PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
SUMMARY
USG and LEPRA, through its sub-partner, Catholic Health Association of India (CHAI), will continue PMTCT
activities from the previous year. Activities, based out of a PHC hub, include: developing linkages with
health workers for follow-up of HIV-positive pregnant women; motivating them to seek HIV counseling and
testing; following up HIV-positive pregnant women to access PMTCT; linking them to existing PMTCT
centers; supervising the delivery of PMTCT services at the PHCs, and continuous training of nurses and
community resource persons (CRP) in PMTCT outreach services. Specific target populations for this
activity include pregnant women, women in self-help groups (SHGs), Village Health Committees, and
community resource persons. Presently, services are being delivered in the 266 Primary Health Centers
(PHCs) spread across 10 high burden (prevalence greater than 1%) districts in the state, covering all PHCs
population of approximately 13 million. In the fourth year of the program, these activities will continue to
primarily be implemented by CHAI.
BACKGROUND
LEPRA Society, an NGO based in Hyderabad, in the southern state of Andhra Pradesh (AP), works among
sub-populations in select villages across 53 districts in four states of India: AP, Orissa, Bihar and Madhya
Pradesh, covering a total population of 12 million. Current programs include activities in public health and
rural development, such as TB interventions, HIV awareness and prevention, care and support to PLWHA,
malaria, and prevention of blindness. Its strengths are grassroots level interventions for rural, vulnerable,
and difficult-to-reach sub-populations. LEPRA emphasizes sustainability and cost-effectiveness by building
individual and partner agency capabilities. LEPRA Society is a leading partner of the State AIDS Control
Society of Andhra Pradesh (APSACS) in implementing a large scale HIV counseling and testing program in
over 500 health facilities and is also a joint implementing partner of APSACS in other critical state level HIV
interventions.
USG has been working in AP with LEPRA, and its sub partner Catholic Health Association of India (CHAI),
since 2005. CHAI, established in 1943, is India's largest faith based organization in the health sector with
nearly 3,226 member institutions that include large, mid-sized and small hospitals, health centers, and
diocesan social services societies. CHAI promotes community health and enables the community,
especially the poor and the marginalized, to be collectively responsible for attaining and maintaining their
health, demand health as a right, and ensure availability of quality health care at reasonable cost.
Andhra Pradesh (AP), a state in South India with a population of 80.8 million, has an estimated 500,000
PLWHA. Antenatal HIV prevalence is over 1% in 19 of the 23 districts, yet access to HIV services is scarce,
especially in the rural areas. Each primary health care clinic (PHC), the most basic health care unit in India,
serves a population of 30,000. Given the vast coverage of PHCs, and the urgent need for rural access to
testing, care, and treatment services, the integration of HIV/AIDS services into the existing PHC level was
urgently needed. APSACS has scaled up counseling and testing services to the rural primary health center
level, unlike other states in India, where the services remain exclusively urban and peri-urban. There is a
total of 677 Integrated Counseling and Testing Centers (ICTCs), which offer PPTCT, CT, and TB/HIV care,
support and treatment services at the PHC level. Facility based palliative care is provided on an out-patient
basis.
ACTIVITIES AND EXPECTED RESULTS
Furthering the need for effective PMTCT programming in the state is the government's ambitious promise of
zero HIV-positive babies delivered in 2007, also known as the "0 by 7" campaign, for which USG has
stressed data-driven and evidence based technical assistance to APSACS. Unlike other ICTC testing
facilities, the PMTCT services in LEPRA's program are offered by a nurse practitioner (NP), supported by
APSACS and trained by USG, in the PHC facilities. The strategy is not only cost efficient, but also
facilitates the integration of HIV services within routine PHC services. The nurse practitioners are
government staff, not paid for by LEPRA. The USG pays for the a system of supervision, whereby one
supervisor for every 10 NPs visits each center, on average once every two weeks, to provide on-site
supervision, training, and feedback.
AP state's PMTCT program suffers a high loss to follow-up for many positive pregnant women before
delivery. From January and December 2006, 46.9% of 6,028 HIV- positive ANC clients received NVP from
the state's PMTCT services due to low patient confidence in the PHC level services, poor record keeping
and linkages between service levels, and limited capacity to follow-up patients after testing. USG plans to
address these issues in USG-supported PHCs in FY08 through increased access to quality HIV services at
the PHC level and enhanced patient follow-up by program trained nurses.
ACTIVITY 1: PHC Enhancement Model
CDC/India, in partnership with the SACS and CHAI, piloted a model of strengthening services at 20 PHCs in
high-burden districts. The strategy provided a nurse to each PHC, who was trained in the delivery of
comprehensive HIV/AIDS care and treatment, including VCT, PMTCT, OI & STI treatment, community
prevention outreach, home based follow-up care, and referral services. These services provide a
continuum of care for PLHA by networking with other existing HIV care, treatment, and support providers.
They include counseling and testing for the surrounding communities, demand generation for PMTCT
services through outreach, administration of Nevirapine (NVP) prophylaxis, and referrals for treatment and
support through partnerships with local NGOs and CBOs. HIV-positive clients are linked to government
centers for CD4 screening and ART, if appropriate.
In addition, state government resources were leveraged for supporting trainings, nurse salaries, and
supplies. Within 12 months in FY07, this model was scaled up from 10 to 266 PHCs, covering 36.2 million
people in 10 high burden districts. Between July and December 2006, 38,889 clients accessed counseling
and testing services made available at the program PHCs. Of 20,311 ANC clients, 186 tested positive
(0.9%).
USG, in collaboration with district health authorities, will train the existing technicians and outreach staff of
the PHCs on HIV counseling and testing. Nurses are provided refresher training on PMTCT skills twice
Activity Narrative: yearly. This will facilitate the mainstreaming of the activity into the routine work of the PHC, a key strategy of
the Government of India's recently released five-year National AIDS Control Plan (NACP-3). Integration with
existing government program staff, such as auxiliary nurse midwives (ANM) and PLHA outreach workers,
for the follow up of positive pregnant women, and babies of positive mothers up to 18 months after birth, are
also specific program activities. Nurses also encourage testing of spouses and are trained in couple
counseling and partner notification at the PHCs.
The number provided PPTCT services in FY08 will be 95,441 and the number of positive women
administered Nevirapine during delivery will be 400.
Activity 2: Supervision, Monitoring and Program Management of District-Level PMTCT Services
To monitor PMTCT services provided by the trained nurses in the PHCs, LEPRA has trained, financially
supported, and provided consistent TA to 6 District Program Managers (DPMs). These program managers
supervise and mentor USG and APSACS field staff, including the nurses, in the field. DPMs are trained in
comprehensive HIV prevention, care, and treatment—with a special emphasis on monitoring data registers
from the PHC to ensure PMTCT services provided are meeting quality standards and targets. This district
support structure is similar to the District AIDS Prevention and Control Units, planned under NACP-3.
Among most-at-risk populations (MARPs) and bridge populations in Andhra Pradesh, the need for
prevention messages on safer sex practices is still great. Strategic interventions must focus on encouraging
correct and consistent condom use, reducing the number of partners and reinforcing mutual monogamy in
marriage. Also important are issues related to sexuality and gender violence, need for counseling and
testing, and early detection and treatment of sexually transmitted infections (STI).
Pradesh, covering a population of 12 million. Programs include activities in public health and rural
development, such as TB interventions, HIV awareness and prevention, care and support to PLHA, malaria,
and prevention of blindness. Its strengths are grassroots level interventions for rural, vulnerable, and difficult
-to-reach sub-populations. LEPRA emphasizes sustainability and cost-effectiveness by building individual
and partner agency capabilities.
AP has a population of nearly 78 million, divided in 23 administrative districts. It has an estimated 500,000
people living with HIV/AIDS (PLHA), the largest number in the country. LEPRA is a leading partner of the
Andhra Pradesh State AIDS Control Society (APSACS), in implementing an HIV counseling and testing
program in over 500 health facilities and is also a joint implementing partner of APSACS in other critical
state level HIV interventions. USG has been working in AP with LEPRA, and its sub partner Catholic Health
Association of India (CHAI), since 2005. LEPRA, with support from USG and APSACS, rolled out a large
comprehensive prevention, care, treatment, and support program in AP in 2006. These activities are being
continued in FY08.
ACTIVITY 1: Training Women in Self Help Groups (SHG) on Sexual Health Communication and Negotiation
Self Help Groups (SHGs) have promoted micro finance by rural women, aged 18-60, for the past 20 years
in India. In AP, there is a voluntary SHG membership of over a million women, many of whom are at a high
risk of acquiring HIV due to high risk behaviors of their spouses. Factors fueling the epidemic include a
limited role in sexual decision making by women and an extreme societal reluctance to discuss issues
related to sex and sexuality. It is therefore essential that women be well informed about sexual health and
develop sufficient self-efficacy in communication and negotiation with their partners.
USG continues this project from FY07, when LEPRA tapped into an existing government SHG network, and
initiated a training process that included the use of pictorial flip books, guided discussions, problem solving
techniques, games, and "homeworks." Women thus develop skills to address their sexual health concerns
and seek services related to HIV/AIDS and STIs. The objectives of the intervention are to: develop sexual
negotiation and communication skills in women; increase their knowledge about HIV/AIDS and STIs; equip
them with information on how and where to seek care, support, and testing for HIV/AIDS and STIs; and
promote their intention to be change agents in the community.
The SHG training was implemented in three high prevalence (>1%) districts in AP with support from USG
trained nurses in primary health centers (PHCs). LEPRA, through its sub grantee, CHAI, leveraged
Government of India funds (Global Fund Round 2) to support nurses in 266 PHCs to implement a
comprehensive care and support package in 10 districts. These nurses do outreach work two days every
week, including training SHG women and Community Resource Persons (CRP) on HIV/AIDS. In the first
phase, more than 40,000 women from three districts in AP were trained.
Since the nurses' tasks have shifted, LEPRA, in collaboration with the AP District Rural Development
Agency will now train Community Resource Persons (CRPs) to train SHG women in villages. Training
materials were developed by CDC staff, in collaboration with TNSACS (see TNSACS C&OP Activity
Narrative). Using this pre-tested module, LEPRA staff will train 45 mandal (sub-district) Resource Persons
(MRP) who will train 225 CRPs. CRPs at the village level will then train 200 women from each village, with
an overall plan to reach at least 15 villages this year covering 135,000 women. LEPRA will also use an
alternative approach to train 52 MRPs who will then train 30 "Health Activists", who are paid by the State to
promote health activities at the village level. Each Health Activist will train 200 women in SHGs, who will
ultimately train a total of 312,000 women in 9,000 SHGs this year.
Approaching HIV prevention with a tiered, training methodology and engaging community mobilization
through village-level women's organizations appears to be feasible, effective, and cost-efficient for HIV
prevention. In FY08, Lepra plans to add a complementary, village-level HIV action plan aimed at mobilizing
community leaders. This will maximize program benefits by underscoring community ownership in issues
surrounding HIV, such as the care of PLHA in the village.
ACTIVITY 2: Prevention among Men
This activity is aimed at sensitizing men on sexual issues in the context of HIV/AIDS. In AP, a majority of
existing C&OP programs are targeted at women, as they are more accessible through organized groups like
SHGs. The men's intervention will focus on the same sub-district units and villages in two districts, Nellore
and Nizamabad, where the SHG intervention is ongoing. LEPRA will target the husbands of women in
SHGs, and other rural men, to reinforce existing social norms on faithfulness and highlight risks associated
with multi-partner sex.
LEPRA will train men using a simple module (currently being developed) on issues related to STI and
HIV/AIDS. This activity responds to the need for gender-based interventions expressed in the third National
AIDS Control Plan (NACP-3). LEPRA will collaborate with the State Poverty Elimination Ministry to gain
additional access to mens' groups. The program plans to reach 100,000 married men in FY08.
ACTIVITY 3: Mobile Vans for Prevention and Demand Generation for Counseling and Testing (CT)
NACP-3 supports mobile testing in high risk and remote communities. Implementation of this strategy will be
Activity Narrative: facilitated by having cost-efficient Indian models as learning sites. LEPRA supports a mobile van to provide
CT services, and spread prevention messages in select high risk and difficult to reach areas. In these areas,
there is evidence of large numbers of high risk communities, such as urban and rural markets where sex
work is common and areas that employ large numbers of migrant men).LEPRA leverages test kits and
supplies from APSACS. LEPRA will continue to provide CT and C&OP services through its mobile VCT van,
document implementation, and disseminate lessons learned. Sharing these experiences with other state
partners, especially APSACS, will help further scale up.
The program offers one-to-one counseling and group education sessions and provides services ranging
from syndromic treatment for STIs, OI treatment, and antenatal care, screening audio-visuals on HIV and
answering questions from the community. Additionally, a mobile communication van goes to the target area
prior to the testing van to generate demand for testing. The target group covered for education and testing
services is about 10,000 men and women. LEPRA will expand this concept to at least one more district with
CDC support. Harivillu, the mobile VCTC van and Godavari, the mobile IEC van, plan to visit 20 locations in
2 districts that are in need of HIV/AIDS services. LEPRA is likely to leverage funds from the government to
expand this concept to 4 more districts in AP over the next two years.
ACTIVITY 4: Prevention among Migrant Construction Labor
Hyderabad, the AP capital, has a very large construction industry as a result of the booming software
sector. The industry attracts thousands of migrants from rural AP and the states of Orissa, Madhya
Pradesh, Bihar, and Uttar Pradesh. This intervention will facilitate and provide comprehensive prevention
and care services for STI and HIV/AIDS among migrant construction workers, known to engage in high risk
sexual behavior, in selected construction sites of Hyderabad. Currently, even basic healthcare provision is
limited for the target group. The target population for outreach is 10,000 labourers, both men and women, in
8 construction sites. LEPRA will provide information through resource centres and peer education strategies
and will establish service linkages with local government facilities for STI treatment and CT. LEPRA staff will
develop a monitoring system to assess referral efficacy.
ACTIVITY 5: Prevention Education by PHC Nurses
266 PHC nurses, appointed to government PHCs by CHAI and APSACS, will continue to conduct
prevention outreach and promotion of condoms with FY08 funds, focusing their prevention efforts in
communities where high rates of HIV are documented (based on results from ANC and walk-in testing at
the district PHC). Nurses have been placed in the communities where HIV burden is the greatest in the
state or in districts where high-risk behavior is most prevalent. Each nurse covers a population of about
30,000. Nurses visit villages, conduct outreach education sessions for women in childcare centers and for
village men in community halls, and lead the prevention sessions with SHG groups. The nurses are
government staff, not paid for by Lepra. However, their work is monitored by Nurse Supervisors and District
Project Managers, both supported with USG funding. The target population for outreach is nearly 100,000
rural men and women.
LEPRA Society, with support from USG and the Andhra Pradesh State AIDS Control Society (APSACS),
rolled out a large comprehensive prevention, care, treatment, and support program in 2006 delivered
through Primary Health Centers across 10 high burden districts in Andhra Pradesh (AP). These activities
are being continued in FY08. Services will include: opportunistic infections (OI) prophylaxis; counseling on
nutrition and hygiene; demand generation for care and support through follow up counseling modules;
positive prevention , including discordant couple counseling; referral of PLHA for TB testing; DOTS
treatment and linkages with existing services in government and NGO settings. The focus of palliative care
efforts is on training, demand generation, and facilitating linkages. The target group includes those infected
and affected by HIV and community members of the districts in which there are USG-supported PHCs.
LEPRA Society, an NGO based in Hyderabad, AP, works among sub-populations in selected villages
across 53 districts in four states of India: AP, Orissa, Bihar and Madhya Pradesh, covering 12 million
persons. Current programs include activities in public health and rural development, such as TB
interventions, HIV awareness and prevention, care and support to PLHA, malaria, and prevention of
blindness. Its strengths are grassroots level interventions for rural, vulnerable, and difficult-to-reach sub-
populations. LEPRA emphasizes sustainability and cost-effectiveness by building individual and partner
agency capabilities. LEPRA is a leading partner of APSACS in implementing a large scale HIV Counseling
and Testing program in over 500 health facilities and is also a joint implementing partner of APSACS in
other critical state level HIV interventions.
Andhra Pradesh, a southern state in India with a population of 80.8 million, has an estimated 500,000
PLHA. Antenatal HIV prevalence is over 1% in 19 of the 23 districts, yet access to HIV services is scarce,
especially in the rural areas. APSACS has scaled up counseling and testing services to the rural primary
health center level, unlike other states in India, where the services remain exclusively urban and peri-urban.
A total of 677 Integrated Counseling and Testing Centers (ICTCs) offer PPTCT, CT, and TB/HIV care,
support and treatment services at the PHC level. Each PHC, the most basic health care unit in India, serves
a population of 30,000. Given the vast coverage of PHCs, and the urgent need for rural access to testing,
care, and treatment services, the integration of HIV/AIDS services into the existing PHC level makes
services very accessible.
A major impetus for placing a nurse at a PHC was to address the unmet needs for palliative care of PLHA
at the community level. The nurse practitioners (NPs), along with Nurse Supervisors (NS) and outreach
workers (ORWs), mobilize men and women in the community for testing and counseling. Additionally, the
nurses provide comprehensive HIV prevention, care, and treatment services for PLHA through referrals,
including cross-referrals for TB/HIV. Support from local NGOs is leveraged for services, such as nutrition,
shelter, and treatment.
ACTIVITY 1- Primary Health Center Enhancement Project
266 PHC nurses, appointed to government PHCs by CHAI and APSACS and paid for by the government,
will continue to provide palliative care services to PLHA at the community level, focusing their prevention
efforts particularly in communities where high rates of HIV are being documented (based on results from
ANC and walk-in testing at the nearest district PHC). Nurses have been placed in the communities where
the HIV burden is the greatest or in districts where high-risk behavior is most prevalent. Each nurse covers
a population of about 30,000. Nurses visit villages and conduct outreach education sessions for PLHA and
their families. The activities of the nurse are monitored by Nurse Supervisors and District Program teams,
both supported by USG funding (see Activity Narrative for SI). The target population for outreach is nearly
100,000 rural men and women in the select districts.
Community and home-based activities are an integral part of the PHC Enhancement Project. NPs, with
active support from Nurse Supervisors, make follow up visits to PLHA homes to provide medical, and
psychological support. At the PHC, PLHA are provided medical care-- including syndromic management for
sexually transmitted infections, treatment for other opportunistic infections, psychosocial support, and
referral services for ART, TB screening, and CD4 counting. In FY08, there will be a stronger focus on
routinizing select services into the PHC facility. Focusing on palliative care at the PHC level, including
community and home-based activities, will enable sustainability by mainstreaming such referrals into the
regular functions of the PHC.
The palliative care services supported by USG will be managed by LEPRA field staff, district teams, and
NPs--with extensive support from LEPRA partner NGOs and APSACS. Through routine facility surveys and
monitoring of supply chain management, the district team will also ensure drug availability at the PHC level
for opportunistic infection prophylaxis.
ACTIVITY 2: Training of Counselors and Technicians
The PHC Enhancement Project works closely with the HIV-TB division of APSACS to train field staff on HIV
-TB coordination and cross referrals. The NPs are trained by USG to track cross-referrals and complete
treatment of all diagnosed with TB at the PHC, with support of the PHC staff.
In FY08, all existing government counselors and technicians will undergo refresher trainings in counseling
and testing skills, including a focus on palliative care. These trainings will be supported by USG, through
Activity Narrative: the district program teams. LEPRA and DPMs, in collaboration with district health authorities, will also train
existing technicians and outreach staff of the PHCs on palliative care treatment and linkages to provide the
full spectrum of care. This will help mainstream the activity into the routine of the PHC.
positive prevention , including discordant couple counseling; referral of People Living with HIV/AIDS (PLHA)
for TB testing; DOTS treatment and linkages with existing services in government and NGO settings.
The focus of palliative care efforts is on training, demand generation, and facilitating linkages. The target
group includes those infected and affected by HIV and community members of the districts in which there
are USG-supported PHCs. USG will continue to strengthening the linkages between the National TB
program and HIV services by increasing the number of cross-referrals. Activities such as clinical screening,
referral for sputum examinations, and follow up and referrals of DOTS treatment are done by the USG-
supported Nurse Practitioner (NP) based at the Primary Health Center.
USG has been working in AP with LEPRA, and its sub partner, the Catholic Health Association of India
(CHAI), since 2005. CHAI, established in 1943, is India's largest faith based organization in the health
sector with nearly 3,226 member institutions that include large, mid-sized and small hospitals, health
centers, and diocesan social services societies. CHAI promotes community health and enables the
community, especially the poor and the marginalized, to be collectively responsible for attaining and
maintaining their health, demand health as a right, and ensure availability of quality health care at
reasonable cost.
A major impetus for the placement of a nurse at a PHC was to address the unmet needs for palliative care
of PLHA at the community level. The nurse practitioners (NPs), along with Nurse Supervisors (NS) and
outreach workers (ORWs), mobilize men and women in the community for testing and counseling.
Additionally, the nurses provide comprehensive HIV prevention, care, and treatment services for PLHA
through referrals. Support from local NGOs is leveraged for services, such as nutrition, shelter, and
treatment. While the government pays for the salaries of the nurses, USG supports the salaries of the
Nurse Supervisors and of the District Program Managers.
The PHC Enhancement Project works closely with the State TB Control Society, combining efforts to track
all cross-referrals and complete treatment of all patients diagnosed with tuberculosis. The project continues
to work to improve the TB/HIV services delivered at PHCs by referring clients from ICTCs to TB centers
(and vice versa), as well as through providing counseling and testing services for all TB patients referred
from TB centers. In all PHCs, TB diagnosis and treatment facilities are present and operational.
266 PHC nurses, appointed to government PHCs by CHAI and APSACS, will continue to provide palliative
care services to PLHA at the community level, focusing their prevention efforts particularly in communities
where high rates of HIV are being documented (based on results from ANC and walk-in testing at the
nearest district PHC). Nurses have been placed in the communities where the HIV burden is the greatest or
in districts where high-risk behavior is most prevalent. Each nurse covers a population of about 30,000.
Nurses visit villages and conduct outreach education sessions for PLHA and their families. The activities of
the nurse are monitored by Nurse Supervisors and District Program teams, both supported by USG funding
(see Activity Narrative for SI). The target population for outreach is nearly 100,000 rural men and women in
the select districts. Focusing on TB cross-referrals at the PHC level will enable sustainability by
mainstreaming such referrals into the regular functions of the PHC.
routinizing select services into the PHC facility—such as tracking of all referred cases to diagnostic facilities
for TB and establishing an efficient reporting system for TB patients who present at USG-supported PHCs.
Presently, HIV-TB cross referral services are being delivered in all 266 PHCs. TB is a major cause of
morbidity and mortality among PLHA so the integration of these services is vital, and as a result, the Nurse
Practitioner plays a key role in both. Existing data in AP shows that there is large loss of TB cases after
Activity Narrative: referral, resulting in difficulty in follow-up. In FY08, the project will work to improve the TB-HIV services
delivered at USG-supported PHCs by referring clients from ICTC to TB centers. Also, USG will strengthen
the provision of counseling and testing services for all TB patients referred from TB centers, tracking of all
referred cases to diagnostic facilities for TB, and establishing an efficient reporting system. This will be done
by facilitating greater coordination between the nurse and the district TB program staff, which will be
ensured through monthly review meetings and supervision by USG's District Project Management teams.
and testing skills, with specific focus on TB-HIV. These trainings will be supported by USG, through the
district program teams. LEPRA and DPMs, in collaboration with district health authorities, will also train
existing technicians and outreach staff of the PHCs on increasing the number of appropriate HIV/TB cross
referrals. This will help mainstream the activity into the routine of the PHC.
The Leprosy Relief Association (LEPRA) is a nodal NGO providing technical assistance and support to the
Government of Andhra Pradesh's AIDS Control Society (APSACS) in the area of counseling and testing
(CT). USG supports the state in a scaled up CT initiative in 266 Primary Health Centers (PHCs) spread
across 10 high burden (prevalence greater than 1%) districts, covering approximately 13 million persons. A
mobile CT van provides services for areas with high concentrations of vulnerable groups (migrants, clients
of sex workers, truckers at halt points, industries, and tribal communities). Additionally, LEPRA will roll out a
Prevention with Positives intervention, with a focus on follow-up counseling, to support care and treatment
services for PLHA.
LEPRA, an NGO based in Hyderabad, in the southern state of Andhra Pradesh (AP), works with sub-
populations in selected villages across 53 districts in 4 states of India: AP, Orissa, Bihar and Madhya
Pradesh, covering 12 million persons. Programs include activities in public health and rural development,
such as TB interventions, HIV prevention, care and support to PLHA, malaria, and prevention of blindness.
Its strengths are grassroots level interventions for rural, vulnerable, and difficult-to-reach sub-populations.
LEPRA emphasizes sustainability and cost-effectiveness by building individual and partner agency
capabilities. LEPRA is a leading partner of APSACS in implementing a large scale HIV CT program in over
500 health facilities and also partners with APSACS in other state level HIV interventions.
USG has been working in AP with LEPRA and its sub partner the Catholic Health Association of India
(CHAI) since 2005. CHAI, established in 1943, is India's largest faith based organization in the health sector
with nearly 3,226 member institutions that include large, mid-sized and small hospitals, health centers, and
With a population of 80.8 million, AP has an estimated 500,000 PLHA. Antenatal HIV prevalence is over 1%
in 19 of the 23 districts, yet access to HIV services is scarce, especially in the rural areas. APSACS has
scaled up CT services to the rural primary health center level. A total of 677 Integrated Counseling and
Testing Centers (ICTCs) offer PPTCT, CT, and TB/HIV care, support and treatment services at the PHC
level. Each PHC, the most basic health care unit in India, serves a population of 30,000. Given the vast
coverage of PHCs, the integration of HIV/AIDS services into the existing PHC level makes services very
accessible.
ACTIVITY 1: Primary Health Center Project
CDC/India, in partnership with APSACS and CHAI, piloted a model of strengthening services at 20 PHCs in
high-burden districts. The strategy provided a nurse for each PHC, who was trained in comprehensive
HIV/AIDS care and treatment, including VCT, PMTCT, OI and STI treatment, community prevention
outreach, home based follow-up care, and referral services (for example, to the local branch of the Indian
Network of Positives or to government ART centers). The target population for this activity is mostly from
the rural community, including high risk men and women, referrals within the PHC or by local health
practitioners, persons suspected of TB, and families of PLHA. The nurses are government staff, not paid
for by LEPRA. However their work is regularly monitored on site by Nurse Supervisors funded by USG.
The services provide a continuum of care for PLHA by networking with other existing HIV care, treatment,
and support providers. PHC services include CT for the surrounding communities, demand generation for
CT services through outreach, administration of Nevirapine (NVP) prophylaxis, and referrals for treatment
and support through partnerships with local NGOs and CBOs. HIV-positive clients are linked to government
As noted, government resources were leveraged to support trainings, nurse salaries, and supplies. Within
12 months in FY07, this model was scaled up from 10 to 266 PHCs, covering 36.2 million people, in 10 high
burden districts. Between July and December 2006, 38,889 clients accessed CT services at the program
PHCs. Of 20,311 ANC clients, 186 tested positive (0.9%). All clients receive comprehensive HIV services
from the program PHCs.
ACTIVITY 2: Training for PHC Staff
yearly. This will facilitate the mainstreaming of the activity into the routine work of the PHC,which is a key
strategy of the Government of India's recently released five-year HIV National AIDS Control Plan (NACP-3).
Integration with existing government program staff, such as auxiliary nurse midwives (ANM) and PLHA
outreach workers, for the follow up of positive pregnant women and babies of positive mothers up to 18
months after birth, is also a specific program activity. Nurses also encourage testing of spouses and are
trained in couple counseling and partner notification at the PHCs.
In FY08, the program will provide hands on, in-service training to the nurses at the 266 PHCs, which
includes the quality and quantity aspects of counseling.. Monthly refresher trainings on basic and follow up
counseling are also planned using the modules piloted by CDC and INDIACLEN. By the end of FY08,
approximately 300 counselors and technicians at PHC level will have received refresher training. In
collaboration with district health authorities, the project will also train existing government technicians and
outreach staff of the PHCs to offer community based counseling services. This will help mainstream the
activity into the PHC routine.
ACTIVITY 3: On-site Supervision
Cross-field visits will be used to improve the skills of Nurse Supervisors and nurses. Quality assurance
mechanisms and supply chain systems will be monitored and enhanced through technical advisory support
and advocacy with government counterparts. The Nurse Supervisors will be trained in supportive
supervision and quality control mechanisms. A client risk assessment training and questionnaire will be
employed to make HIV testing referral a more targeted and standard operating procedure in CT settings;
the tool will also be available to the community to help increase CT self-referrals. The program will also
strengthen TB-HIV cross-referrals to ensure early diagnosis of TB among PLHA and encourage HIV testing
Activity Narrative: among TB patients.
In FY08, direct supervision will be carried out by six USG supported District Program Managers (DPMs),
who will supervise and mentor USG and APSACS field staff, including PHC nurses. LEPRA will train the
DPMs in HIV/AIDS comprehensive services, with a special emphasis on field data monitoring.
ACTIVITY 4: Mobile CT Van
Under the National AIDS Control Program Phase 3 (NACP-3), mobile testing in high risk and remote
communities will be scaled up. Implementation will be facilitated by using cost-efficient Indian models as
learning sites. LEPRA will continue to provide CT services through its Mobile CT Van, document
implementation and disseminate lessons learned to help further scale-up.
LEPRA supports a mobile van to provide CT and prevention messages in selected high-risk and difficult to
reach areas, such as urban and rural markets where sex work is common and areas that employ large
numbers of migrant men. LEPRA leverages test kits and supplies from APSACS. A mobile communication
van visits the area in advance to generate demand. The program offers individual and group counseling,
testing, and services including treatment for STIs, OIs, and antenatal care. The van also screens audio-
visuals on HIV, and staff answers questions from the community. The program offers one-to-one counseling
and group education sessions. About 10,000 men and women will be targeted for education and CT.
LEPRA will expand mobile CT to at least one more district with USG support and is likely to leverage
government funds to expand this concept to 4 more districts in the next two years.
ACTIVITY 5: Roll-out of Follow-up Counseling Toolkit
LEPRA will begin a new Prevention with Positives program in FY08, in accordance with NACP-3's new
strategic approach. Current counseling programs primarily focus on the prevention of HIV for those at risk.
LEPRA will also address the array of advanced physical, psychological and social issues and vulnerabilities
that clients present during follow-up counseling sessions after immediate post-test counseling, by
integrating follow-up counseling into the existing counseling structure. The purpose of the toolkit, developed
by CDC and IndiaCLEN, is to meet the needs of counselors/support providers, by focusing on the long-term
issues of living with HIV/AIDS, beyond adherence to antiretroviral therapy (ART). The six-module toolkit
complements the existing NACO counseling materials.
LEPRA will support the training of 700 district-level counselors and PHC nurses to deliver the Follow-Up
Counseling modules. Additionally, LEPRA will train members of the Telugu Network of Positive People
(TNP+) and counselors from its partner NGOs to provide follow-up counseling at appropriate sites. Staff at
ART centers and PHCs will also be trained. With FY07 funds, the existing Follow-up Counseling Toolkit will
be adapted and translated into Telugu. With FY08 funds, training and distribution will be rolled out state
wide. LEPRA is also planning to print 1000 toolkits in FY08.
(deleted 10/3/08- There are no LEPRA funds remaining in this program area.)
LEPRA, with support from USG and the Andhra Pradesh State AIDS Control Society (APSACS), provides
strategic information support at the state and district level for program planning, management, and
implementation. A key area of USG support is the strengthening of a system of decentralized, district level
data management, and facilitating its use for strategic decision making.
The southern state of Andhra Pradesh (AP) has a population of nearly 78 million, divided in 23
administrative districts. It has an estimated 500,000 people living with HIV (PLWHA), the largest number in
the country. LEPRA, with the support from USG and APSACS, rolled out a large comprehensive prevention,
care, treatment, and support program in AP in 2006. These activities continue through FY08 and will
benefit from these SI activities.
LEPRA Society, an NGO based in Hyderabad, AP, works among sub-populations in select villages across
53 districts in four states of India: AP, Orissa, Bihar and Madhya Pradesh, covering a total population of 12
million. Current programs include activities in public health and rural development, such as TB interventions,
HIV awareness and prevention, care and support to PLWHA, malaria, and prevention of blindness. Its
strengths are grassroots level interventions for rural, vulnerable, and difficult-to-reach sub-populations.
capabilities. LEPRA Society is a leading partner of the Government of Andhra Pradesh, APSACS, in
implementing a large scale HIV counseling and testing program in over 500 health facilities and is also a
joint implementing partner of APSACS in other critical state level HIV interventions.
With PEPFAR funds, LEPRA initiated a District Program Management (DPM) concept to build a
decentralized model of district level program and data management in the state. Under the National AIDS
Control Program Phase III, there is a strong emphasis on district level program planning, implementation,
and review in the form of District AIDS Prevention & Control Units (DAPCUs). USG's model of DPMs will
work in synergy with the NACP3 as the national plan moves into implementation phase. APSACS has
placed DPMs and Monitoring and Evaluation Officers (MEO) to monitor all HIV program interventions at the
district level. LEPRA and CHAI are in partnership with APSACS in this initiative across six districts and will
continue this support in FY08.
ACTIVITY AND EXPECTED RESULTS
ACTIVITY 1: Data Management and SI Systems Strengthening of State ICTCT Program
With continuing USG support, routine data from the Primary Health Centers (PHC) related to counseling,
HIV testing, PMTCT, and outreach activity is now consolidated at district level and analyzed locally to
support evidence based program planning and decision making. This program is supported in ten high-
burden districts, through Nurse Supervisors and Monitoring and Evaluation (M&E) Officers, supported and
trained by USG. The nurses' salary is leveraged from the state government and USG provides skills-based
and technical trainings on a regular basis.
ICTC data from the USG's enhanced PHCs is of strategic significance. These facilities, located in rural
community settings, are possibly more accurate, surrogate markers of HIV prevalence in the rural general
population, as compared with the HIV sentinel surveillance data that comes from urban and peri-urban
facilities during a limited 3 month period per year. This additional ICTC data will provide the state of AP
strong evidence to better inform program strategy, and enable evidence-based program planning and
implementation.
ACTIVITY 2: District Program Management (DPM) Team Concept
Under Phase 3 of the National AIDS Control Program (NACP-3), District AIDS Prevention and Control Units
(DAPCU) will be formed in all districts of high prevalence states. The DAPCU objective is to decentralize
program implementation and management down to the district (population of 2-2.5 million per district).
Specific activities of the DAPCU will include: 1) ICTC supervision; 2) field-level staff training and mentoring;
3) technical support to district government officials in charge of health and social programming; 4)
establishment of linkage systems between prevention programs, ICTCs, and ART centers; 5) coordination
of all district level partners and activities; 6) technical inputs into communication and condom social
marketing campaigns; and 7) M&E of all district level HIV services.
USG initiated the district program management concept to support APSACS. Six district program
management teams were set up to be a model of decentralized program planning, management and
implementation. USG partners placed one DPM and one MEO in 6 high burden districts to provide
technical, managerial and data management support to the local government counterpart and his/her team
on a daily basis. DPMs also act as a technical resource, ensuring relevance, quality, and consistency in
program implementation. USG implemented the concept before the DAPCU concept of NACP-3 was
disseminated.. When NACP3 DAPCUs are implemented, the DPM concept will be sustained within the
national program. In FY08, the USG support to DPMs will be scaled up to cover 18 of the 23 districts in the
State of AP.
Specifically, the MEOs will manage the data flow from all field reporting units (counseling and testing
centers, ART centers, targeted interventions, and community care centers). They will consolidate, analyze,
and interpret the data at the district level, and offer technical and programmatic feedback to reporting units
and government authorities. They will also organize presentations and trainings for various staff in the
Activity Narrative: government system to improve their ability to use data for decision making at the programmatic level.
Additionally, USG will play a technical role in training district staff on basic public health principles, field
management skills, HIV prevention strategies, HIV care and treatment operational guidelines, and M&E
evaluation skills.
ACTIVITY 3: Data Management Capacity Support to Field Staff
Lepra trains USG-supported field staff in the districts on data collection. This information better informs
USG programs on existing and emerging high-risk communities within districts, CT seeking behaviors, VCT
needs and testing volumes, and supports routine M&E data that will be collected in FY08-09.
ACTIVITY 4: Training of District AIDS Prevention and Control Units (DAPCUs)
Currently USG supports six district program management teams as a model of decentralized district level
program planning, management and implementation (see Activity 2). USG was requested, by NACO and
APSACS, to develop and conduct skills-based trainings for these district staff. In FY08, LEPRA and CHAI
will play a technical role in training DAPCU staff on basic HIV prevention strategies, HIV care and treatment
operational guidelines, and monitoring and evaluation skills. There will be a strong focus will be on building
the capacity of the DAPCU staff to use data for decision-making and provide timely feedback to field staff
regarding their monthly monitoring reports.
LEPRA, with support from USG and the Andhra Pradesh government's State AIDS Control Society
(APSACS), provides policy and systems strengthening support at the state and district level for program
planning, management, and implementation. A key area of USG support is the strengthening the capacities
of the district-level program management team to support management of HIV/AIDS, in accordance with the
third phase of the National AIDS Control Plan (NACP-3).
care, treatment, and support program in AP in 2006. These activities continue through FY08 and the impact
of the program is strengthened by the complementary systems strengthening activities.
HIV awareness and prevention, care and support to PLWHA, malaria, and prevention of blindness. Program
capabilities. LEPRA is a leading partner of APSACS, in implementing a large scale HIV counseling and
testing program in over 500 health facilities and is also a joint implementing partner of APSACS in other
critical state level HIV interventions.
decentralized model of district level program and data management in the state. Under NACP-3, there is a
strong emphasis on district level program planning, implementation, and review in the form of District AIDS
Prevention and Control Units (DAPCUs). USG's model of DPMs will work in synergy with the NACP-3 as
the national plan moves into its implementation phase. APSACS has placed DPMs and Monitoring and
Evaluation Officers (MEO) to monitor all HIV program interventions at the district level. LEPRA and CHAI
are in partnership with APSACS in this initiative across 6 districts and will continue this support in FY08.
ACTIVITY 1: District Program Management Team Concept
Under NACP-3, District AIDS Prevention and Control Units (DAPCU) will be formed in all districts of high
prevalence states. The DAPCU objective is to decentralize program implementation and management
down to the district (population of 2-2.5 million per district). Specific activities of the DAPCU will include: 1)
supervision of Integrated Counseling and Testing Centers (ICTCs); 2) field-level staff training and
mentoring; 3) technical support to district government officials in charge of health and social programming
4) establishment of linkage systems between prevention programs, ICTCs, and ART centers; 5)
coordination of all district level partners and activities; 6) technical inputs into communication and condom
social marketing campaigns; and 7) monitoring and evaluation of all district level HIV services.
USG initiated a district program management (DPM)concept to support APSACS by placing DPM teams in
6 districts as a model of decentralized program planning, management and implementation. USG partners
place one DPM and one MEO in 6 high burden districts to provide technical, managerial and data
management support to the local government counterpart and his/her team on a daily basis. DPMs also act
as a technical resource, ensuring relevance, quality, and consistency in program implementation. USG
implemented the concept before the NACP-3 set out the DAPCU concept: as a result, USG-supported
DPMs will work in synergy with the NACP-3 placed staff. When NACP3 DAPCUs are implemented, the
DPM concept will be sustained within the national program. In FY08, the USG support to DPMs will be
scaled up to cover 18 of the 23 districts in the State of AP.
management skills, HIV prevention strategies, HIV care and treatment operational guidelines, and
monitoring and evaluation skills.
ACTIVITY 2: Systems Strengthening of the State ICTC Program
The nurses in the PHC Enhancement Project, supported by USG and APSACS, offer HIV counseling and
testing, and relevant linkages, in 266 PHCs. Nurse Supervisors, in collaboration with DPMs and MEOs,
supported in 10 districts with PEPFAR funds, monitor the work of the PHC nurses and mentor them on
administrative issues to ensure quality in service delivery. The PHC Enhancement Project provides
comprehensive supervisory, monitoring, and evaluation support, including the organization of district level
reviews in which government authorities participate. Additionally, Nurse Supervisors help build referral links
with public, private, and NGO sector hospitals for services not available in the PHC. USG-supported district
teams strengthen the quality of ICTC service delivery, including strengthening supply chain systems,
enhancing quality of HIV testing and counseling at the PHCs, improving referrals and follow up, and
standardizing supervisory monitoring protocols.
Activity 3: Partnership with APSACS to Provide Technical and Management Support
This is an ongoing activity in which USG provides one full time technical expert, a district program team
Activity Narrative: Management Consultant, to support district level activities. In FY08, the consultant's role will be to continue
to provide technical and management support to the district management teams, be a technical resource
and be a direct supervisor who offers state level programmatic support and guidance. The consultant will be
placed under the APSACS Project Director and mentored by CDC and LEPRA staff. Currently, he is
responsible for strengthening systems in the following areas: building organizational capacity to effectively
monitor and evaluate districts and district programs; creating minimum standards for all training programs
for DAPCUs/DPMs; establishing procedures for routine program reviews at district level; advocating and
developing better systems of program supervision, field evaluations, logistical and supply chain
management; and developing tools and processes for collecting, consolidating, and analyzing data at the
state and district level.
Activity 4: Support to National HIV Testing Kits Quality Assurance (QA) Systems:
With USG support, LEPRA will coordinate technical assistance to the National AIDS Control Organization
(NACO) for quality assurance testing for all batches of centrally procured HIV rapid test kits. LEPRA will
provide technical, managerial, and equipment support and align experts from international and national
agencies, and NACO, to fully implement this project. LEPRA will develop clear roles and responsibilities for
various stakeholders and will identify appropriate sub partners.
Specifically, LEPRA will support NACO in adapting and implementing a quality assurance system for HIV
testing, prior to bulk procurement by the Government of India. This will involve providing management
support to the NICD (National Institute of Communicable Diseases) for project implementation, through
personnel, equipment, laboratory supplies, and protocols developed and adapted by CDC and NACO. The
first such project has been identified and involves building the capacity of the NICD to conduct batch testing
of all NACO-procured HIV rapid test kits.
Currently, only the first batch has been tested, which is problematic since millions of HIV test kits are
procured and released in multiple batches each year. Ensuring the quality of each batch of test kits is an
initial key step in any national quality assurance program. For optimal quality assurance, subsequent testing
at post-release and user sites is recommended, but due to limited funds in FY08, the scope of this QA
testing is limited to pre-procurement, central testing only. HIV-related tests, such as CD4, viral load, and
cryptococcal India ink testing may also be added to the quality assurance agenda in future years. The
identification of lab scientists at NICD who will develop a long term relationship with USG technical experts
will facilitate the development of local capacity in laboratory QA. This collaboration is expected to be a
catalyst for future laboratory systems strengthening in the nation.
