The Guyana HIV/AIDS Reduction and Prevention Project (Prime: FHI) will support the GoG's ongoing HIV prevention, care and treatment program by helping to establish the necessary health infrastructure systems and improving provider skills so they can safely and effectively provide PMTCT with appropriate links to follow-up services. FY07 will bring a strong focus on eliminating the large number of non-tested deliveries occurring at L&D sites as was mentioned in the context adhering to new MOH SOPs and policy decisions for PMTCT and for ensuring quality services.

GHARP will continue to strengthen human resource capacity by building capacity of PMTCT support groups (including support packages for providers established in materials produced by CDC), strengthening MOH capacity to manage PMTCT, train labor and delivery ward staff using CDC/FXB-developed materials on protocols and procedures, post-exposure prophylaxis, safe obstetric practices, ARV prophylaxis issues and post-birth counseling, including infant feeding counseling. Site support will include continued training, provision of counseling support materials, operations manuals, infrastructure support as needed and quality assurance and monitoring/evaluation system support. A great deal of collaborative work has resulted in as many as 12 ANC forms being streamlined into one paper-based, triplicate copy, ANC form that includes all necessary PMTCT information which is processed through statistical unit of the MOH. Further strengthening of this system will continue as well, keeping in mind such models as the CDC-developed PMTCT-MS.

In FY07 FHI/GHARP will conduct TOT for hospital setting; train labor and delivery ward staff from 5 L & D sites using CDC/FXB-developed materials on protocols and procedures, post-exposure prophylaxis, safe obstetric practices, ARV prophylaxis issues and post-birth counseling, including infant feeding counseling and the newer MOH policy on opt-out testing in L&D wards. Recruitment and training for counselor/testers to support the Labour and Delivery sites to adequately support the shift system at all Labour and Delivery sites. The assessment conducted by GAP/CDC as well as FHI operational research in FY06 showed that there was a shortage of counselor/testers at several L and D sites. This resulted in mothers having missed opportunities to be counseled and tested at L and D. Hence, all plans will continue to support the increased personnel at these sites (with all personnel rolling over to MOH contracts upon COP approval and award of funds in the first quarter of calendar year 2007).

The results of the qualitative PMTCT Drop-out Study found that the concept of discordant couples was not widely understood among women who received PMTCT services, and many couples held the belief that a woman's HIV status reflected her partner's status. In an effort to reinforce the concept of HIV discordance among couples and increase the number of male partners who are tested, there will be a focus in FY07 in emphasizing the concept of discordance both during training of counselor/testers as well as during the provision of PMTCT services.

In an effort to follow the GHARP exit strategy, FHI will develop guidelines for assessment of the PMTCT program (including human resource alignment) to help strengthen MOH capacity to manage PMTCT- in collaboration with MOH/MCH and MOH STATS Department along. Meetings will be held between MOH and GHARP and USG partners to determine the most appropriate way forward as it relates to the full management, QA/QI, monitoring, evaluation, and reporting of the program progress. FHI will technically support the process of integrating PMTCT into MCH services through the safe motherhood program - focusing on the 5 prongs of safe motherhood initiative that aims to reduce the illnesses and deaths among women of childbearing age. In-service training will already begin to integrate the five prongs of safe motherhood as a first stage of the process. During this transition period FHI will continue to conduct QA/QI follow up visits to clinical sites to observe implementation of new skills and will collaborate with CDC/GAP, MOH on quality assurance program for management of PMTCT sites, focusing on strategic information, commodities management, and skills testing/training. (A draft tool has already been developed). This will enable staff at every level of program operation to implement an effective QA/QI program to ensure maximum performance and quality of all our interventions.

Specific Supported Activities will include:

1.) Pilot a follow-up/ community outreach program. This will be achieved through the nurses based at the health centers and linkages to NGOs and Palliative service providers. 2.) Provide training support as requested by MCH. 3.) Enhance the linkages between VCT, PMTCT, OI, STI and referral to ART and other technical areas. 4.) Provide support for the revision and finalization of PMTCT and VCT guidelines, protocols, Standard Operating Procedures and training curriculum including VCT/ CT TOT curriculum. 5.) Provide support for establishing links with overarching capacity develop and M&E and quality assurance plans. 6.) Undertake a review of PMTCT target based on detailed review of Maternal and Child Health records. 7.) Support the MOH/MCH in development and implementation of regular comprehensive review of the program to identify and solve issues that affect implementation of the program. 8.) Include of ‘high-yield' sites such as Woodlands Hospital as PMTCT sites. 9.) Enhance the uptake at primary care facilities through strategic blood collection at the health centers through the use of mobile counseling and testing teams and MCH phlebotomists. 10.) Collaborate with the MOH, staff for the identification of awards based on staff performances standards. 11.) Provide regional awards/appreciation for MOH staff working in PMTCT/VCT. 12.) Collaborate with the Private Sector (Partnership Program) to provide low interest loans, discount cards and insurance incentives to providers of care for nurses involved in PMTCT.

Howard Delafield Inc.(HDI) is a sub-contractor under GHARP. The firm is responsible for critical communication activities within the PMTCT program. Their communication responsibilities range from print material; interpersonal education materials; messaging early uptake of PMTCT services to increase women's knowledge of how to protect themselves and their babies and improve outcomes; messaging couples counselling to address the concept of discordant couples, as well as to increase male participation and responsibility in the ANC process, and; production of clinic materials in collaboration with FHI, such as cue cards and educational brochures.

Specifically, HDI will air and reproduce the community mobilization materials (print, radio and TV) that have previously been produced for PMTCT; develop a reward/incentive scheme for care providers that leverages support from the private sector; targeted distribution of PMTCT brochures, posters and interpersonal education materials to private sector partners with high numbers of female employees; and as highlighted in the CDC PMTCT evaluation--HDI will coordinate with WB and GFATM to produce and disseminate an ANC waiting room info-mercial to further support the initiative.

GHARP through FHI and the Caribbean Conference of Churches (CCC) will continue to technically support 12 NGOs/CBOs, including 4 FBOs to effectively implement Abstinence and Faithfulness prevention programs for youth and adults alike in the ten Regions of Guyana.

In collaboration with its sub-partner the CCC, GHARP developed an abstinence and faithfulness manual which is a sub-set of the Guyana "Body Works" tool called "Faith Matters" that is inclusive of all major religions in Guyana (Christian, Hindu, and Islam). The NGOs/FBOs will continue to use this Peer Education manual to conduct workshops on delayed sexual debut until marriage, refusal skills, secondary abstinence, stigma and discrimination with religious and lay leaders, sermon development workshop with FBOs, and capacity building of Faith Leaders to incorporate information on "AB", VCT and fidelity during marital & pre-marital counseling. The pre-marital counseling support will aid in transitioning the couple to sexual activity with responsible behavior, emphasizing fidelity. The primary objective is to avert HIV/AIDS infections by encouraging behavior that will reduce the risk of infection.

To achieve our program objectives our efforts will be focused on creating an enabling environment for positive behavior change. These activities will include promotion of the benefits of partner reduction, increased family time, pre-and post marital counseling, and the promotion of individual, familial and societal responsibilities. Training will also focus on cultural norms, gender issues, human sexuality and domestic violence. Our FBOs will be integral partners in promoting this prevention strategy as well as in counseling their members to access pre-marital counseling and testing.

There will also be targeted activities to encourage and support male involvement in FBO HIV/AIDS work. Through our partnership with the religious organizations such as the Central Islamic Organization and Hope Foundation, male constituents will be communicated directly to discourage cross-generational sex, and to support and normalize fidelity, partner reduction and other behavior change. Men will also be targeted at the workplaces and other sites where men congregate through our HIV/AIDS workplace programs to stress male sexual and familial responsibility.

Our program will also encourage Guyanese leadership to promote partner reduction and faithfulness, and denounce violence against women and girls, and design, implement, and evaluate a culturally relevant intervention that prepares community leaders to guide community dialogue on sexual coercion, violence against women and girls, partner reduction and faithfulness.

Community outreach activities with the NGOs will serve to support and reinforce the uptake of key prevention behaviors among youth. Several local partners like Volunteer Youth Corps will engage youths and stimulate community discussions, promote positive social values and social responsibility, removal of misconceptions about sex and sexuality, and community mobilization approaches to youth empowerment. Messages on abstinence are presently included in counseling and mentoring sessions as well as in peer education outreaches. There are also community interventions which are designed for persons to be aware of risky behaviors and in so doing eliminate or reduce those said behaviors. Young persons are especially being given messages about self-worth, dignity and the necessary skills for practicing abstinence. They are also informed of the risk associated with early sexual activity, sex outside of marriage, multiple partnerships and cross generational sex, and are trained on alternatives such as healthy lifestyles and negotiation skills.

Special efforts will be made to target sexually active young boys 15-19 with partner reduction and secondary abstinence messages given the number of partners reported among this group. Additionally, some gaps have been identified in the level of knowledge among some sections of the population, hence discussions within these groups have commenced in order to strengthen our program in FY07.

Howard Delafield Inc. (HDI) is a partner company on the GHARP initiative. This privately, women-owned business has a successful history in public health marketing and communication development. Their responsibility within AB will be to support the current communication and educational material concepts by integrating them into community outreach media and inter-personal communications. HDI will work with partners/stakeholders to adopt materials into educational curriculum; and in the print media; covering all costs of design, development, pre-testing, production, reproduction and air/print dissemination.

HDI also has strengths in building on private sector partnerships, and as such will be continuing to work with beverage companies to address drinking and substance abuse as part of the abstinence program.

HDI will develop tailored messages on faithfulness for adoption by the National AIDS Program Secretariat (NAPS) and produce, faithfulness materials (billboards, print, TV, and radio) as well as cover the expenses of media coverage/airings. HDI will also produce tailored messages on faithfulness for different religious organizations for distribution at a community level.

HDI will be tracking thier own process indicators, but will not have direct targets as they contribute to increasing access to care and in mobilizing the community. The actual service delivery targets are set within the GHARP/FHI section as they have the overall responsibility to monitor and report on USAID/GHARP overall program implementation.

GHARP will continue to use information from the BSS completed in 2005 to inform program design and implementation, and will focus on customizing specific packages of services to meet each target MARP needs for individualized prevention services. Sex workers will partner with outreach workers doing risk reduction support. This target population will be reached with services promoting the desired behavior change, including increased access to counseling and testing through MARP-friendly mobile VCT and STI testing sites, a decrease in alcohol and drug intake through education and psychosocial support networks, and, consistent and correct condom use with clients.

Vulnerability reduction and partner reduction activities for sex workers will include offering skills-building opportunities to increase alternative income generation or employment options, in addition to condom negotiation skills and strategies for avoiding violence (avoiding alcohol and drugs). Specific NGO interventions are carried out by such groups as Artistes in Direct Support, Comforting Hearts, Lifeline, and SwingStar. GHARP has been able to develop cue cards that have been pre-tested among CSW and are used for group and individual peer education by the NGOs and CSW contacts who were trained as peer educators. These same NGOs, linked to their points of contact within the target population, deliver interactive sessions with a series of pre-tested tapes that have simple story-lines, just a few characters, and walk the CSWs through different scenarios that educate and reinforce strong prevention behaviors and practices. The same six NGOs have also self-selected themselves to target MSM. Only a few strong points of contact exist within this target population and as such, the training of MSM to work within their own network is critical until the community organizations are able to reach a wider population directly. Through peer education and supportive referal for clinical and preventative services, men having sex with men will be encouraged to adopt safer sexual behaviors such as condom use with clients and regular partners, a reduction in the number of partners, and to increase their health seeking behaviors for STI/OI and HIV care and treatment.

The six NGOs who are currently working with most at-risk populations will be providing HIV/AIDS/STI prevention education, risk reduction counseling, and referrals for care and treatment to a recommended network of services. The program will also work with MARP and PLWHA support groups and drop-in centers that offer a supportive environment to reinforce behaviors that reduce risk of HIV transmission.

Miners will be provided a similar set of support services, customized to meet their own individual needs and risk factors. This population will be encouraged to adopt safer sexual behaviors and to increase positive health seeking behaviors. One very promising opportunity to promote the uptake of HIV/STI services by miners and loggers is to offer malaria testing. Given the high level of concern among this population, this is a possible way of encouraging these mobile, high risk men to access condoms and clinical services, including HIV/STI counseling and testing.

Mobile services for VCT and STI syndromic management will be used wherever high risk populations are present and access to services is limited. NGOs who are currently working in these areas will be providing targeted prevention and risk reduction education to persons at high risk, as well as counseling, testing, and appropriate referrals for care and treatment.

GHARP will support the development of prevention programs for positives and sero-discordant couples. Through twinning, these programs will assist local PLWHA groups to increase their capacity to provide post-test counseling for positives, and to conduct support groups for positive pregnant women (and provision of family planning counseling and support), counseling for discordant couples, testing for the families of HIV+ persons, and support for family access to key health services.

Individualized prevention programs that include sensitization, education, peer counselor training, and targeted materials development will be implemented to reach those high risk behaviors identified in the BSS among the in and out-of-school youths, GuySuco workers, and uniformed services. The desired behavior changes that will be promoted are all aimed at eliminating or reducing risk of transmitting or becoming HIV infected, reducing alcohol and drug use; consistent and correct condom use where appropriate; promotion of secondary abstinence; mutual monogamy and/or partner reduction (MSM primarily);

increasing health seeking behaviors and referrals; increasing correct knowledge of HIV transmission, and a decrease in the levels of stigmatizing beliefs held by the groups.

In an effort to expand its reach to MARP, GHARP will utilize a number of interventions. Activities will include targeted prevention education that is adapted to fit the risk reduction needs of specific MARP target groups, increase access for STI treatment by offering MARP-friendly mobile syndromic management, increase access for HIV/OI treatment by sensitizing clinical providers to issues of stigma and discrimination and offering flexible clinic hours, aimed at establishing a friendlier setting for high risk persons to access services. Special emphasis will also be placed on creating male friendly spaces where men will feel free to be able to access HIV/AIDS/STI prevention services at times convenient to them and to speak with male counselors in many instances. Promotion and training for staff on the expectation of service delivery that emphasizes empathy will be implemented, which will foster thus exhibiting a certain degree of tolerance for apparel and mannerisms, and will create a safe environment for all clients and their families. One partner NGO, the Guyana Responsible Parenthood Association has been quite successful in building client-patient relationships with high risk groups and expects to continue to see an increasing number of regular clients. Also, staff from public and community based-HIV/AIDS programs in hinterland villages will be sensitized to the specific needs of their clients and the increased need for anonymity in such an isolated setting. The coordination with FXB and CIDA-supported STI, TB and ART centers will be integral so that those sites also integrate a similar "MARP friendly" non-stigmatizing approach.

Additionally, GHARP will continue to build the capacity of NGOs to provide targeted prevention education to specific MARP populations, and services to the most vulnerable populations that reinforce and support risk reduction through behavior change. The project aims to strengthen local NGO managerial and technical capacity to provide prevention programs and services for vulnerable populations through outreach, and facilitate direct referral to clinical services in Georgetown.

Howard Delafield Inc. (HDI) is a small, privately owned business that is sub-contracted within the GHARP consortium. HDI will continue to implement and monitor strategy to strengthen and expand partnerships with private sector organizations with a special focus on MARP such as miners, loggers, transport workers (shipping, river transport services, mini buses), including contractors of the primary organizations. HDI is also responsible for continuing to develop strategic distribution outlets for targeted distribution of condoms, expanding the role of sales-promoters to include collection of informal data on the "pulse" of the community in relation to the success of GHARP communication programs. Their condom marketing campaign will not only generate demand for branded and un-branded condoms alike, but will increase access by high risk persons to non-traditional condom sales outlets in mining and hinterland areas, and promote correct, consistent use of condoms in most-at-risk populations. These populations will also receive prevention education messages promoting being faithful and partner reduction as an important means of reducing one's risk of HIV/AIDS/STI infection, with a focus on promoting responsible male behavior.

In addition, they will continue to cover all costs for design, field test, produce, reproduce, air, print, and dissemination of communication material for bars/brothels/mobile populations and materials focused on other prevention. HDI will build on the private sector's initiatives to conduct/implement joint trade promotions with private sector condom distributors. Finally, HDI will produce, distribute ‘value kits' (condoms, lubricants, cologne etc) for female sex workers.

FHI will maintain the responsibility for the overall cohesion of the GHARP project as the prime and will continue to report financially and programmatically for the program.

Family Health International, as the prime partner for GHARP, provides technical support, monitoring and data quality assurance, and program oversight implementation for the NGOs funded through the Maurice Solomon & Parmesar mechanism. The package of care that NGOs/FBOs provide includes all four aspects of essential palliative care services and follows PEPFAR guidance. The clinical aspects of care are provided at the clinic level within the community and the other three aspects are provided through a network of FBO/NGO partners that are trained and supervised by GHARP. Currently, there are eleven NGOs that are supported to provide services, and in FY07, USAID/GHARP will release a request for proposal to add two additional civil society organizations. In some cases, FBO/NGO partners have been determined to possess the necessary capacity to provide clinical care outside of the facility setting and are supported in delivering such services. GHARP focuses on building the capacity of local service providers in an effort to facilitate the transfer of skills and to improve and expand the range of services offered. All activities are being developed and implemented in close collaboration with the MOH; with the network continually being strengthened to provide home based counseling and testing or a direct referral to facility-based VCT, ART, and OI/STI treatment provision. At sites where none of the aforementioned services are possible, the patient is referred to the nearest site for clinical assessment, STI/OI screening, prophylaxis and treatment, child immunization, nutrition hygiene counseling and reproductive health services. The reverse of these referrals is witnessed when treatment sites call their palliative care coordinator within the facility, supported by GFATM and the National AIDS Program, to register the client for palliative care services. This coordinator then works with the client as well as available community-based HBC providers to ensure that the client is not lost to follow-up.

FHI/GHARP will specifically focus on providing assistance as follows: 1.) Provide technical and management assistance and conduct monitoring of NGO progress through regular field visits; 2.) Conduct quarterly mentoring site visits and conduct an annual assessment of NGO progress; 3.) Monitor, evaluate, and report of the implementation of palliative care programs.

In FY06, Cicatelli and Associates was prime on the USAID/GHARP team in three disciplines of palliative care which included: Palliative/Home Based Care, PLWHA Development, and Micro-Enterprise programs. Cicatelli was also able to have computerized HBC reporting and referral system for the immediate use of MOH. PLWHA have been highly valuable contributors within HBC programs, and we would like to continue utilizing available PLWHA services in HBC. However, we believe that it would be beneficial to utilize PLWHAs in more than just the HBC area. Experience thus far in Guyana indicates that the incorporation of PLWHAs in supportive workplaces has very good outcomes for both the workplace and the individual. Cicatelli has had national/international success in PLWHA development which includes training PLWHAs for enhanced outreach, navigation, peer mentoring (including adherence and secondary prevention), and as recruiters in a new project called Social Networking (described below). In FY06, an innovative micro-enterprise program was developed with the Institute of Private Enterprise Development (IPED) and an indigenous furniture and art company called Liana Cane whereby skills building and training for PLWHA is provided, with the possibility for future employment, as well as training of current staff at the company and support for HIV/AIDS policy and workplace programming. In FY07, Cicatelli will expand this model for working within the expanding field of trade and tourism industry as well as training and employment programs with Habitat for Humanity and Victoria's Secret (through the local manufacturer, Denmour Garments). Also within the parameters of micro-enterprise, Cicatelli worked closely within GHARP with Howard Delafield International to establish a micro-enterprise loan program for PLWHA from the IPED office. Cicatelli will continue to work with PLWHA associations and its palliative care program to link PLWHA to these opportunities. Also, in FY06, Cicatelli initiated the very critical approach of focusing on the long-term viability of HBC training by working with the Institute of Distance and Continuing Education to establish a certification course for care providers. They will continue to work on strengthening this training course and provide mentorship to the organization to effectively deliver the course.

In FY07, Cicatelli will therefore be specifically responsible for the following:

1.) Provide support and quality assurance to those we trained as trainers for volunteers in HBC certification in ‘06 2.) Train providers on and support the process of introducing home-based VCT 3.) Implement HBC computerized reporting and referral system developed in ‘06 4.) Work with MOH to develop a national policy on pain management and hospice care 5.) Develop a quality assurance program for HBC jointly with MOH 6.) Continue working with nurse supervisors on their roles in HBC 7.) Develop curricula and training for community and family members caring for loved ones at home 8.) Integrate into MOH's HBC demonstration project using community health workers who provide home based care for persons with diabetes and hypertension. At present, home based care is synonymous with HIV; we would like to change that. This is an important strategy because by integrating services for persons with chronic diseases such as diabetes and hypertension and HIV/AIDS, we can take some of the stigma away and improve confidentiality measures. 9.) Continue working with NGOs to develop multidisciplinary teams and using PLWHAs as enhanced outreach workers, navigators, etc. 10.) Support the MOH Case Navigation Demonstration Project. This is a project in which PLWHAs would be employed and trained to navigate those testing positive in anonymous testing sites into treatment and care. This project is necessary because there is no current follow up method to track those who are tested at VCT centers and get positive test results. MOH has committed to hiring 4 PLWHAs to be employed as case navigators working with anonymous testing and counseling sites with positive clients to assist them with accessing treatment and care. MOH proposes hiring four PLWHAs in region three. Two of them would work in the regional hospital, and two would work in the far end of region 3, in a satellite clinic. CAI would develop jointly with MOH an implementation manual; training and supervisory curricula; and reporting, tracking and evaluation tools. Based upon the success of this demonstration project, this model could be implemented in all clinic sites in which case navigators could assist in all anonymous testing sites, assisting those testing positive into treatment and care. This project would serve as a model for connecting resources between MOH clinics and NGO VCT sites. 11.) Implement Social Networking, a CDC research to practice program which utilizes

"recruiters" (PLWHAs) to recruit friends from their social networks into testing. This is a very focused and specific form of outreach to bring people into testing using people who have tested positive within the past 3-6 months. Based upon preliminary findings, in areas of high incidence of HIV, the prevalence rate from using Social Networks is 6 times the rate seen in publicly funded clinics. CAI is the CDC funded partner on this program and we developed the training curriculum for Social Networking. We are currently training all state HIV/AIDS health directors on this program. We would implement this program in three sites. 12.) Continue working with the people we are funding through IPED 13.) Continue working with the HIV+ women trained in crafts through Liana Cane 14.) Develop a partnership with Habitat for Humanity in Guyana. GFATM and WB will partner with Cicatelli to fund Habitat for Humanity in Guyana up to $50,000 to develop low income housing for PLWHAs. We would in addition provide funding to Habitat to provide skills training in carpentry and masonry for high risk youth and young men living in households with PLWHAs, as well as PLWHAs. 15.) Partner with Victoria's Secret to provide employment slots for HIV positive and high risk women. We would fund the establishment of a sewing training program and an employment readiness program prior to the women being employed. 16.) Partner with the trade and tourism industry for the establishment of training and job-placement programs for PLWHA in many of the hinterland regions where employment opportunities are very limited.

Family Health International, as the prime partner for GHARP, provides technical support, monitoring and data quality assurance, and program oversight and will report on Cicatelli's program achievements.

Howard Delafield Inc. is a private, woman-owned organization within the USAID/GHARP program. In FY06, an innovative micro-enterprise program was developed in collaboration with another GHARP partner, Cicatelli & Ass., along with the Institute of Private Enterprise Development (IPED). Together, they established a micro-enterprise loan program for PLWHA. HDI was able to secure funding from the Guyana Telephone and Telegraph Company to pay the salary of a dedicated IPED officer to oversee these loans and provide technical assistance to PLWHA in developing their applications and small-business plans. HDI was then able to secure support from the Guyana Lotto company to make the commitment of putting up the collateral for the loans. Cicatelli then worked with PLWHA associations and its palliative care program to link PLWHA to these opportunities. To date there have been over 22 successful loans.

In FY07, HDI will also:

1.) Develop a strategy to bring together the insurance industry to create incentives such as reduced rates for companies that offer comprehensive workplace programs; 2.) Develop and implement a strategy to work with other USAID/GHARP program areas such as HBC, and other offices regarding PMTCT, OVC, VCT e.g. Liana Cane , Citizens Bank, Scotiabank Partnerships 3.) Develop and stage first annual private sector awards program and ceremony 4.) Develop and produce media campaign and community advocacy as well as "take home" reference materials for home based care (Production, media placement, printing).

Family Health International, as the prime partner for GHARP, provides technical support, monitoring and data quality assurance, and program oversight and will report on HDI's program achievements.

Through its NGO network and its dedication of targeted technical assistance, GHARP will mobilize community leaders and organizations to form (and/or strengthen existing) committees to support vulnerable families. These committees can play several important roles including identification of vulnerable children & families. GHARP partners will support these committees to involve community members (i.e., CBOs, FBOs, Rotary) that can in turn identify and develop local resources. For example, similar committees in other countries have developed community owned day care centers, vegetable gardens, and apprenticeships to support vulnerable children and their families. Committees also play a key role in facilitating referrals to services (and between service providers). They are also the most appropriate group to ascertain gaps in community resources. Through training and mentoring in assessment, strategic action planning and resource development, GHARP will build the capacity of the committees to sustain efforts beyond the life of the project.

GHARP, through its NGO partners, will focus its energies on increasing the reach of the OVC program through innovative means. Creative approaches are needed given the relative low HIV prevalence in Guyana which suggests that the number of HIV/AIDS-related OVC is small compared to OVC of all causes (HIV/AIDS OVC /OVC of all causes). GHARP will therefore focus its energies on high probability sources for case-finding e.g. ART sites, PT/HBC centers, PMTCT, VCT, PLHA groups and community (drop-in) centers. Additionally GHARP will assist in exploring options of alternative funding through wrap-around services.

GHARPs network of NGOs will also promote the development of a non-discriminatory environment by conducting educational sessions with the Parent-Teachers-Associations, school children, and local community groups through the use of peer educators. In-house counselling for care-givers will also be conducted in order to promote an enabling environment for positive attitudinal change. The NGOs will also seek to promote anti-stigma and discrimination messages at various national events.

A significant role of GHARP will be in program oversight, monitoring and evaluation, reporting to USG, networking, and technical backstopping.

New activities 1. Support and encourage the development of community committees 2. Support referral system strengthening through HBC-for-children training 3. Support referral system strengthening through support of HBC volunteers 4. Technical support for OVC through work internships, etc in collaboration with Ministries of: Labour, Human Services and Social Security Education Culture, Youth and Sport Agriculture Amerindian Affairs 5. Maintenance of quality and effective services at NGOs and Ministries through mentoring, coaching and facilitated supervision, as well as reporting responsibility for OVC to USAID 6. Development and dissemination of Child counseling manual 7. Development and dissemination of manual on access to welfare grants 8. Support for OVC inclusion in IMCI training at MCH/MOH

GHARP will increase the number of ARV referrals in FY07 (699 as of June 30, 2006), and in order to do so will work diligently to increase the access to and uptake of C&T services with an increased focus on reaching high-risk populations. An extensive level of effort will be dedicated to mobilizing the populations to seek testing through public, private, NOG/FBO, and PMTCT providers, in support of the MOH "Know Your Status" program. Counselors will continue to be trained in the use of guidelines and provide ongoing follow-up training in addition to basic counseling skills.

C&T has been transitioned to MOH and NGO partners such as Hope for All, Lifeline, Guyana Responsible Parenthood Association, Comforting Hearts, St. Francis Community Developers, Hope Foundation, Linden Care Foundation, and Youth Challenge Guyana, but GHARP continues to monitor, evaluate and report on C&T. In FY07, GHARP will support NGOs/FBOs in C&T service delivery and community mobilization by providing training, information management, personnel, and management and support for the rapid testing teams. GHARP will also implement a Quality Assurance/Quality Improvement (QA/QI) program to coordinate quality assurance programs with CDC/GAP and the MOH to track counseling & rapid testing proficiency, training needs, and commodities management. Tools for quality of counseling and testing have been developed and piloted at several VCT sites. Presently, quality assurance efforts for testing using the Rapid Test Kits (RTK) are being conducted by CDC/GAP. QA/QI measures for Counseling will be further developed and implemented at VCT sites. GHARP, in partnership with the MOH and CDC/GAP, will also dedicate a significant level of effort for the assurance of efficient and appropriate data collection form development, oversight, and accurate reporting among all partners.

To ensure a trained cadre of persons to support VCT activities, Counseling and Testing Training will be institutionalized through the Institute of Distance and Continuing Education (IDCE), University of Guyana. The IDCE program reaches a wide cross section of persons which will allow for C&T programs to be afforded to persons in the regions.

In FY07, GHARP will continue to support the expansion of C&T services. Community organizations working in remote, hinterland areas where the largest proportion of mining and timber industries operate, will continue to provide mobile counseling and testing. GHARP will provide technical support and guidance to increase uptake of these services by leading focus-group discussions to ensure that the organization's service delivery matches the needs of the high-risk groups. Additional faith-based C&T services will be supported, as requested by the Central Islamic Organization. A total of five mobile units will focus on reaching the current demand from workplace, NGO/FBO, government, public, and high-risk/non-traditional sites. Youth Challenge Guyana has already successfully transitioned to leading one of the mobile teams; the other NGOs that will be chosen to manage the remaining mobile units are currently under review and a transition plan is being developed. Efforts have been made with the mobile unit to initiate Community Mobilization in hard-to-reach and high-risk populations. GHARP will continue to technically assist partners to develop C&T expansion strategies in support of the National HIV/AIDS Strategy based on risk behavior and prevalence information. All program expansion strategies will be developed in full support of the National HIV/AIDS Strategy, conducted through a coordinated response with MOH, GFATM, and WB programs, and based on risk behavior and prevalence information gleaned from FY05 targeted evaluations. In FY07, GHARP will focus on addressing barriers that ultimately prevent men from accessing services by conducting a situation analysis and developing an action plan to address identified issues with strategies to better provide services to men. GHARP will continue to promote opportunities for male access to VCT through community based outreach and workplace programs, peer education, community mobilization, and mass media, as well as targeted programs for sports clubs, interventions for minibus drivers, and male clinics. Working with its NGO/FBO partners, GHARP will continue to encourage couples counselling in an effort to reduce transmission in sero-discordant couples and encourage faithfulness in concordant negative couples. Additionally, GHARP strategy will include home-based C&T for families of orphans and vulnerable children, persons on treatment, and persons identified through the PMTCT program.

GHARP will continue to focus on integration of C&T into the basic package of support services at health facilities in FY07. GHARP will support the revision of Standard Operating Procedures (SOPs) that have not been adopted and will retrain staff accordingly. Currently, strong referral links are being developed at PMTCT sites for family-centered

counseling and testing at out-patient clinics using the same C&T staff and rapid testing technology. Focus will be placed in FY07 on strengthening the established referral system between C&T, treatment, home-based care, OVC, and all other public and private service points. Integration of provider-initiated C&T at sites delivering diagnosis and treatment for TB, STIs, and HIV will be done in coordination with CDC/FXB as they continue to provide the majority of site-support for these clinics. C&T services will also be integrated into the outpatient and medical clinics of selected facilities and to in-patient services to capture clients already seeking health services.

Abstinence and faithfulness education will continue to be integrated into C&T service provision as is protocol when discussing risk reduction practices during counseling sessions. Prevention programs for the high risk groups identified and reached through counseling and testing will follow ABC guidance and will serve as an integral part of the package of services delivered. Prevention messages and programs will also be delivered during the community mobilization efforts.

GHARP will collaborate with NAPS to initiate a Care for the Caregivers (offloading) program for health care providers. GHARP will facilitate the formation of a counselors' network for each geographical area by providing forum for interaction. Quarterly VCT meetings have already started and will continue with counselor/testers from all the regions except regions 1 and 8.

Howard Delafield Inc. (HDI) is a partner company on the GHARP initiative, with responsibility for public health marketing and communication material development. Their responsibility will be to support community acceptance and health service-seeking behavior. HDI will develop and cover costs for printing and reproduction of community outreach C&T print, periodicals, advertisements, and focus heavily on providing the public health system and civil society with the materials and skills needed for interpersonal communication (IPC). Materials will be developed to reach specific target groups such as youth, males, couples, and will be tailored for both clients and providers so that messages are conveyed effectively and will service to assist health care professionals in providing accurate information as well as influence individuals to change their behaviors.

HDI also has expertise and a track record of engaging the private sector to support HIV/AIDS prevention initiatives. In collaboration with GHARP and the International Labor Organization (ILO), the workplace programs have been rapidly scaled up since the inception of the project. There are currently 45 workplace programs in place, compared to 35 at the beginning of FY06. Plans are underway to increase the number of workplace programs by an additional 15 sites in FY07. HDI works to bring private sector on board, foster workplace interest and commitment as well as provide direct support, while the ILO collaborates by supporting workplace programs and policy development.

Howard Delafield will also work with GHARP and the private sector to stimulate demand for C&T through the workplace programs. The GHARP workplace program officer will continue to promote onsite C&T for employees using the GHARP mobile VCT team as well as referring persons to NGOs and other public sector testing sites as part of the comprehensive approach to workplace intervention programs.

Targets

Target Target Value Not Applicable Number of service outlets providing counseling and testing  according to national and international standards Number of individuals who received counseling and testing for HIV  and received their test results (including TB) Number of individuals trained in counseling and testing according to  national and international standards

Target Populations: Adults Business community/private sector Commercial sex workers Factory workers Most at risk populations Discordant couples HIV/AIDS-affected families People living with HIV/AIDS University students Out-of-school youth

Coverage Areas: National

Table 3.3.09:

In FY07, GHARP will continue to provide support for building capacity within the central Ministry of Health, the National AIDS Program, Line Ministry HIV/AIDS Programs, Regional Health Administrations, NGOs and other agencies/Ministries working on HIV/AIDS related programs in the areas of monitoring and evaluation, research, and the use of data for policy and decision making.

Technical assistance will be given to key M&E officers at the central and field offices, hired as contract staff by the MOH through CDC/GAP funding. Staff capacity strengthening will include training and mentoring, definition and collection of appropriate data, and support for the development and maintenance of routine health information systems. Data collection forms will continue to be revised for each program area, integrated into the National system, and compiled data will be housed and managed in the MOH. Technical assistance will be given to strengthen this process and increase its efficiency. At the national level, GHARP will provide support for the development, training on, and dissemination of the National HIV/AIDS M&E plan.

The same level of support is needed within the NGO/FBO sector, and as such, GHARP will assist partners in developing M&E work plans to accompany annual work plans and longer-term strategies. Frequent, routine field visits and on-sight technical guidance will be dedicated to all NGO/FBO partners. This will also assist in the data quality assurance work needed under the GHARP program. GHARP will assist NGO/FBO partners to develop programmatic databases for monitoring processes and outputs. Lastly, GHARP will collaborate with UNICEF on development of the OVC child protection database, and support training and technical assistance for M&E frameworks to be developed by Line Ministries receiving HIV/AIDS funding through the World Bank and GFATM grants.

In FY 07 GHARP will begin evaluating the impact of some of the PEPFAR-supported targeted interventions through implementation of behavioral surveillance surveys (BSS) in two target populations and will lay the groundwork for the implementation of the BSS in the other populations that were surveyed in the first round of the BSS. The first round of the BSS was conducted in 2003/2004 before the inception of the GHARP project and serves as the project baseline for interventions in at-risk populations. The first round of the BSS was conducted among female commercial sex workers (CSW), men who have sex with men (MSM), youths (in and out of school), the uniformed services and employees of the sugar industry. The BSS in CSW and MSM were combined with a biological component, which included testing for HIV and other sexually transmitted infections. The data from these surveys were used to guide the development of interventions that targeted the various populations. As the end of the project approaches, this is the ideal opportunity for GHARP to measure any changes that may have resulted from the various activities that were supported by PEPFAR. Moreover, sufficient time has elapsed for the interventions to work and for changes to reach measurable levels. As such, GHARP will conduct a second round of BSS in target populations beginning in FY07. In FY07, GHARP will map and estimate the size of the CSW population in the gold mining and logging areas in Guyana, and conduct a combined biological and behavioral surveillance survey (BBSS) in the entire CSW population. This data will document any effect of the current intervention targeting CSW, as well as provide data for guiding the expansion of this project to ensure national coverage of this project. The BSS will also examine an additional at-risk population in FY07: Despite evidence from some surveys that there may be a close association between drug use and HIV risk, the exact role which this population plays in driving the epidemic is not clearly understood. In the beginning of FY 07, GHARP will map and estimate the size of this population and assess the behaviors among them which may be driving the epidemic. Subsequently, the project will conduct a BSS among this population in the latter part of the year. The foundation will also be laid in FY07 to repeat the BSS in FY08 among MSM, youths (in and out of school), the uniformed services and employees of the sugar industry.

Support is also required in FY07 to support the roll out of the QA/QI program for the various program areas thus ensuring that, all programs have in place the necessary tools and SOP and that the programs are delivered according to available guidelines.

An additional targeted assessment for FY07 is a formative assessment to determine the needs of PLWHAs in relation to the development of a targeted prevention program to decrease the transmission of the virus to others (Prevention for Positives). The expansion

of the care and treatment program will lead to the improvement in the health and well being of a number of HIV-positive persons who will likely return to becoming sexually active. Targeting these healthy HIV-positive persons with interventions that lead to the adoption of low risk behaviors is a necessity for reducing the probability that they infect others. Such an intervention must take into account the unique circumstances of these persons and the context within which they have sex.

FHI/GHARP will continue to technically support and manage the annual civil society work plan development process of its current 18 NGO/FBO partners as well as two additional community-based organizations in FY07. This process requires significant resources and time from all staff at GHARP, on-sight proposal development, related workshops, site visits, technical review in each program area, and development of annual M&E plans. GHARP also supports Health Sector Development Unit to implement a similar program for the NGOs and FBOs funded through GFATM and WB initiatives.

With civil society programs having only been concretely established in the last ten years, building their technical as well and financial and administrative capacity is a daily commitment and requires a significant dedication of human resources, time, attention, site visits, mentoring, conflict resolution, and responding to immediate needs and demands of the organizations. Hence, NGO system strengthening will continue to be a priority as the role these community-based organizations are playing is critical across the continuum of prevention, care and support. FHI/GHARP will continue to attain critical benchmarks in program cycles (proposal development, implementation, quality assurance, reporting) as well as to facilitate a rapid-scale up of management systems for new NGO/FBO partners that are now receiving funds and reporting requirements from several different streams. The goal will be to continue enhancement of the sustainable HIV/AIDS programs and the capacity needed to support the organization and its work, by diminishing their reliance, over time on external technical assistance by building partnership with a local capacity building institution to provide on-going assistance needs at the field-level. Currently, the FY06 request for proposal yielded a strong candidate, but contracting this firm requires a delay as it finalizes its registration as a solely indigenous organization.

FHI will continue to support technical and administrative assistance requests made by MOH and HSDU/GFATM for ensuring HIV/AIDS program sustainability and to support program management through staffing, oversight, and to ensure maximization of funds available from various sources within Guyana.

Deliverables/additional targets: Number of NGO proposals finalized, technically approved, and implemented - 18

Management Science for Health is the prime partner within GHARP for provision of technical assistance for supporting the capacity strengthening throughout the year for Ministries of the Government of Guyana that are funded through GFATM and WB, human resource development programs for leadership and management skills-building, and for the support of an indigenous organization to assume the responsibility of providing the necessary administrative, management, and policy support needed within civil society.

MSH will strengthen the human resource system within civil society and ministries (Ministry of Education; Ministry of Culture Youth and Sports; Ministry of Labor, Human Services and Social Security; Ministry of Agriculture; Ministry of Ameridian Affairs; and the Ministry of Local Government and Regional Development) to create conditions that foster retention, effective performance, and supportive supervision through Leadership Development workshops by building effective teams to collaboratively identify challenges and problem solve, and enhance their engagement in HIV/AIDS effort.

MSH will also increase multi-sector coordination and planning in support of the World Bank project, continue efforts to mainstream HIV/AIDS in the aforementioned ministries through: • A targeted program of direct technical assistance (HIV/AIDS skills development workshops for line ministry focal persons, development of M&E plans, program management, planning and budgeting workshop) • Work to deepen the engagement of line ministries in HIV/AIDS work by enhancing prevention and work place efforts • Strengthening the implementation of two of the ministry programs with focused attention and increased on-site support aimed at ensuring the implementation of the line ministry project • Providing targeted short-term direct technical assistance as requested by the HSDU in support of the planning, implementation, and reporting of GFATM. • Provide targeted direct technical assistance, as needed, to strengthen the Regional AIDS Committees

Family Health International, as the prime partner for GHARP, provides technical support, monitoring and data quality assurance, program oversight and will report on MSH's program achievements.

Deliverables/Additional Targets: •6 line ministries with adopted anti-discrimination initiatives •6 line ministries implementing approved work plans •2 line ministries with a workplace policy developed and being implemented

Targets

Target Target Value Not Applicable Number of local organizations provided with technical assistance for  HIV-related policy development Number of local organizations provided with technical assistance for  HIV-related institutional capacity building Number of individuals trained in HIV-related policy development  Number of individuals trained in HIV-related institutional capacity  building Number of individuals trained in HIV-related stigma and  discrimination reduction Number of individuals trained in HIV-related community  mobilization for prevention, care and/or treatment

Target Populations: Host country government workers

Table 3.3.14:

Howard Delafield Inc. (HDI) is a small, woman-owned business that is the lead partner for USAID/GHARP in private sector programming and in creating an environment free of stigma and discrimination. HDI has expertise and a track record of engaging the private sector to support HIV/AIDS initiatives to address issues of stigma and discrimination as well as private sector partnerships and policy development. In FY06, HDI in collaboration with GHARP and the International Labor Organization (ILO), established a private sector business coalition with over 25 businesses. This coalition has formed a Private Sector Advisory Committee headed by chief executive officers and human resource directors from each partner and working group sub-committees, which focus on identifying and securing resources from other private sector organizations, NGOs, and donors. The Advisory Committee serves as a forum for private-sector partners to share best practices with each other, to continue to create partnerships, and foster leadership to prevent and reduce HIV/AIDS in the workplace and community.

To date, several achievements have included: Citizen's Bank sponsored a physician and pharmacist to host monthly clinics in Bartica (Region 7) to treat and screen patients for HIV/AIDS and tuberculosis; GT&T, Lotto, and IPED collaborated to offer loans to persons living with HIV/AIDS to start small enterprises; Companies sponsored mass media events to promote tolerance and sensitivity for persons living with HIV/AIDS; Work places began to provide on-site voluntary counseling and testing by partnershing with NGOs who are trained to provide such services; Partners such as Scotia Bank and Citizens Bank have been actively involved in monthly "Dress Down Days", in which employees wear pins with supportive messages for PLWHA and partner NGOs staff awareness booths to distribute HIV/AIDS information in an environment free from stigma and discrimination; and Several other companies have provided exemplary education and training for HIV/AIDS prevention for their employees through GHARP and its partner non-profit organizations.

In FY07, HDI will continue to strengthen the existing private sector partners to develop and implement workplace policies while also recruiting new private partners, particularly in private sector industries with potentially higher levels of MARPs (shipping, mining, forestry). HDI will work with the private sector partners to promote the development of workplace policies with focus on stigma and discrimination and promotion of correct prevention messages (AB messages and consistent condom use and risk reduction behaviors where appropriate), while strengthening the linkages and referrals for the workplace programs to GHARP and NGO services such as VCT, condoms, etc.

HDI will work to ensure the sustainability of these workplace programs and policies by creating strong linkages between the private sector businesses and partner NGOs, as well as linking Guyana to other regional HIV/AIDS workplace initiatives such as the Pan Caribbean Business Coalition on HIV/AIDS and the Global Business Coalition on HIV/AIDS. HDI will support the Private Sector Advisory Committee to create a strategy for the Public/Private sector coalition to become The Guyana Business Coalition on HIV/AIDS which will function as a self sustaining body. HDI will provide this Advisory Committee and its Working Groups technical and administrative support and will assist to develop a Mission Statement and work plans. Funding will be provided for the Private Sector Manager/Advisor to attend regional and international meetings to learn and share best practices.

Family Health International, as the prime partner for GHARP, provides technical support, monitoring and data quality assurance, and program oversight and will report on HDI's program achievements.

Deliverables/Additional Targets: •10% increase in number of private sector partners •Loan program being implemented with 25 loans to PLWHA approved •Formal relationship established linking Guyana Business Coalition on HIV/AIDS to Regional HIV/AIDS workplace initiatives

Targets

Target Target Value Not Applicable Number of local organizations provided with technical assistance for  HIV-related policy development Number of local organizations provided with technical assistance for  HIV-related institutional capacity building Number of individuals trained in HIV-related policy development  Number of individuals trained in HIV-related institutional capacity  building Number of individuals trained in HIV-related stigma and  discrimination reduction Number of individuals trained in HIV-related community  mobilization for prevention, care and/or treatment

Table 3.3.14: