work by providing specific training on specimen management,

transport and storage, and recording and reporting. The specimen-management, transport, and referral

system will be followed using the strict guidelines and standard operating procedures (SOP) developed by

the National Reference laboratory and PEPFAR Ethiopia. The National HIV Laboratory will continue

providing referral diagnostic services for HIV/TB/STI drug resistance and external quality assurance (EQA),

including HIV DNA polymerase chain reaction (PCR) for infant diagnosis, CD4, hematology, and chemistry

tests. EHNRI will also support the regional laboratories to provide referral-testing services (CD4,

hematology, chemistry, viral load, and DNA PCR-based HIV infant diagnosis) and EQA services to hospital

and health center laboratories. EHNRI supported eight regional laboratories (Addis Ababa, Adama, Nekmet,

Bahir-Dar, Dessie, Awassa, Mekele and Harar) to support sample transport and referral services.

The logistic support for referral testing services is a major undertaking. The specimen transport and transfer

system continued to be supported through courier system. This activity will be contracted to a

nongovernmental agency that has a track record in the management and transport of clinical sample from

primary health centers to regional hospital or referral laboratories. This includes transport of specimens and

results to and from health centers to the next level hospital or regional laboratories and/or to National HIV

Reference laboratory. University partners, Supply Chain Management System, and Management Sciences

for Health will provide technical support to EHNRI and regional laboratories for effective coordination and

implementation of the referral testing services.

The lab tests done at the hospital laboratories are returned within two days. It is anticipated that the turn-

around time from health center to test site and back to the clinic will be 2-3 days. Samples are collected in

test-specific containers that already contain any necessary preparation reagents. After the samples are

collected, the laboratory request form is included in the collection container and the sample is placed in a

cooler and transported. All the regular samples are transported in cool gel packs, and local samples are

delivered within a day using cargo or courier mode to maintain integrity of samples.

The responsible contractor or agent receives the samples from the peripheral clinics and transports them to

the nearby hospital and/or regional laboratories, following guidelines and regulation on specimen

management and transport. The sample transfer for testing CD4, chemistry, and hematology tests will be

coordinated at a regular time interval.

Clinical samples are transported from 281 health centers and 25 peripheral hospitals once or twice a week

and transported to the testing site (zonal or regional hospital laboratories). The results are returned within

two days of the test. Turnaround time is 2-3 days. Sample transport from the clinics to hospitals will be

coordinated with health center clinics and laboratories on specific days, in order to make the most efficient

use of limited laboratory equipment and staff.

Laboratory Quality Assurance Program

The Ethiopian Health and Nutrition Research Institute (EHNRI) is the technical arm of the Ethiopian Ministry

of Health (MOH) responsible for providing guidance to laboratory services. It is the lead institution in

coordinating laboratory programs in Ethiopia, and has a national plan to support HIV laboratory services. It

also serves as the National Reference Laboratory for the country.

In 2007, EHNRI provided national leadership in strategic planning, laboratory policies, guidelines, standard

operating procedures (SOPs), training, integrated services and testing. EHNRI also implemented laboratory

quality assurance, including the National External Quality Assurance Scheme program to specialized

general referral hospital laboratories, regional laboratories (RL), and regional hospital laboratories (RHL).

EHNRI worked to implement tiered laboratory services for accreditation and certification of clinical

laboratories. The 2007 activities were focused on quality assurance programs, training, diagnosis,

establishing tiered laboratory services, and referral linkages. EHNRI focused also on improving laboratory

services through support to the National HIV surveillance program, establishing laboratory methods,

developing standard training curricula, training laboratory personnel in HIV testing and treatment monitoring,

conducting operational research on TB/STI/HIV drug resistances, and evaluating diagnostic technologies.

These activities have been implemented in collaboration with MOH, CDC, the Association of Public Health

Laboratories, and the American Society of Clinical Pathologists (ASCP). EHNRI played a major role in

improving the quality of the 2007 National HIV Surveillance in antenatal clinics. Implementation of the

quality assurance program for HIV serological screening was a further success.

Early infant diagnosis of HIV was established at the National HIV Laboratory at EHNRI. Procedures for HIV

pro-viral DNA polymerase chain reaction (PCR) detection from dried blood spots has been validated and

piloted at selected ART sites. The DNA PCR-based infant diagnosis was expanded to six regional reference

laboratories and regional reference testing services were initiated.

The National HIV Laboratory renovated by PEPFAR Ethiopia is intended to serve as the national model and

center of excellence, and has started preliminary laboratory work. EHNRI worked closely with CDC Ethiopia

to maximize support and implement the national quality assurance program, including a training-of-trainers

(TOT) program.

EHNRI supported eight regional laboratories (Addis Ababa, Adama, Nekmet, Bahir-Dar, Dessie, Awassa,

Mekele and Harar) to strengthen overall quality of laboratory services. With EHNRI support, the regional

laboratories continue to support complex tests that hospital laboratories cannot perform, and to provide

suitable referral-based test results.

The FY08 activity plan will focus mainly on the continuation and expansion of FY07 programmatic areas:

quality assurance programs, training, diagnosis, and establishing tiered laboratory services.

EHNRI will continue supporting the establishment and strengthening of laboratory standards and work

closely with the eight regional laboratories. Together they will strengthen the tiered laboratory services from

health center to district hospitals, from district to zonal/ regional hospitals, and then to reference

laboratories.

Regional laboratories will support routine quality assurance and control plan for voluntary counseling and

testing (VCT), diagnosis of opportunistic infections (OI), and laboratory monitoring of ART at hospitals and

health centers. The regional laboratories will have the capacity to develop their own PT panels for rapid HIV

testing. The regional laboratories will report on all hospitals and health centers every three months. Quality

control materials (proficiency panel) will be distributed to sites twice yearly. External quality assessment,

including site visit reports and proficiency panel test results, will be regularly communicated to sites.

Regional laboratories will also continue reporting their activities to EHNRI quarterly. In collaboration with the

CDC's Atlanta laboratory, EHNRI will continue establishing external quality assurance for early infant

diagnosis of HIV.

EHNRI will continue its training activities, with more emphasis on TOT of laboratory personnel in: rapid HIV

diagnosis; monitoring of ARV therapy; maintenance of laboratory equipment; laboratory quality

management systems; tuberculosis (TB) and OI diagnosis; and HIV surveillance. EHNRI will work on simple

diagnostic techniques for sexually transmitted infections (STI), such as HSV2 serology, and compare with

the syndromic approach. EHNRI will also conduct a study on the prevalence and causes of urethral

discharge and genital ulcer syndromes among HIV-positive subjects. The information collected from this

study will help to update the STI Syndromic Management Approach algorithm. In addition to the

abovementioned activity, EHNRI will also conduct chemo-sensitivity studies of N.gonorrhea among HIV-

positive and negative subjects throughout the country. EHNRI will ensure that standardized training

modules are used for regional and site-level training programs supported by Regional Reference

laboratories and U.S. universities.

With technical assistance from PEFPAR Ethiopia, EHNRI will support and ensure accreditation of clinical

laboratories that support HIV/AIDS, TB, STI, OI, and related services. EHNRI will closely work with the

Clinical Laboratory Standards Institute and ASCP to strengthen the laboratory system per the national

laboratory plan and to improve the standards of clinical laboratories.

Equipment Maintenance and Technical support for Laboratory services

The Ethiopian Health and Nutrition Research Institute (EHNRI) is the technical arm of the Ethiopian Ministry

of Health (MOH) responsible for providing guidance to laboratory services. It is the lead institution in

coordinating laboratory programs in Ethiopia, and has a national plan to support HIV laboratory services.

EHNRI provided technical assistance to strengthen the quality of laboratory service at all levels. Technical

assistance included preventive and curative maintenance services of equipment, inventory laboratory

management, and on-site practical trainings. EHNRI also provided follow-up and supportive supervision to

all ART hospital laboratories.

In FY07, EHNRI provided preventive and curative maintenance service for major laboratory equipment at all

expanded 131 hospitals, 240 health centers, and ten regional laboratories. Included in the quarterly

preventive maintenance and calibration of major equipment were centrifuges, FACS counters, and

hematology and chemistry analyzers at all sites. Broken machines were repaired and spare parts changed

to prevent or minimize service interruption. Technical assistance included maintenance and troubleshooting

of laboratory equipment (e.g., refrigerators, freezers, microscopes, incubators, autoclaves, chemistry

analyzers, hematology analyzers, and FACS count machines) at all ART hospitals and health centers.

EHNRI contracted out maintenance services for major diagnostic and monitoring equipment.

In FY08, all activities, including the performance contract services, will continue and will be expanded to

additional ART sites. Support will be provided for purchase of critical spare parts and establishment of an

Equipment Maintenance Center at EHNRI. Technical support will continue and expand to new sites which

initiate ART services, including all health center laboratories. In collaboration with other partners like Supply

Chain Management System (SCMS), Rational Pharmaceutical Management Plus (RPM+), MSH and

university partners Technical assistance, including curative and preventative maintenance of equipment,

and functional and structural organization of laboratory, on-the-job-training in test procedures, specimen

management, data recording, and reporting, inventory laboratory management, on-site practical trainings

and follow up and supportive supervision. Technical support includes inventory and laboratory management

for maintenance of clinical laboratory services and ensures laboratory standards are implemented at all

ART hospital, health center and voluntary counseling and testing (VCT) laboratories. Reviewing existing

laboratory operating procedures, recording and reporting at facility levels will be performed. Technical

assistance will continue to be provided for production of laboratory stock management tools, disseminate for

use at selected sites; implement a system of scheduled requisitioning of laboratory reagents and test kits

and other supplies and institute a quarterly reporting system for laboratory commodities consumption and

stock status. The contracts will be technically reviewed and there will be periodic evaluation of services

provided and the laboratory technical working group will be represented in this process.

Title of Study:

Health Impact Evaluation of Ethiopia's National Response to HIV/AIDS, Tuberculosis and Malaria

Time and Money Summary:

Timeframe: September 2007 - May 2008 Budget: $450,000

Local Co-Investigator:

Ethiopian Health and Nutrition Research Institute (EHNRI) is leading Ethiopia's health impact evaluation

phase one, funded by the Global Fund for AIDS, Tuberculosis and Malaria (GFATM).

Project Description:

At its 14th meeting in November 2007, the GFATM Board of Directors approved the launching of the Five-

Year Evaluation of the GFATM. Under the guidance of the Technical Evaluation Reference Group, the Five-

Year Evaluation is a major effort to review the functioning and performance of the GFATM as an institution

and as a partnership, and to identify areas of strength and weakness that will lead to improving day-to-day

operations. In particular, the Five-Year Evaluation calls for an Impact Evaluation to assess the reduction in

the burden of the three diseases associated with the collective scale-up of prevention and treatment

activities by all partners.

The design of the Five-Year Evaluation foresees work in and with 20 countries to evaluate impact. This

work comprises an in-depth analysis including primary data collection, as appropriate, in 8 countries; and

impact analysis based on secondary data in 12 countries. Ethiopia is one of the eight countries where

primary data collection will be carried out to evaluate the health impact of GFATM.

The Ethiopian Health and Nutrition Research Institute (EHNRI) was assigned by the GFATM Country

Coordinating Mechanism (CCM) for Ethiopia to facilitate and play a leadership role for the establishment of

a Task Force that is to work closely with the global evaluation team on the Ethiopia-specific implementation.

The Task Force is chaired by EHNRI and Ethiopia's UNAIDS Secretariat serves as the Secretary. The

Task Force has formed a Core Group to serve as the technical arm of the evaluation. The Task Force

includes a broad representation of the major in-country stakeholders, technical experts and selected

representatives. EHNRI, UNAIDS, Ministry of Health (MOH) Tuberculosis Control Unit, MOH Malaria Unit,

HIV/AIDS Prevention and Conrol Office (HAPCO), the Central Statistics Agency, World Health

Organization, PEPFAR Ethiopia, Tulane University, Italian Cooperation/HIV-AIDS Donors' Forum, Addis

Ababa University/Community Health Department are the main stakeholders and Task Force and core group

members.

Evaluation question:

The primary evaluation question is: What collective impact has PEPFAR, the Global Fund and other

national and international partners had on reducing the disease burden of HIV, tuberculosis and malaria in

Ethiopia?

Programmatic importance/anticipated outcomes:

The health impact evaluation results will be used for accountability and program improvement. The

evaluation will assesses the collective impact that PEPFAR, GFATM and other national and international

partners have achieved on reducing the disease burden of HIV, tuberculosis and malaria at the national

level. It will measure the national HIV, malaria and TB program effect on disease morbidity and mortality. It

will lay the foundation for improved monitoring and evaluation in the future. It can also serve as a baseline

for future impact evaluations.

Methods:

The evaluation efforts will involve a series of data collection efforts, including surveys, surveillance,

research studies, service and administrative records. The evaluation uses the adequacy evaluation

approach by comparing the performance or impact of the project with previously established adequacy

criteria (Habicht et al, 1999). This kind of adequacy assessment does not require control groups and

provides information about how well program activities have met the expected objectives. It will not be

possible to assure cause-effect relationship with the interventions themselves and the outcomes measured.

The evaluations will look into the performance of the interventions in the three diseases, including provision,

utilization, and coverage of services) as well as the impact of the interventions. The study design will be

cross-sectional or longitudinal depending on the data sources required and available.

Information Dissemination Plan

EHNRI and member of the taskforce will be responsible to devise the dissemination strategy to ensure all

Stakeholders are aware of the evaluation's findings. The dissemination strategy is likely to include:

publication of the final report and/or the executive summary; a presentation and discussion at workshops

with key stakeholders; national, regional or local conferences; and dissemination of information and final

report to all concerned.

Budget:

The total budget that is required for implementation of the Health Impact Evaluation as per the designed

work plan is estimated at $1,287,000. Approximately $500,000 is available from the GFATM Impact

Evaluation funding, and PEPFAR will supplement the study by providing $450,000. The balance will be

provided by other donors.

Supporting the National HIV/AIDS/STI Surveillance System

The Federal Ministry of Health (MOH) began work on strengthening and supporting the National

HIV/AIDS/STI (sexually transmitted infections) Surveillance system in 2002. Activities have been ongoing;

however, implementation of activities was slowed in the second half of FY06 and first quarter of FY07 due

to organizational changes at the Ministry, at which time the responsibility for implementing and coordinating

HIV/AIDS/STI/TB (tuberculosis) surveillance was given to the Ethiopian Health and Nutrition Institute

(EHNRI). Since then, PEPFAR Ethiopia has been heavily involved in supporting EHNRI in the facilitation

and implementation of most surveillance activities; however, recently EHNRI reorganized itself and has

been better able to handle these activities.

Funds from FY07 have been used for building the capacities of the EHNRI and regional health bureaus

(RHB) to enable them to extend their support to zonal health departments (ZHD), district health desks, and

health facilities that are directly involved and benefiting from HIV/AIDS, TB/ HIV and STI surveillance

programs. Moreover, in FY07, EHNRI, with PEPFAR Ethiopia funding, extended support to RHB to allow

them to support 19 additional health facilities as sites for antenatal clinic (ANC)-based HIV surveillance.

EHNRI will train site staff in the collection, compilation, and reporting of HIV case surveillance data.

IN FY07, communication between and among all the surveillance partners was also enhanced. The

capacity of RHB to provide supportive supervision to all the health facilities involved in surveillance activities

was strengthened. EHNRI, in collaboration with CDC and other relevant partners, also provided support to

RHB to conduct their annual surveillance planning and review meetings with their respective surveillance-

site staff.

RHB, ZHD, district health desks, and health facilities were all supported through EHNRI in their preparations

for the planning and execution of the 2007 National HIV/AIDS/STI surveillance activities. EHNRI provided

them with technical guidance in the selection of staff for trainings, selection and preparation of sites, data

and sample collection, sample transportation, supportive supervision, and data management.

In FY08, preparatory work for the 2009 round of ANC-based, sentinel-site HIV surveillance activities will

commence. These activities include: assessment of sites; training of site-level ANC clinic and laboratory

staff; procurement of test kits and other supplies to be used by sites; and conduct of national and regional

review workshops.

PEPFAR will also support EHNRI in the initiation of several new types of surveillance, including HIV case,

STI, and TB/HIV surveillance. These programs will be implemented based on the guidelines developed by

EHNRI and PEPFAR over the past several years. EHNRI will work this year toward building its own capacity

and the capacity of regional laboratories, RHB, and health facilities involved in established and new

surveillance programs.

PEPFAR will also support EHNRI to build a national drug-resistance surveillance system. This will help

PEPFAR partners and the Government of Ethiopia to ensure the generation, analysis, and use of

information that can help develop and maintain effective strategies for ARV use. This activity will help to

produce the evidence to guide national the HIV/AIDS treatment plan and other measures to sustain the

effectiveness of ART among newly infected patients.

Finally, PEPFAR will also support EHNRI to design and implement an HIV/AIDS/STI surveillance system

using selected sites that provide HIV/AIDS/STI services to the most-at-risk populations (MARPs), especially

to commercial sex workers. This will help PEPFAR and the country to generate information that can be

used to guide HIV/AIDS/STI/ programs for MARPs, given the nature of the low-level, generalized HIV

epidemic in the country.