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
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
The following new activity will be undertaken in FY09:
ACTIVITY 4: Community Mobilization & Demand Generation Activities
APAC, in consultation with Tamil Nadu State AIDS Control Society (TNSACS), will support a rapid
assessment of the existing community mobilization and demand generation activities for PMTCT. Based on
the assessment's findings, appropriate communication tools will be developed for use in public and private
sector PMTCT centers. The communication tools will focus on: spouse counseling; minimizing risk of HIV
transmission during delivery; ARV prophylaxis for HIV-infected mother and newborn; maternal nutrition; safe
breast feeding; early infant diagnosis; and linkages with care continuum services.
APAC will also work with the auxiliary nurse mid-wives, anganwadi workers, link workers and NGOs
working in reproductive and maternal health programs, to create awareness and demand for PMTCT
services. At the district and block headquarter hospitals, the project will support street plays focusing on
PMTCT messages. Counselors will be oriented on counseling of sero-discordance and supported
disclosure. APAC will also review the existing systems available for HIV infected mother-baby follow-up,
and based on need will introduce a mother-child health follow-up card. Through these efforts the project
aims to: a) reduce the loss to follow-up cases from 15% to 5%; b) increase infant diagnosis from 70% to
85%; and c) increase the knowledge and skills of PMTCT staff on the full package of PMTCT services.
FY 2008 NARRATIVE
SUMMARY
Prevention of mother-to-child transmission (PMTCT) programs in the state of Tamil Nadu are relatively less
developed and are primarily implemented in public sector health care settings. Additionally, there is an
overall lack of expertise within the medical community in the area of PMTCT programs. In FY08, the AIDS
Prevention and Control (APAC) project will support comprehensive PMTCT initiatives in the private sector
through: supporting a network of 19 private hospitals, building the capacity of 300 private physicians
working with medical associations, and ensuring linkages of the trained physicians with PLHA networks and
other care continuum providers. The project will also build the capacity of the public sector through provision
of technical assistance (TA) to the local State AIDS authorities for comprehensive scale up of a quality
PMTCT program.
BACKGROUND
For the past twelve years, with USG support, Voluntary Health Services (VHS) has been implementing the
APAC project in the southern state of Tamil Nadu. APAC initially focused primarily on targeted interventions
for most-at-risk-populations (MARPs), but has expanded efforts over the last few years to support a more
comprehensive approach to HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in
controlling HIV (prevalence among antenatal women has dropped from 1.13% in 2001 to 0.5% in 2005) and
the APAC project has significantly contributed to this success. The National AIDS Control Organization
(NACO) has recognized the expertise and contributions of the APAC project and has requested APAC to
provide technical support to the State AIDS Control Societies (SACS) of Tamil Nadu, Puducherry and
Kerala by setting up a Technical Support Unit (TSU) in Tamil Nadu and Kerala, consisting of a core team of
consultants/experts co-located with the SACS, with a mandate to assist the SACS in scaling-up programs,
improving efficiency and quality. APAC also serves as the vice-chair on the Technical Working Group on
Targeted Interventions for the country.
PMTCT services for pregnant women in India are primarily concentrated in the public sector. Despite a high
proportion of pregnant women in India accessing antenatal services in the private sector, PMTCT has still
not received adequate emphasis from private sector health care providers. The national objective of
reducing infections in the newborn can be attained if access to PMTCT services is expanded to private
health care settings. Existing data from public sector health care institutions in Tamil Nadu indicate that
while there is an increase in the number of pregnant women getting counseled and tested, a large
proportion (more than 30%) of HIV-positive pregnant women do not receive ARV prophylaxis due to lack of
adequate follow-up. Data pertaining to the private sector is also sparse at best. The APAC project will
support activities that encourage the private sector to provide comprehensive PMTCT services, thereby
complementing public sector efforts. The APAC project will also coordinate with the SACS and other
stakeholders to evolve systems to increase the proportion of HIV positive pregnant women receiving
prophylaxis and follow-up care from public health care settings.
ACTIVITIES AND EXPECTED RESULTS
ACTIVITY 1: Increasing Access to Comprehensive PMTCT Services through a Network of Private Hospitals
The APAC project will support 19 private hospitals (16 secondary-level hospitals with provision for
institutional deliveries and three tertiary-level hospitals to provide comprehensive PMTCT services) in
selected high-prevalence districts in the states of Tamil Nadu and Puducherry. These hospitals will provide
PMTCT, TB-HIV co-infection management, and palliative care services including ARVs. Through this
initiative, APAC aims to increase the coverage of antenatal women in these high-prevalence districts,
motivate private sector health care institutions to get involved in HIV/AIDS management, and establish
sustainable models for replication. In each of the private hospitals, the project will support the services of
trained counselors who will provide counseling for antenatal, delivery and postnatal care for all pregnant
women. Counselors will be part-time. Each counselor will provide services to a minimum of two private
hospitals, each having a good client load of antenatal women. The PMTCT package of services will include
counseling and testing for pregnant women, ARV prophylaxis for HIV-infected pregnant women and
newborns, counseling and support for maternal nutrition, post delivery follow-up for safe infant feeding
practices, infant diagnosis and need-based linkages to care and treatment services for the mother, child and
family. Counselors will also focus on counseling and motivating the husbands of the antenatal women for
HIV testing.
Activity Narrative: APAC will train health care providers in private hospitals on: a) provision of comprehensive PMTCT
services; b) national PMTCT guidelines and standard operating protocols; c) universal precautions; and d)
establishing strong linkages with NGOs, PLHA networks and other care continuum providers. The private
hospitals will also provide palliative care services, thus ensuring that HIV-positive pregnant women and their
families have access to clinical services under one roof even after delivery. Quality assurance and
accreditation of the private hospitals is planned though State AIDS Control Societies and other agencies.
Demand generation for PMTCT services will be done through NGOs (both APAC- and SACS-supported),
networking with other health care providers, agencies and local communication campaigns. It is estimated
that nearly 6000 antenatal mothers will benefit annually through this initiative. This initiative is based on the
existing experience of APAC's support to IRT Perundurai Medical College, which is a tertiary care center
that has been supported by APAC since FY06.
ACTIVITY 2: Increase the Pool of Trained Health Care Providers Providing PMTCT Services
In two high-prevalence districts of Tamil Nadu, APAC plans to collaborate with the Federation of Obstetrics
and Gynecologists Society of India (FOGSI) to train obstetricians on comprehensive PMTCT services,
thereby increasing the pool of trained health care providers in the district. A total of 350 obstetricians will be
trained and followed-up. Existing training modules will be reviewed and modified to comply with the national
guidelines and protocols. The training curriculum will have a focus on: a) provider initiated counseling and
testing; b) counseling HIV- positive pregnant women on continuation of pregnancy and delivery; c) ARV
prophylaxis for HIV-infected pregnant women and newborns; d) counseling and support for maternal
nutrition and safe infant feeding practices; and e) referral for the continuum of care services. There will be
periodic follow-up of trained health care providers and experience-sharing meetings with other doctors in
the state. Linkages between the trained health care providers and local NGOs working on HIV programs
will be established. FOGSI will be the coordinating agency for training the doctors. Efforts will be begun to
mobilize support from leading pharmaceutical companies to sponsor training costs and the cost of providing
subsidized drugs to the trained health care providers. This initiative is designed to facilitate sustainable
networks between FOGSI, trained doctors, NGOs and pharmaceutical companies.
ACTIVITY 3: Strengthen Systems in the Public Sector for Comprehensive PMTCT Services through TSU
Support
APAC will provide assistance to the SACS through the TSU to scale up the PMTCT programs in Tamil
Nadu and Kerala. APAC, in coordination with SACS and other USG partners including CDC, will assess
gaps in the delivery of PMTCT services in public sector health care settings through a review of data from
public sector PMTCT sites, carry out joint field assessments, and develop a plan to improve systems for
delivery of comprehensive PMTCT services in public health care settings. APAC support will also include
strengthening the Management Information System at the state level to help better understand the program,
identify gaps, and facilitate timely and effective program-related decisions. The TSU will also assist the
District AIDS Prevention and Control Units to effectively monitor the quality of field-based PMTCT
programs.
New/Continuing Activity: Continuing Activity
Continuing Activity: 14154
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
14154 10933.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $148,500
International Services
Development
10933 10933.07 U.S. Agency for Voluntary Health 5604 3949.07 $245,000
Emphasis Areas
Gender
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Child Survival Activities
* Safe Motherhood
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
The National AIDS Control Organization (NACO) continues to place emphasis on interventions with
truckers, migrants and youth populations as they act as a bridge population to the general population. The
approach for reaching these groups, however, has changed. NACO has withdrawn support to NGOs
engaged in interventions with these groups and is instead working closely with the related government
ministries to mainstream HIV/AIDS programs. NACO is also coordinating with the trucking associations to
roll-out a national program for truckers through the association. At the state level, the Tamil Nadu State
AIDS Control Society (TNSACS) plans to lead coordination efforts with different ministries, departments,
and associations to implement HIV/AIDS prevention programs among truckers, migrants and youth
populations. This is in-line with the USG policy of increased ownership of HIV/AIDS programs by the state
and using USG support for interventions in critical areas / target populations.
ACTIVITY 1: Community Outreach Services for Bridge Populations and Other Sub-Populations in High-
Prevalence Districts
This activity will not be continued in COP09 as TNSACS plans to support interventions with bridge and
vulnerable populations for the entire state.
ACTIVITY 2: Transitioning Targeted Interventions to the Private Sector and SACS
The project has developed a clear plan to transition the truckers, migrant and youth intervention programs
to TNSACS. The transition plan was developed in consultation with NGOs and SACS. A coordination
committee will oversee the transition process and ensure quality services are provided to these target
communities. As a result, APAC will not continue to support these activities in COP 09.
ACTIVITY 3: Technical Assistance to SACS on Targeted Interventions
APAC, through the Technical Support Units (TSUs) will continue to provide technical assistance to
TNSACS, NGOs, associations and different ministries for mainstreaming HIV/AIDS. APAC will also work
with TNSACS to develop gender specific policies and tools and to train NGOs and agencies on
incorporating gender into their HIV/AIDS initiatives.
ACTIVITY 4: Demonstration Projects for Mainstreaming HIV/AIDS Programs in Universities
APAC is working with TNSACS to mainstream HIV/AIDS into the University program, and will not support
any direct interventions for university youth in COP09. This shift aligns with the PEPFAR review team's
recommendation to focus on MARPs and mainstream programs for low-risk groups.
ACTIVITY 5: Promoting HIV/AIDS Prevention to Out of School Youth through Social Networks
The project is working with TNSACS to mainstream HIV/AIDS into existing youth programs, and will not
continue support for direct interventions for youth programs in COP09. This shift aligns with the PEPFAR
review team's recommendation to focus on MARPs and mainstream programs for low-risk groups.
ACTIVITY 6: Building the Capacity of NGO Staff and Peer Educators
This activity will not be continued in COP09, as TNSACS plans to support interventions with bridge and
vulnerable populations at the state level. The Technical Support Unit (TSU), in consultation with TNSACS
will, however, introduce appropriate modules on Abstinence and Be Faithful in the NGO staff and peer
educator training programs.
In COP 09 the following new activity will be supported by the project:
ACTIVITY 7: Demonstration Project on Short-Stay Migrant Intervention
In COP09, APAC will support one or two associations (construction sector / other sectors where large
numbers of short-stay migrants work) and demonstrate models of mainstreaming HIV/AIDS work. This
model project will be located in suburban areas of Chennai to address the migrant population. The project
will cover 10,000 migrants in partnership with local corporations / industries and infrastructure development
agencies. This project will also serve to demonstrate different best practices. The same will be
documented and shared with NGOs involved in interventions among migrants. Peer educators among the
migrants will be identified, recruited, and trained so as to more effectively reach migrants. Multi-lingual
outreach workers will be recruited for promoting behavior change. IEC materials will be designed / procured
in different languages.
Interventions among bridge & other selected sub-populations continue to be a priority in the third phase of
the National AIDS Control Plan. The most recent Behavioral Surveillance Survey conducted in Tamil Nadu
indicates that a significant proportion of bridge populations and youth engage in risky sex behaviors.
Current interventions primarily focus on condom promotion with limited emphasis on other options. APAC
will promote expansion of options by providing comprehensive and gender sensitive information on
abstinence, fidelity, partner reduction, condom promotion for groups with established risk behaviors, and
promoting value-based lifestyles.
In FY08, APAC will support interventions among bridge and other selected populations through delivering a
behavior change communication (BCC) package based on risk assessment of these sub-populations.
Important strategies to address these populations will include supporting NGOs and social networks to
reach out to the selected target audience, and capacity enhancement of the NGOs to scale up and improve
the quality of interventions. APAC will support two model university programs and a limited number of
projects with truckers' associations for demonstrating effective mainstreaming strategies. As a Technical
Support Unit, APAC will also assist the State AIDS Control Societies of Tamil Nadu and Kerala to
strengthen their capacity for project management including evidence-based planning and monitoring, with
the aim of scaling up interventions at the state level and quality improvement.
Activity Narrative: VHS has been implementing the APAC project in Tamil Nadu for 12 years. APAC initially targeted most-at-
risk-populations, but has expanded efforts over the last few years to support a more comprehensive
approach to HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in controlling HIV
and APAC has significantly contributed to this success. The National AIDS Control Organization has
recognized the expertise and contributions of the APAC project and has requested APAC to provide
technical support to the SACS of Tamil Nadu, Puducherry and Kerala by setting up a Technical Support
Unit at Tamil Nadu and Kerala, consisting of a core team of consultants/experts co-located with the SACS,
with a mandate to assist the SACS in scaling-up programs, improving efficiency and quality. APAC also
serves as the vice-chair for the Technical Working Group on targeted interventions for the country.
In a recent development, the Tamil Nadu State AIDS Control Society has taken a decision that it would take
the lead to support bridge and vulnerable population interventions for the entire state of Tamil Nadu, and
has requested the other stakeholders to saturate coverage of MARPs in their respective districts. As a
follow-up of this decision, APAC starting Oct 08, will transition all its bridge and vulnerable population
intervention programs in Tamil Nadu and support more NGOs / CBOs to saturate coverage of MARPs.
Only one migrant intervention will be supported by the project. Due to this change the overall budget and
targets in the Abstinence and Be Faithful program area have been decreased.
Eight NGO sub-partners will use peer educators to deliver A and B messages to target populations in
selected high-prevalence districts of Tamil Nadu and Puducherry. Peer educators will strategically
encourage unmarried young adults to abstain from sex, married adults to remain faithful, and those with
established high-risk behavior to use condoms and access VCT services. USG funds will support capacity
building of NGO staff and peer educators, increase access to preventive services through community-based
peer educator programs, create an enabling environment for behavior change and support advocacy efforts
for stigma reduction. Community drop-in-centers will be established by APAC's sub-partners to provide
space for the community to share experiences, as well as offer counseling and testing and basic medical
support to the target populations. APAC will build the capacity of sub-partners through regular training,
exposure visits and monitoring, and will support 1320 peer educators with motivational strategies. This
activity aims to reach nearly 69,000 individuals from bridge and other populations with A and B messages.
Efforts to reach women (spouses of truckers and migrating women involved in construction, agriculture
work) will also be supported through NGO outreach and workers' associations.
Since 1996, APAC has supported NGOs by building their capacity to manage projects and mobilize
resources from other donors. In FY08, APAC will support initiatives to transition 16 NGO sub-partners
(involved in interventions with bridge and other selected populations at risk) to SACS and other agencies.
APAC will build the capacity of sub-partners to showcase achievements and leverage resources from
private companies through tapping corporate social responsibility opportunities. APAC will establish a
coordination team to develop mechanisms for transition and follow-up of transitioned projects to ensure
continuance of the quality and scale of interventions.
In line with the NACP-III policy, NACO has designated APAC to be the Technical Support Unit to provide
ongoing technical assistance to the SACS of Tamil Nadu and Kerala and build capacity for effective
interventions among bridge and selected sub-populations. Technical support to SACS will cover a range of
areas such as a) strengthening project management systems; b) standardizing training modules consistent
with the national guidelines and strengthen the capacity of NGO and CBO training institutions; c) evidence-
based planning including periodic mapping, size estimation and need assessment of target populations; d)
documentation and dissemination of best practices for learning and replication; e) development of a
mainstreaming strategy; and f) periodic evaluation and behavioral impact assessments. APAC and SACS
will develop a joint technical support plan and technical assistance will be provided based on the plan.
APAC will also build NGO capacity by supporting two demonstration projects (one each for truckers and
migrants) as centers of learning.
APAC will support two model projects in universities to integrate HIV/AIDS programs for HIV/AIDS
prevention education, with an emphasis on abstinence. Volunteer peer educators will be selected and
trained to deliver appropriate HIV/AIDS information to the students. The training content will particularly
emphasize the vulnerability of women to HIV/AIDS and build their skills in handling risky situations. A few
peer educators will be trained as peer counselors to provide counseling to at-risk youth and link them with
NGOs and other support agencies. An infotainment troupe will provide HIV information through traditional
and modern media. Two youth-friendly centers offering holistic youth services (career guidance, personality
development, sexual and premarital counseling, fitness and personal care) will be established in partnership
with private companies to serve as a pull factor and help leverage resources from the private sector.
APAC will collaborate with the Ministry of Parliamentary Affairs to conduct youth parliaments on HIV/AIDS
issues in colleges. District-level competitions will be conducted in various colleges with awards given to the
teams. Winners from each district will participate in state-level youth model parliaments. An estimated 5000
college youth will be reached through these model projects. To ensure greater ownership and sustainability,
the project will involve the principals and key faculty in designing college-specific interventions and a
monitoring strategy, and build the capacity of the faculty in counseling and handling youth-specific issues.
The experience of these model projects will be disseminated to NACO, SACS and the Ministry of Youth for
replication.
ACTIVITY 5: Promoting HIV/AIDS to Out Of School Youth through Social Networks
APAC will support a pilot project in one high-prevalence district to mainstream HIV/AIDS within Nehru Yuva
Kendra, a large social network. The project will address out-of-school youth in 25 large slums of Tamil
Nadu. NYK will establish Youth Health and Development Clubs in these slums to promote awareness on a
Activity Narrative: range of HIV/AIDS and social issues, and link out-of-school youth to various government-aided programs.
Through this initiative, over 1250 out-of-school youth will be reached. In each slum, 25 male and female
youth will be identified as peer educators and trained on HIV/AIDS prevention messages, life-skills
education, and other social and health issues. Efforts will be made to sustain the activities by ensuring
coordination with local NGOs, FBOs, the Tamil Nadu slum clearance board, the Women's Development
Corporation and other social networks.
ACTIVITY 6: Build the Capacity of NGO Staff and Peer Educators
APAC will identify and support strong organizations to build the capacity of NGO staff and peer educators in
interventions among selected populations focusing on promoting A and B messages. Risk assessment tools
will be developed for outreach workers and peer educators to ascertain the risk behavior of bridge and other
populations. NGO staff and peer educators will be provided a series of trainings focusing on issues such as
participatory mapping and needs assessment, risk assessment, interpersonal communication, gender, and
project management. The project will train 176 NGO staff and 1320 peer educators.
Continuing Activity: 14155
14155 10936.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $68,200
10936 10936.07 U.S. Agency for Voluntary Health 5604 3949.07 $821,000
Table 3.3.02:
Tamil Nadu (TN) has the largest number (140) of NGOs and CBOs working in HIV/AIDS prevention
programs among MARPs, bridge and vulnerable populations in the country. Nearly 76% of the estimated
81,000 female sex workers (FSWs) in TN and 80% of the estimated 48,500 men having sex with men
(MSMs) are covered through the joint efforts of Tamil Nadu State AIDS Control Society (TNSACS), USG
and The Bill & Melinda Gates Foundation programs. The concentrated efforts of all agencies engaged in
HIV/AIDS programs have helped in controlling the epidemic in the state and the adult prevalence has
dropped from 1.13 percent in 2001 to 0.38 percent in 2006. Trends indicate that prevalence among FSWs
(3.6%) and MSMs (5.6%) are also on the decline and are lower than the national average of 4.9% and 6.4%
respectively.
Many challenges still persist in sexual prevention programs. Less than 50% of FSWs have correct
knowledge on HIV and 30% report suffering from STIs in the last 12 months (NACO 2006 BSS). There are
concerns about a lack of timely treatment-seeking behaviour and consistent condom use. Nearly 60% of
sex workers have never had an HIV test and only 60% report having been reached by an HIV/AIDS
intervention program. 5% of sex workers consume alcohol during sex and a high proportion report injecting
drugs in the last 12 months.
Current programs are not structured to meet the needs of specific sub-groups of MSMs, based on identities
and sexual behaviour patterns. MSMs, in particular transgenders, face a high level of stigma and violence.
Furthermore, interventions among MARPs have not addressed structural issues and have been primarily
limited to urban settings.
All activities planned in COP 08 will be continued in COP 09 except for Activity 3.
In addition, the following new activities are planned in COP 09:
ACTIVITY 7: Interventions with Non-Brothel and Non-Street Based Sex Workers
The dynamics of sex work is changing rapidly across the country; sex workers now operate from diverse
settings including homes, parlors, vans, etc. Anecdotal information indicates that women in certain
professions, such as the film industry, operate as part time sex workers. Information on sex workers in
these unique settings is very limited. Due to this lack of information, NACO and SACS have asked APAC to
study the changing dynamics of sex work and to implement a pilot project for interventions among non-
brothel, non-street based sex workers. The pilot project will be implemented in one district after assessing
the estimated population size, needs, and opportunities for intervention. The assessment findings and
experience of interventions will be shared with NACO, SACS and other NGOs for necessary policy and
programmatic changes.
ACTIVITY 8: Comprehensive Services to MARPs
Most interventions currently focus only HIV/AIDS messages and services. APAC MARP interventions,
however, strive to support comprehensive needs of MARPs and will: a) ensure active participation of the
target community in the development, implementation and monitoring of project activities; b) increase
access to male and female condoms and promote consistent use of condoms with all partners; c) promote
periodic medical check-ups for STIs; d) promote counseling and testing (CT) and increase access to CT
services; e) establish appropriate linkages of HIV-infected MARPs with care, support and treatment service
providers and regular follow-up to ensure quality of services; f) integrate gender and violence reduction
strategies in programs; g) establish linkages with social welfare services for MARPs and their families
(particularly to prevent second-generation sex work); h) provide vocational training and pilot community -
health financing options.
APAC, in coordination with TNSACS, will establish appropriate policies and mechanisms for addressing
sexual abuse, violence and legal issues of MARPs. The project will train NGO staff to address broader
concerns including dealing with trafficked sex workers. A state-level Watchdog Committee on Sexual
Abuse, Violence and Human Rights will be formed.
ACTIVITY 9: Transition Program Management to Community Based Organizations (CBOs)
The third phase of the National AIDS Control Program (NACP-III) places greater emphasis on CBO
managed programs and a target has been fixed where by 50 percent of targeted interventions projects will
be managed by CBOs by 2012. As part of APAC's transition plan, the project will train core groups of
community members on community mobilization, project management, advocacy and leadership initiatives.
An expert team of consultants and NGOs will be formed to guide the process of transitioning and to support
the community members in complex and challenging areas. Task shifting will also be introduced in a
phased manner. Peer counselors will be identified and trained in each intervention. The transition process
will be documented and disseminated to NGOs, CBOs, SACS and NACO.
Mapping studies estimate there are 80,000 female sex workers and 35,000 men who have sex with men in
Tamil Nadu. Sex work in Tamil Nadu is not brothel-based, but rather street and home-based. Currently the
AIDS Prevention and Control project, through Voluntary Health Services, the Tamil Nadu State AIDS
Control Society, and the Bill and Melinda Gates Foundation are the three major agencies involved in
targeted interventions among Most At-Risk Populations reaching 60-70% of FSW. However, coverage of
MSM and injecting drug users continues to be low.
In FY08, the APAC project implemented by VHS in Tamil Nadu, will support a variety of behavior change
interventions addressing MARPs implemented through a network of 16 NGOs and civil society. The
interventions will include: behavior change communication through community outreach, increasing access
to condoms, building capacity of NGO staff and retailers on social marketing of condoms, linking MARPs
and their partners to counseling and testing and STI services, and promoting risk reduction strategies
Activity Narrative: among IDU. The APAC project will also provide technical assistance to the State AIDS Control Societies in
Tamil Nadu and Kerala to enhance their capacity and systems for effective interventions with MARPs.
For the past twelve years, with USG support, VHS has been implementing the APAC project in the southern
state of Tamil Nadu. APAC initially focused on targeted interventions for MARPs, but has expanded its
efforts over the last few years to support a more comprehensive approach to HIV/AIDS prevention, care and
treatment. Tamil Nadu has been successful in controlling HIV and the APAC project has significantly
contributed to this success. The National AIDS Control Organization has recognized the expertise and
contributions of the APAC project and has requested APAC to provide technical support to the SACS of
Tamil Nadu, Puducherry and Kerala by setting up a Technical Support Unit at Tamil Nadu and Kerala,
consisting of a core team of consultants/experts co-located with the SACS, with a mandate to assist the
SACS in scaling-up programs, and improving efficiency and quality. APAC also serves as the vice-chair on
the national Technical Working Group on Targeted Interventions.
The third phase of the National AIDS Control Program aims to halt and reverse the epidemic. A key strategy
to achieve this objective is to saturate coverage of MARPs including FSW, MSM, and IDU by tripling the
number of targeted interventions amongst MARPs from 700 to 2100, and engaging community-based
organizations more intensively. Estimates indicate that there are 1.2 million FSW, 2.3 million MSM, and
220,000 IDU in the country and nearly 10% of these MARPs are estimated to be HIV infected. Recent
studies also indicate that sex work is no longer confined to urban areas but has spread to rural areas,
making interventions with MARPs more complex and challenging.
intervention programs in Tamil Nadu and support more NGOs/CBOs to saturate coverage of MARPs. Only
one migrant intervention will be supported by the project.
ACTIVITY 1: Community Outreach for Most-at-Risk Populations in Selected High-Prevalence Districts
The APAC project will support 16 sub-partners to implement comprehensive HIV/AIDS interventions with
MARPs in selected high-prevalence districts of Tamil Nadu and Puducherry. The project will make
additional efforts to improve coverage of MSM by increasing the number of interventions. NGO staff will
impart behavior change messages to MARPs through interpersonal communication, and will promote
consistent condom use, and encourage periodic STI check-ups and HIV testing. Sub-partners will identify
community-preferred health care providers for STI treatment, refer MARPs for periodic STI check-ups and
follow up for treatment adherence. Periodic NGO and Health Care Provider meetings will be organized for
coordination and sharing of information. In FY06, the Gates Foundation supported the establishment of STI
clinics in APAC-supported NGO sites. During FY08, APAC will continue to leverage support from the Gates
Foundation for STI treatment for MARPs. Community drop-in-centers will be established by sub-partners to
provide space for the community to share experiences as well as to offer user friendly counseling and
testing and basic medical services to MARPs. APAC sub-partners will establish linkages with the Link
Workers to reach-out to MARPs and bridge populations in rural areas.
MARPs infected with HIV will be linked to a continuum of care services and followed-up for ART adherence.
APAC's sub-partners will coordinate with APAC-supported and other care and support NGOs to ensure that
family members of PLHAs are trained to provide home care and to ensure a good quality of life for PLHAs.
USG funds will support: capacity building of NGO staff and peer educators, increased access to preventive
services through community-based peer education programs, creation of an enabling environment for
behavior change and advocacy with stakeholders. APAC will build the capacity of its sub-partners through
regular training, exposure visits and monitoring. The project will support 960 peer educators and adopt
motivational strategies for their continued involvement in the program. Through this activity, the project
plans to reach 20,000 MARPs and 46,000 high-risk individuals from bridge and other selected risk
populations.
ACTIVITY 2: Increasing Access to Condoms by MARPs in Selected High-Prevalence Districts
APAC will support leading condom manufacturers to strengthen condom distribution networks and promote
condoms in NGO intervention areas in the high-prevalence districts. This will be achieved through
promoting condom sales through non-traditional outlets and by increasing demand. The project will support
linkages between NGOs and condom manufacturers to service outlets in intervention areas thereby
ensuring increased access and expanding product range to MARPs and bridge populations. This initiative
will also ensure sustainability of services and greater coordination between condom manufacturers and
NGOs in condom social marketing. Successful interventions between APAC and condom manufactures in
the past have resulted in tripling of commercial condom sales in Tamil Nadu from 17 million in 1996 to 54
million in 2006. Innovative marketing initiatives by NGOs to enhance condom distribution to MARPs will be
explored. Condoms for free distribution and demonstration will be leveraged from the Government of India.
Retail audit reports will be used to assess trends in the condom market, and for reporting to USG and other
agencies.
ACTIVITY 3: Assessments of Condom Use among MARPs and Sero-Discordant Couples
Behavioral Surveys indicate the nearly 36% of FSW and 40% MSM report inconsistent condom use, citing
objections due to reduced pleasure. APAC will support pilot initiatives to market lubricants among MSM and
female condoms among FSW while assessing the impact on consistent condom use. An assessment of
condom use patterns among sero-discordant couples, including motivating factors and constraints, will be
also undertaken by APAC.
ACTIVITY 4: Build Capacity of NGOs and Retailers for Condom Social Marketing
In FY08, a capacity-building agency will be contracted by the project, as in the past year, to train 400 NGO
staff on the concepts and the processes of condom social marketing and train 500 potential retailers in
marketing techniques.
Activity Narrative: ACTIVITY 5: Technical Support to SACS to Strengthen State-Wide Interventions with MARPs
In line with the NACP-3 policy, NACO has designated APAC to be the Technical Support Unit to provide
continuous technical assistance to the SACS of Tamil Nadu and Kerala and build capacity for effective
targeted interventions. Technical support to SACS will cover a range of areas such as: a) strengthening
project management systems for targeted interventions; b) standardizing training modules and
strengthening the capacity of training institutions involved in training NGOs and CBOs; c) evidence-based
planning, including periodic mapping, size estimation and needs assessment of target populations; d)
documentation and dissemination of best practices for learning and replication; e) developing a
will develop a joint technical support plan and specific areas of technical assistance will be determined.
APAC will also support three demonstration projects as learning sites (one each for FSW, MSM and IDU) to
build the capacity of NGO staff.
ACTIVITY 6: Build Capacity of NGO Staff in Enhancing the Quality of Interventions
The APAC project will identify and support training institutes to build the capacity of NGO staff and peer
educators on targeted interventions. The areas of training, conforming to national standards, will include a)
participatory mapping and needs assessment; b) risk assessment; c) interpersonal communication; d)
gender; e) condom social marketing; f) CBO formation and management; g) project management; and g)
reporting and management information systems. The project will train 128 NGO staff and 960 peer
educators.
Continuing Activity: 14156
14156 6150.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $2,158,800
10826 6150.07 U.S. Agency for Voluntary Health 5604 3949.07 $1,029,000
6150 6150.06 U.S. Agency for Voluntary Health 3949 3949.06 $1,306,560
* Addressing male norms and behaviors
* Increasing women's access to income and productive resources
* Increasing women's legal rights
* Reducing violence and coercion
Estimated amount of funding that is planned for Human Capacity Development $96,548
Table 3.3.03:
NEW ACTIVITY NARRATIVE
Injecting Drug Use is no longer limited to the north-east of India. Many towns in the country have now
reported the presence of Injecting Drug Users (IDUs). Coverage of IDUs has been minimal with only 44%
of the estimated IDUs (0.22 million) reached through interventions. A major development in the recent past
is the approval by the Government of India (GOI) to introduce oral substitution therapy for IDUs. GOI plans
to provide Buprenorphine to more than 10,000 IDUs by March 2009 and to an additional 30,000 IDUs by
2012.
Current interventions among IDUs primarily focus on HIV/AIDS awareness, condom distribution, STI
treatment, needle exchange, abscess management and counseling. Greater emphasis must be placed on
the promotion of CT services among IDUs; reaching IDUs with multi-partners for consistent condom use ;
periodic STI check-ups; referrals for medication assisted treatment programs; linkages with care and
support programs for HIV infected IDUs; advocacy with law enforcement agencies; and counseling family
members of IDUs.
Tamil Nadu has an estimate of 8,000 injecting drug users. There are currently only five IDU programs
(proposed six partners) covering 50 percent of the estimated IDUs. The National Behavioral Surveillance
Survey (BSS) (2006) indicated that less than 33% of IDUs have undergone HIV testing. The HIV Sentinel
Surveillance (HSS) (2006) also reveals that the HIV prevalence among IDUs in Tamil Nadu is the highest in
the country. There is therefore a definite need to scale-up IDU interventions providing comprehensive and
quality services.
ACTIVITY 1: Learning Site for Interventions Among IDUs
APAC will identify one NGO/CBO and build its capacity to function as a nodal agency for the state to train
other NGOs/CBOs on interventions among IDUs. The learning site will reach a large number of IDUs, offer
comprehensive services (including the provision of medication assisted treatment), advocate with law
enforcement agencies and policy makers, and demonstrate strong linkages with care and other social
development programs. The learning site will also convene a national annual meeting of NGOs/CBOs
implementing IDU programs and disseminate experience and concerns to NACO, SACS and TSUs.
ACTIVITY 2: Saturate Coverage of IDUs in Intervention Districts (linked to Act.1 of OP08)
APAC is engaged in the provision of prevention to care continuum programs in seven high prevalence
districts of Tamil Nadu. In these districts, the project plans to build the capacity of existing NGO/CBO
implementing interventions with female sex workers and MSMs, to identify and reach-out to IDUs with
comprehensive services. A special training on this will be provided by the project to the NGOs/CBOs. This
is a new approach and can be a model for places where the IDU population is small and spread-out.
ACTIVITY 3: Technical Support to SACS
APAC's Technical Support Units (TSUs) will support SACS to scale-up IDU interventions based on the
mapping data collected by the APAC project. The TSUs will also work for a faster roll-out of the medication
assisted treatment to IDUs in the state and to develop a package of comprehensive services in IDU
New/Continuing Activity: New Activity
Continuing Activity:
Program Budget Code: 07 - CIRC Biomedical Prevention: Male Circumcision
Total Planned Funding for Program Budget Code: $0
Program Budget Code: 08 - HBHC Care: Adult Care and Support
Total Planned Funding for Program Budget Code: $3,205,158
Program Area Narrative:
Overview: The burden of HIV/AIDS on the health system in India remains a major challenge, though the estimated number of
persons living with HIV/AIDS (PLHAs) was recently revised down to 2.47 million. Compared to many developing countries, India
has a large, vibrant health sector with an estimated 200,000 licensed physicians and a larger number of unlicensed medical
practitioners. However, major systems issues persist, including poor infrastructure, continuing stigma among medical
practitioners, limited medical education on HIV/AIDS, and a lack of government regulation of private sector services.
The use of care and treatment services by PLHAs has been reported to be low. Women PLHAs face special challenges in
accessing services, as they often are constrained from leaving their villages to seek treatment by the responsibilities of managing
their families, and in many cases, caring for a sick husband. There is limited data on the use of care and treatment services by the
marginalized, most-at-risk populations (MARPs) most affected by the epidemic. NGO experience reveals that the proportion of
these groups using HIV/AIDS services is less than 5%.
Over the past five years, the National AIDS Control Organization (NACO) has dramatically scaled up care and treatment
programs especially in the higher-prevalence states, with support from the Global Fund. Under the third National AIDS Control
Plan (NACP-III), 10-20 bedded NGO/FBO-run inpatient care facilities, called community care centers (CCCs) were established in
over 100 districts. Several functioned primarily as end-of-life care centers and were not linked to counseling and testing (CT) or
antiretroviral therapy (ART) services. After a recent review, 30% of centers were discontinued because of lack of quality in
provision of services and poor accessibility and linkages to CT and ART centers. The CCC concept has been redesigned to
provide more comprehensive services, including pre-ART outpatient care, management of opportunistic infections (OIs) including
TB, inpatient services, maintenance of stable ART patients, and psychosocial support and prevention for PLHA. NACO will open
250 centers over the next two years and this number may expand to 500 centers by 2012.
Developing systems to provide ART to a significant fraction of those who require it is daunting, given the continuing levels of
stigma against HIV in the medical community and the functional limits of India's public health manpower and infrastructure. Yet
significant strides have been made over the four-year history of the ART program: drug procurement systems have improved,
M&E indicators have been standardized, and operational and technical guidelines published. From 8 centers in 2004 the number
has increased to 174 centers in 2008 (the goal is to set up 250 by 2012). Similarly, the number of patients receiving ART has
increased from 24,400 in 2005 to 146,600 in 2008 (the goal is to treat 300,000 adult by 2012). NACO estimates that another
35,000 seek ART services from the private sector. The current cost for first-line ART is $155 per year per patient. Over 71% of
patients put on treatment are alive.
With plans to reach 300,000 by 2012, alternative strategies besides GOI-funded free ART must be developed and scaled up. In
India, the private sector accounts for 87% of the total health expenditure and hence plays a significant role in meeting the demand
for care and treatment services. Despite the size and complexity of the private sector, the services it offers and its general
structure are poorly understood. Public health experts are concerned by the potential for the unregulated private sector providing
ART in India, which could lead to increased drug resistance. Although NACO had initially restricted support for ART to the public
sector, it is now supporting 10 private sector ART programs under Global Fund Round 6.
While the number of ART patients has been constantly increasing over the years, 40% of HIV-positive CT patients still do not
reach the ART centers. The reasons are lack of demand generation efforts commensurate to expansion; poor accessibility due to
distance and inadequate referral systems. In order to reduce barriers and improve accessibility to ART services, NACO has rolled
out Link ART Centers at sub-district hospitals and plans to establish 250 centers by 2009. NACO has also initiated efforts to
improve access to care and treatment for MARPs such as accompanied referral to ART centers and monthly reporting of the
number of MARPs treated.
NACO has also stepped up national monitoring efforts in order to reduce the drop-out rates at ART centers. Of the registered
patients for ART, 83% are on treatment, 7.5% are lost to follow up, 6% have died and 3.5% are defaulters. Yet another concern is
adherence to treatment. In a qualitative study examining adherence in India, patients currently not taking ART identified the high
cost of travel to ART center including food, family commitments, and having more than one person in the household infected with
HIV as barriers. The Link ART Centers were established to reduce the barriers to treatment.
The extent of treatment failure/drug resistance is estimated at 2.8% per year but may be higher in the private sector. Currently,
viral load testing is not part of the ART monitoring system and is not widely available, limiting the ability to accurately identify
PLHAs failing first-line therapy. NACO understands this problem and will establish 10 centers throughout the country to address
drug resistance. NACO has started second-line ART in two sites and plans to expand to eight more sites.
Although the present emphasis on ART access and adherence is crucial, appropriate and timely prophylaxis of opportunistic
infections must also be a part of HIV clinical management. NACO is currently piloting cotrimoxazole prophylaxis in one state to
understand the implementation mechanism and based on the findings will scale up to the entire country.
Coordination and Other Donor Support: The Government of India (GOI) and several donors support the care and treatment
programs in India: the ART program is supported by the World Bank, Global Fund, and the World Health Organization; the Global
Fund (Round 6) supports the CCCs in several states and community-based care is supported by HIV/AIDS Alliance in two states.
USG programs coordinate with the government and donor supported HIV/AIDS care and support services, including private sector
services, to ensure each patient can access the services he/she needs and minimize duplication.
Current USG Activities: USG partners have played a key role in developing NACP-III's care and treatment strategy, including
chairing the Care and Treatment Technical Working Groups at national and state levels and helping NACO to develop overall
quality standards and clinical care guidelines. USG has developed various models of care in community, public and private
hospital settings. Great emphasis has been placed on supporting patients throughout their illness by linking clinical facilities with
community support. This concept has been incorporated into NACP-III.
In Tamil Nadu (TN), USG has pioneered care and treatment services in public and private health care institutions. At the
Government Hospital for Thoracic Medicine (GHTM) in TN, USG has established an ART outpatient center, state-of-the-art
laboratory, training center, computerized patient information system, counseling center for couples and families, staff trainings and
leadership development, and a hands-on fellowship in HIV/AIDS clinical medicine and leadership for 14 young physicians per
year. This effort has led to GHTM being labeled a Center of Excellence in HIV by NACO. The USG is also supporting IRT
Perundurai Hospital, a large tertiary health care institution, to expand care and treatment services through a network of 50
secondary-level private hospitals in a district.
NACO has nominated USG as the lead for public-private-sector partnership (PPP) programs in HIV/AIDS prevention, care and
treatment. In this role, USG has developed the draft national PPP policy and operational guidelines. The PPP policy will be
launched by the Prime Minister of India at the National AIDS Council meeting in late 2008. Following this meeting, USG will assist
NACO in scaling up PPP programs in the area of care and treatment.
A critical gap identified by NACO is a lack of demand for the care and treatment services provided by CCCs and ART centers.
Hence, NACO recommended that the Avert project in Maharashtra develop a demonstration program on community mobilization
to increase the uptake of services in six districts and assist the State AIDS Control Society (SACS) and the national program in
scaling-up lessons learned through this effort. USG will support six programs that use link workers to increase access to care and
treatment and provide home-based care and support. The link workers will develop systems to improve access to services by
establishing linkages between ICTCs and care and treatment centers. The link workers will also facilitate access to user friendly
services for MARPs.
In FY08, USG provided care and support for over 100,000 individuals at 211 service outlets at the tertiary, secondary, and
community levels. More than 16,500 PLHAs were reached in USG-funded home and community care projects. A key strength of
the USG program has been the active involvement of PLHAs in the program. In Maharashtra, the USG program has successfully
demonstrated expanded and improved access to care by supporting nine networks of positive people reaching to sub-district and
village level.
USG support has also focused on providing ART-related technical support to NACO as well as to the SACS in high-prevalence
states. USG is not purchasing ART drugs due to our limited budget. Key USG ART-related technical support activities include: 1)
Representation on the national ART Technical Working Group. 2) USG staff and technical support to SACS. 3) USG led the
development and implementation of a 4-day and 12-day national ART training curriculum.
FY09 Support:
1. Develop and scale up private (for-profit) models for HIV care services: USG's goal is to increase the level of engagement and
quality of HIV services among private sector physicians and hospitals.
a) USG, as the lead for the PPP program on HIV/AIDS, will guide the expansion of the national PPP activities in care and
treatment. USG will assist NACO in developing PPP plans and in the selection of an institution to manage the network of private
partners. USG will also assist in developing a PPP advocacy package, capacity building, and M&E of care and treatment PPP
b) At the state level, USG will strengthen the APAIDSCON consortium of 15 private medical colleges in Andhra Pradesh (AP) and
the collaboration with 19 private medical hospitals by the AIDS Prevention and Control (APAC) project in TN to expand access to
and strengthen the quality of private sector care and treatment services. Similarly, the model center of training for the private
sector at Perunderai Medical College in TN will be further strengthened. These will serve as models for scaling-up private sector
involvement.
2. Support and strengthen NACO-funded CCCs: Under NACP-III, these centers will be scaled up and will play a more significant
role in meeting the overall care and support needs of PLHAs. NACO has developed operational guidelines to ensure
comprehensiveness of CCC services, including standardization, staff training, and monitoring. In the six states where USG is
supporting Technical Support Units (TSUs), technical assistance (TA) will be provided to the SACS in identifying training
institutions, developing training curricula and supporting them to build the capacity of over 130 CCCs including monitoring the
quality of training programs.
3. Link PLHAs in the community to services: USG has historically supported strong community and home-based care programs.
Direct support for home and community care will be reduced in FY09 in response to the need under NACP-III for USG to build
sustainable institutional care capacities. Under NACP-III, NACO will focus on establishing link workers in high-prevalence
communities who will assist and empower PLHAs to seek care and treatment services. USG will play a key role in developing and
implementing this link worker scheme in priority districts. In Maharashtra, USG will support link worker programs in six districts
that will mobilize PLHAs to access care and treatment services through networking with the government Integrated Counseling
and Testing Centers (ITCTs), PLHA networks and prevention programs for MARPs. Based on lessons learned, USG will provide
TA at the state level in Maharashtra and Goa and at the District level in Mumbai to implement community mobilization programs to
increase the uptake of care and treatment services. Additionally, the Avert project will share best practices in community
mobilization with NACO and USG partners and provide technical support for implementation.
4. USG will play a critical role in improving access for MARPs to care and treatment services: USG will enhance the capacity of
NGOs in the focus states to establish effective referral linkages with ICTCs, care and support and ART services. TSUs in USG
focus states will assist the SACS in developing referral systems and monitoring the utilization of care and treatment services by
MARPs.
5. USG will continue to support GOI's ART program through TA, capacity building, and addressing selected critical issues in
service delivery. These include ensuring quality ART in the private sector and strengthening linkage of vulnerable populations to
ART services. USG will contribute to revisions/additions to the national ART curriculum as requested by NACO. USG will plan
training programs and workshops on ART operational and technical challenges, including second-line therapy policies and
guidelines. USG will help the GOI to develop an accreditation process for publicly-funded ART to improve quality and
standardization of services. The USG-developed fellowship in clinical medicine and leadership will expand to 18 fellows per year
and may be replicated in one other institution.
6. USG will address gender concerns in the delivery of care and treatment services: Women PLHA experience a high degree of
stigma and discrimination which may involve forced estrangement from their marital homes, physical and psychological abuse,
loss of property rights, and custody of their child. In order to address these concerns, USG will support innovative outreach and
community support strategies for women PLHA to offer them physical, psychological and economic protection and support.
Table 3.3.08:
Based on the latest (2006) HIV prevalence rate among adult population (0.38%) it is estimated that there
are 100,000 People Living with HIV/AIDS (PLHAs) in Tamil Nadu. Of this, 96% are adults (Males - 49,000
and Females 51,000) and 4% are children below 15 years. Due to the rapid scale-up of care, support and
treatment centers, the state now has 27 Adult Community Care Centres, 5 Pediatric Community Care
Centres, 27 ART centres and 7 PLHA drop-in-centres.
However there are still many challenges remain. Nearly 30% of the estimated PLHAs are yet to be
identified and even among those identified, only a small proportion are in regular contact with the care and
treatment centers. Other challenges include: a) continued stigma and discrimination of PLHAs in education,
workplace and health care settings; b) limited engagement of the private medical sector to provide care,
support and treatment services to PLHAs; c) discriminatory treatment practices by private health care
providers; d) quality of care provided at public and private health care centers, e) adherence to ART; f)
stock-out situations of OI drugs and supply chain management, and g) limited focus on positive prevention.
The APAC project currently supports 10 NGOs for implementing Home Based Care (HBC) Projects in
selected high-prevalence districts of Tamil Nadu. The project also supports the Institute of Road Transport
Perundurai Medical College Hospital for provision of secondary and tertiary care to PLHAs. Together these
projects have been able to reach out to 7,000 Adult PLHAs in the last two years.
All activities in COP 08 will be continued in COP 09. In addition, the following new activities are planned:
ACTIVITY 5: Expanding Access to Adult Care, Support and Treatment Services Beyond the District
Headquarters
Most of the care, support and treatment services are located at district headquarter hospitals. The Tamil
Nadu State AIDS Control Society (TNSACS) plans to expand these and to provide care, support and
treatment at the primary health center level located at the sub-block level catering to 30,000 people.
TNSACS has requested APAC to undertake a facility and need assessment of the primary health centres
and to develop a district plan for saturation of services. APAC will also be engaged in building the capacity
of the heath care providers in the primary health centers. APAC will monitor their progress and disseminate
this experience with other districts in the state and at the national level.
ACTIVITY 6: Model Project to Demonstrate Convergence of HIV/AIDS Activities at the District Level
In two high-prevalence districts of Tamil Nadu, APAC and TNSACS will jointly implement a model project to
demonstrate convergence of HIV/AIDS activities. Most HIV/AIDS activities (prevention and care) currently
implemented in the district operate on their own and there is limited coordination between these programs.
A team of expert consultants will be located in the pilot districts and will coordinate with the District AIDS
Prevention and Control Units (DAPCUs) and the different agencies implementing HIV/AIDS programs
(prevention, care) to: a) identify gaps and overlaps; b) establish optimal targets for each program area
(PMTCT, Adult care, Pediatric care, ART, TB-HIV co-infection management etc.); c) refine strategies and
specific roles and responsibilities for the different agencies for achieving the targets; and d) establish
mechanisms for coordination, stock-taking and grievance redressal. The team will also support DAPCUs in
mainstreaming activities within the district rural health mission programs, women child development
programs, etc. to leverage their infrastructure and increase their ownership of and engagement in HIV/AIDS
programs. Community mobilization and demand generation for different HIV/AIDS care and support
services will also be supported by APAC in these selected districts.
Palliative care services for people living with HIV/AIDS (PLHA) are primarily provided through the public
health care system. Many private health care institutions do not treat PLHA due to inadequate knowledge,
stigma, and lack of infrastructure. In FY08, the AIDS Prevention and Control (APAC) project will support 18
home-based care projects in selected high-prevalence districts to provide palliative care services to 6000
PLHAs and their family members. The project will also support a network of 19 private health care
institutions in these high-prevalence districts to provide facility-based clinical care and psychosocial support
to PLHAs. The project will train private physicians on palliative care, link them up with NGOs and PLHA
networks and follow up these physicians periodically. As the Technical Support Unit, APAC will build the
capacity of the State AIDS Control Societies (SACS) in the states of Tamil Nadu and Kerala to increase
demand for palliative care services, implement national guidelines and deliver comprehensive palliative care
services to PLHAs.
APAC project in the southern state of Tamil Nadu. APAC, which initially focused on targeted interventions
for most-at-risk-populations (MARPs), has expanded its efforts over the last few years to support a more
Kerala by setting up a Technical Support Unit at Tamil Nadu and Kerala, consisting of a core team of
improving efficiency and quality. APAC also serves as the vice-chair of the national Technical Working
Group on Targeted Interventions.
The recent findings of the third National Family Health Survey estimated there are 170,000 to 200,000
Activity Narrative: PLHAs in the states of Tamil Nadu and Kerala. Palliative care services supported by the SACS include
community care centers and PLHA drop-in-centers. Less than 40% of the estimated PLHAs are currently
registered with the SACS and receive palliative care services. Major gaps include the limited awareness of
the palliative care service providers, and the quality and comprehensiveness of the services.
Provision of palliative care services will be an ongoing activity funded by APAC. In FY06, APAC supported
five NGOs to deliver home-based care, providing 6,000 PLHAs with clinical care and psychosocial support.
Of the 6,000 PLHAs reached by the project, 10% were treated for TB and 10% are on ART. In FY06, the
project also supported a private medical college in a high-prevalence district, Perundurai, for diagnosis,
monitoring and institutional care of PLHA, resulting in 3,000 PLHAs getting clinical services.
ACTIVITY 1: Improving Access to Home and Community Care for PLHAs and their Family Members
APAC will support 18 NGOs to provide home and community care to people living with HIV in selected high-
prevalence districts of Tamil Nadu and Puducherry. The NGO staff (which includes outreach workers and
nurses) will sensitize community leaders, and coordinate with Government of India Link Workers and PLHA
networks to create demand for a continuum of care services in public and private health care settings. At
the community level, the NGO staff will be involved in strengthening HIV/AIDS awareness among
community leaders, advocacy with community leaders concerning stigma and discrimination affecting
PLHA, and mobilizing community support for PLHA and their family members. The NGO team will visit
PLHA homes at regular intervals to: a) counsel PLHA and family members on health monitoring and
periodic medical check-ups; b) identify opportunistic infections (OI) and assist with possible management at
home; c) train and follow-up PLHA and their family members on self-care, care-giving, positive living, and
treatment adherence for DOTS and ARV; d) refer for medical and non-medical needs to secondary and
tertiary level institutions; and e) provide end of life care. The home and community based care NGOs will
also network with other agencies involved in issues such as nutritional care and legal aid, to provide wrap-
around services. All these services will also be provided by the NGOs and PLHA networks at selected
project supported drop-in-centers. Though this initiative, 6000 PLHA will be able to get quality palliative
care services at different locations and 1200 PLHAs will be treated for TB infection through public and
private sector hospitals.
ACTIVITY 2: Increasing Access to Palliative Care for PLHAs through Facility-Based Private Sector Support
To increase access to care, and model the involvement of private physicians, APAC will train and support a
network of 100 private physicians in selected high-prevalence districts to provide medical care to PLHA.
The physicians will be trained in HIV/AIDS management including management of OI and counseling, and
linked to NGOs and other care continuum providers in the district. APAC will support the physicians by
providing basic infrastructure (for ensuring confidential counseling and treatment), and nominal
remuneration for maintenance of quality standards at their clinic and for reporting to APAC. The
experiences of these physicians will be shared with physicians' associations, SACS and other stakeholders
for learning and replication.
APAC will also support a network of 16 private hospitals for secondary care and three private hospitals for
tertiary care. In these hospitals, APAC will support a part-time counselor and train related health care
providers. The trained counselors will counsel antenatal women, TB patients attending the hospital and
PLHAs. Linkages will be established between these private hospitals, NGOs and other care continuum
service providers. In FY06, APAC's support to IRT Perundurai Medical College resulted in increased
coverage of PLHA. The approaches adopted by APAC include: a) supporting medical camps to promote
health care services including HIV/AIDS services; b) strong networking with private physicians, NGOs, and
PLHA networks to refer PLHA for treatment; c) training health care providers based on national guidelines
for quality of health care; d) supporting the cost of counselors for antenatal women, TB patients and PLHA;
e) strengthening management information systems; and f) subsidizing the cost of clinical diagnosis and
treatment for needy PLHAs. In FY08, using a similar approach, APAC will support two more private
hospitals for tertiary care services, but it will be on a smaller scale in terms of coverage of PLHA and range
of services. Through this initiative, over 5,000 PLHA will be provided with palliative care services and 1000
PLHAs will be treated for TB infection from the project supported private sector hospitals. About 9,500
registered TB patients will receive HIV counseling and testing under this initiative.
ACTIVITY 3: Building the Capacity of Private Sector Health Care Providers in Palliative Care
APAC will support one state-of-the-art training institute to build the capacity of private physicians on
HIV/AIDS palliative care, thereby expanding the pool of qualified and trained health care providers. An
estimated 300 physicians will be trained by the project, focusing on building the knowledge and skill of
health care providers. Due focus will be given to gender-based inequities and special needs for women on
palliative care. The trained doctors will be periodically monitored by APAC consultants and through a
system of self-assessment checklists/toolkits. The training of private health care providers complements the
SACS' initiative on providing quality clinical care for PLHA. Partnerships will be established with private
pharmaceuticals for the supply of basic medicines at subsidized rates. Similarly local philanthropists,
advocates and village volunteers will be coordinated to mobilize resources to support the nutritional,
livelihood and legal needs of PLHA.
ACTIVITY 4: Technical Support to SACS
APAC will provide technical support to SACS to strengthen their systems on palliative care as part of
APAC's role as the Technical Support Unit for the states of TN and Kerala. Technical assistance will include
training the SACS team on palliative care policies and guidelines, technical updates through national and
international consultants, exposure visits, monitoring of community care centers, and technical assistance to
training institutes (those involved in training NGOs) and public health care institutes (involved in training on
HIV/AIDS care and treatment).
Continuing Activity: 14157
14157 6151.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $970,000
10827 6151.07 U.S. Agency for Voluntary Health 5604 3949.07 $682,000
6151 6151.06 U.S. Agency for Voluntary Health 3949 3949.06 $739,950
* Family Planning
* Malaria (PMI)
* TB
Workplace Programs
Estimated amount of funding that is planned for Human Capacity Development $283,020
CONTINUTING ACTIVITY - NEW NARRATIVE
Since the role-out of NACP-III in 2006, the National AIDS Control Organization has taken serious efforts to
increase access to ARV services nationally, and in particular, in the six high-prevalence states. These
services are however limited to public health care settings and there are several areas which need
strengthening such as: quality assurance, follow-up, supply chain management and monitoring and
evaluation. The APAC project through the Technical Support Units will support the State AIDS Control
Societies (SACS) of Tamil Nadu and Kerala to increase demand for ARV services and address these
issues. The APAC project will also improve access to ARV services by focusing its efforts on the private
medical sector through its support to the network of private hospitals and physicians.
Tamil Nadu has an estimated 100,000-150,000 people infected by HIV/AIDS and of this nearly 25,000
individuals are currently on ART. The state has scaled-up access to ART and 29 of the 30 districts in Tamil
Nadu now have a government-run ART center. ART drug adherence in the state is above the national
standard, however, private sector involvement in ART services can be described as sparse at best. In COP
09 the APAC project plans to support the following activities:
ACTIVITY 1: Provision of Comprehensive HIV/AIDS Treatment through Private Medical Institutions
APAC will support the Institute of Road Transport (IRT), Perundurai Medical College for comprehensive
clinical management of PLHA focusing on ARV therapy. This institute will be supported for HIV-related
disease and response monitoring (such as CD4 testing, liver function, and lipid profiles), counseling for ART
initiation and adherence. ARV drugs will be available at the hospital at subsidized rates and patients will be
required to pay for the drugs. For those unable to afford them, patients will be referred to the Government
of India's ART centers for drugs but monitoring of drug response, adherence, and follow up will be done by
the institute. An estimated 750 new PLHAs will be provided services through the hospital. The project will
build the capacity of the center through infrastructure strengthening, laboratory support, quality assurance,
systems strengthening and onsite supervision by consultants. The project will subsidize the cost of
diagnostics for a limited number of PLHAs who are unable to afford this service.
ACTIVITY 2: Capacity Building of Private Health Care Providers on ARV Services
The APAC project will support IRT Perundurai Medical College to train 120 physicians on ARV services.
Training will be based on nationally approved guidelines. These trainings will provide the physicians with
hands-on experience of HIV disease management and will be conducted at the IRT campus. The project
will coordinate with SACS to ensure services of the trained private physicians are utilized. The project will
also establish mechanisms for periodic follow-up and experience sharing among the trained physicians. The
project will place greater emphasis on the identification of HIV infected MARPs and, once identified, to link
them with public and private health care providers for HIV treatment.
ACTIVITY 3: Technical Assistance to SACS for Strengthening ARV Services
Technical support will be provided to SACS to strengthen and operationalize standard operating
procedures, increase demand for ARV services, improve supply chain management and strengthen
management information systems. The project will also support the SACS to develop prototype materials,
which aim to create demand for ARV services with an emphasis on drug adherence, nutrition and other
critical aspects of ARV services.
Continuing Activity: 14163
14163 6154.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $34,100
10829 6154.07 U.S. Agency for Voluntary Health 5782 5782.07 $196,000
6154 6154.06 U.S. Agency for Voluntary Health 3949 3949.06 $194,300
Estimated amount of funding that is planned for Human Capacity Development $96,602
Table 3.3.09:
CONTINUNING ACTIVITY - NEW NARRATIVE
Voluntary Health Services (VHS) has been implementing the AIDS Prevention and Control (APAC) project
in the southern state of Tamil Nadu for 12 years. APAC initially targeted most-at-risk-populations (MARPs),
but has expanded efforts over the last few years to support a more comprehensive approach to HIV/AIDS
prevention, care and treatment. Tamilnadu has been successful in controlling HIV (prevalence among
antenatal women has dropped from 1.13% in 2001 to 0.38% in 2007) and APAC has significantly
contributed to this success. NACO has recognized the expertise and contributions of the APAC project and
has requested APAC to provide technical support to the SACS of Tamilnadu, Puducherry and Kerala by
setting up a Technical Support Unit (TSU) in each state, consisting of a core team of consultants/experts co
-located with the SACS, with a mandate to assist the SACS in scaling-up programs, improving efficiency
and quality. APAC also serves as the vice-chair for the Technical Working Group on targeted interventions
for the country.
Based on the existing HIV prevalence rate, it is estimated that there are 100,000 to 150,000 PLHAs in Tamil
Nadu. Of this 96% are adults (Males - 49,000 and Females 51,000) and 4% are children below 15 years.
In the last two years the state has significantly scaled-up the number of centers providing care, support and
treatment. There are now 27 Adult Community Care Centres, 5 Pediatric Community Care Centres, 27 ART
centres and 7 PLHA drop-in-centres. Despite the increase in the number of centers providing care, support
and treatment, many challenges continue in this area. Nearly 30% of the estimated PLHAs are yet to be
identified as of Sept 2007 and even amongst them a very small proportion are in regular contact with the
agencies involved in provision of care, support and treatment. Other major challenges include: stigma and
discrimination; limited engagement of the Private Medical Sector, discriminatory treatment practices by
private health care providers; quality of care; adherence; supply chain management; and a limited focus on
positive prevention.
In the last few years considerable work has been done with regard to pediatric care. Of the estimated 6,000
infected children, nearly 5,000 children have been identified by Clinton Foundation through a special drive
for Pediatric ARV. In addition, in all pediatric wards at the district headquarters hospital, the Clinton
Foundation has placed two outreach workers for identifying children with symptoms of HIV and for referral
to CT and care continuum services. 750 children have benefited through this initiative to date. The UK-
based Children Investment Fund Foundation has supported child counselors in three ART centres and also
supplies micro and macro nutrients to infected children.
The gaps identified in the current programs include: lack of demand generation activities, limited follow-up
of children born to HIV positive mothers, and lack of monitoring. Some of the main problems are
transportation costs, Pediatricians lack skills in proper treatment and psycho-social support of children with
HIV, Counselors are not trained in Pediatric counseling, and there is a lack of community-based models on
Care and support for children. In schools there is still stigma. Nutrition and psychosocial needs must be
addressed. Outreach plans need to be further strengthened to ensure continuous adherence of ART.
There is a need for developing a systematic training plan for care givers.
The APAC project currently supports ten NGOs for implementing Home Based Care (HBC) Projects in
selected districts of Tamilnadu. The project also supports the Indian Road Transport Perundurai Medical
College Hospital for provision of secondary and tertiary care to PLHAs. Together these projects have been
able to reach out to 7,000 PLHAs in the last two years. (88% being adults and 12% children below 15)
ACTIVITY 1: Improve Access to Home and Community Care for Children with HIV
The APAC project will support prevention to care continuum in selected high prevalence districts. In these
districts the project will support NGOs for provision of home-based care and support services to PLHAs.
The project will train the NGO staff on the issues of pediatric care and support and take a proactive role to
identify children infected with HIV/AIDS care and support services. Individual pediatric records will also be
maintained to ensure the provision of quality services and regular follow-up.
ACTIVITY 2: Increasing Access to Palliative Care for HIV-Infected Children Through Facility-Based Private
Sector Support
In selected high-prevalence districts, the APAC project plans to support a network of 19 private hospitals
and 50 physicians to provide care, support and treatment services. This would increase the access to
quality care and support services. The private hospitals and physicians will be trained specifically on
pediatric counseling and provision of care and support. The hospitals and physicians will also be linked with
other non-health service providers to cater to the needs of pediatric PLHAs.
ACTIVITY 3: Technical Support through SACS
The Technical Support Units in Tamil Nadu and Kerala will update the SACS team on the issues and
success stories in provision of care and support services to PLHAs. They will also work with SACS to
develop appropriate strategies to address the issues.
Table 3.3.10:
The TB/HIV activities undertaken by APAC in FY08 will continue, as mentioned in the FY08 Palliative Care
narrative (below). In addition to these activities, APAC will support the following two new activities in FY09.
ACTIVITY 5: Capacity Building of Lab Technicians at TB Centers
Training will be provided to Counseling and Testing staff and TB clinic lab technicians on HIV/TB
coordination through a nodal agency. Onsite mentorship will be provided on a regular basis to all TB clinics,
thereby strengthening the coordination between HIV/AIDS and TB programs. It is expected that 1,000 lab
technicians will be reached through this initiative.
ACTIVITY 6: Capacity Building of Nurses to Deliver Quality Care on TB
40 nurses from APAC NGOs will be trained in a) identifying TB cases and assist with possible management;
b) networking with DOTS center/provider c) adherence to Anti Tuberculosis Treatment.
FY08 NARRATIVE
PLHAs in the states of Tamil Nadu and Kerala. Palliative care services supported by the SACS include
Activity Narrative: The physicians will be trained in HIV/AIDS management including management of OI and counseling, and
Table 3.3.12:
APAC has been supporting Orphan and Vulnerable Children (OVC) initiatives over the last three years, with
more than 800 OVCs reached through the project-supported home and facility based programs. The
response from the state government to OVC programs is encouraging: pediatric ART has been made
available in all government medical hospitals. The State has also planned to form a separate HIV/AIDS
OVC Trust to meet the health and socio-economic needs of OVCs. The concept of the OVC Trust was
initiated by APAC and has been taken over by the State, thereby ensuring sustainability and greater
ownership. There are still many challenges, however. Data on the number of HIV-infected and affected
children are not available to plan comprehensive programs. Issues pertaining to stigma and discrimination
in schools and access to quality education and job-oriented training are yet to be addressed more
effectively.
All activities in COP 08 except for Activity 3 will be continued in COP 09. APAC will not undertake Activity 3
(Developing a Community Based Model Project for OVC) because the state plans to roll-out the Trust for
Children Affected by AIDS (TFCAA). APAC will, however, support the Trust in the following new activity:
ACTIVITY 5: Support to the Trust for Children Affected by AIDS (TFCAA)
The Tamil Nadu State AIDS Control Society (TNSACS) has initiated an OVC Trust with a vision to support
all infected and affected children in the state by addressing their basic needs. The Trust will be chaired by
the project director of TNSACS and will include both government officials and major funding partners as
advisory members. The state government will support the Trust with Rs Five crores ($1.25 million) to
address the basic needs of OVCs in areas such as education, clinical care, nutrition and economic
strengthening of families. The Trust will also seek support and involvement from the private sector. APAC
will support TNSACS in developing relevant strategy and operational guidelines for effective roll-out of the
trust activities. APAC will also assist in: estimating the OVC population in the state; conducting a needs
assessment; mobilizing private sector resources for the Trust; monitoring the implementation of the OVC
Trust activities; and in the documentation and dissemination of lessons learnt and best practices to policy
makers and implementers at state and national level. The Trust will reach 5,000 children within the first two
years of the project.
The Trust also seeks to give equal attention to girl children by motivating their parents/ guardians to send
their girl children to school by providing school fees and other educational materials to help girls complete at
least secondary level of education. The support from the government will ensure that the Trust will function
beyond the life of the project period of SACS or any funding agency and thereby ensuring continuous and
uninterrupted support to needy children.
In the second phase of the National AIDS plan, there was minimal emphasis on the issue of OVCs. During
the same period, the USG took the lead in developing models of OVC programming. In the current, third
phase of the National AIDS Control Program (NACP-3), there is now an emphasis on supporting activities
on orphans and vulnerable children (OVC) who are infected or affected by HIV/AIDS. Much of the guidance
in this new area for national policy has been provided by USG. In FY08, the AIDS Prevention and Control
(APAC) project will provide comprehensive home-based OVC services to over 1000 children. It will support
two demonstration projects on OVC, one being a faith-based initiative and the other led by the NGO
community. The project will also provide technical assistance to build the capacity of State AIDS Control
Societies (SACS) to promote OVC programs in the state.
and improving efficiency and quality. APAC also serves as the vice-chair of the national Technical Working
In general, little importance was given to the issue of OVC in the second phase of the National AIDS Plan.
Consequently, except for support from USG and a handful of other agencies, there were minimal activities
addressing OVC, both nationally and in Tamil Nadu. It is recognized that limited information is available on
OVC, however, broad estimates suggest there are 3500 HIV- infected children in Tamil Nadu. In FY06,
APAC supported six NGOs to provide primary and secondary services to OVCs, reaching 400 HIV infected
and 2000 affected children with OVC services. Of the total of 2000 infected and affected children, 1000
children were provided support for education, 10 for shelter and 100 for other support services.
ACTIVITY 1: Provision of OVC Services through Home Based Care Projects
The project will continue to provide comprehensive OVC services to over 1000 children, in their homes,
Activity Narrative: through existing and proposed home-based care projects providing palliative care services. USG funds are
used to provide medical/clinical care to the children who are also regularly monitored in all six of the core
PEPFAR OVC areas. Other needs of the children such as education, nutrition, and child protection are
fulfilled by leveraging resources through linkages or local fund generation. This home-based care OVC
project utilizes the medical care team of the palliative care intervention to provide clinical services to the
children, thus saving resources and promoting synergy for the program.
ACTIVITY 2: Develop a NGO-Managed Model OVC Project
APAC will support one sub-partner with long experience of working with OVC to become a model project on
OVC. This program will reach 500 HIV/AIDS infected and affected children. The activities will include life
skills education training for children, provision of medical, nutritional and educational aid, linkages with CT
services, and strengthened referral linkages with government, corporates and other stake holders to
leverage resources. The project will become a learning site and a training center to build the capacity of the
State and will provide support to the APAC project in its role as the manager of the State's Technical
Support Unit.
ACTIVITY 3: Developing a Community Based Model Project for OVC
The APAC project will support one Faith-Based Organization (FBO) as a model community based project to
provide care for OVC. In this project, faith leaders will take the lead in planning and providing support for the
OVC program. The faith leaders will assist in undertaking stigma reduction activities, and will facilitate
support for wrap-around activities such as nutrition support, provide admissions for OVCs to schools
managed by the FBOs, and promote adoption and foster care. The OVC programs will primarily focus on
health, education and nutrition, and will reach 200 OVC. The APAC project will provide assistance to the
FBO for system strengthening, quality of programming including counseling for children, and monitoring and
evaluation.
SACS has limited experience in supporting OVC projects and needs a considerable amount of capacity
building. Since there is an increased emphasis on this activity in the national plan, APAC, as part of its role
as manager of the State Technical Support Unit, will build the capacity of SACS staff and their NGO
partners on the national OVC policy, guidelines and OVC programming and expose them to some of the
important OVC projects in the state and country.
Continuing Activity: 14158
14158 6155.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $297,000
10830 6155.07 U.S. Agency for Voluntary Health 5604 3949.07 $146,000
6155 6155.06 U.S. Agency for Voluntary Health 3949 3949.06 $233,390
Program Budget Code: 14 - HVCT Prevention: Counseling and Testing
Total Planned Funding for Program Budget Code: $1,655,939
Overview: Though HIV counseling and testing (CT) services are available throughout the country, only 25-30% of those who are
HIV positive are aware of their status (National AIDS Control Organization [NACO] report, 2008). The continued low uptake of HIV
counseling and testing has limited the scale-up of HIV care and treatment for the estimated 2.47 million infected persons.
Increasing the number of people, especially most-at-risk populations (MARPs), who know their HIV status is key to expanding
access to HIV prevention, care and treatment. According to the National Behavioral Surveillance Survey study (2006), only 14.4 %
of sex workers have been tested for HIV. Similarly, only 17.9% of the clients of the brothel-based and 12.7 % of non-brothel based
sex workers have been tested.
Uptake of client-initiated HIV CT has been limited by low coverage of services, fear of stigma and discrimination, and the
perception by many people, including those in high prevalence areas, that they are not at risk. Other challenges to expanding CT
services are the highly variable patient load, lack of referral services and inadequate systems to monitor counseling quality. NACO
is starting to address these issues. Rapid test kits have been supplied to CT centers to facilitate same-day results. A national HIV
testing quality assurance system is in place. NACO has developed a trainer's manual and guidelines for CT in collaboration with
WHO and USG.
Under the National AIDS Control Program phase three (NACP-3), existing CT services and PMTCT centers are being remodeled
to serve as a hub that integrates all HIV-related services, called Integrated Counseling and Testing Centers (ICTCs). ICTCs are
envisaged to be the key entry point for both men and women for a range of HIV/AIDS services. NACO has rapidly scaled up ICTC
services across the country. Currently, there are 4,567 ICTCs and the number of people tested has taken a quantum leap from
4.3 million in 2006 to 7.6 million in 2007 (surpassing the national target of 7 million). As part of the integration plan with the
National Rural Health Mission (NRHM), CT services are now being expanded to over 2000 24-hour Primary Health Centers
(PHCs), the lowest unit of care in the Indian administrative system. In collaboration with NRHM, a nurse and laboratory technician
are being trained in these PHCs to reach the rural underserved high-risk populations. NACO is also promoting public-private-
partnerships (PPP) to expand the reach of CT services. Over 100 PPPs have been established in private/non-profit hospitals (to
be expanded to over 860 in FY08).
Pediatric CT has not received attention nationally despite the need to diagnose early and provide care and treatment to children.
Similarly, there has been limited attention to family-centered and couple-centred CT. USG supports a family and couple-centred
approach at the General Hospital for Thoracic Medicine in Tamil Nadu and the Government Chest Hospital in Andhra Pradesh but
this approach needs to be expanded.
NACO is investing intense resources in strengthening the capacity of SACS to improve the quality of CT programs. NACO has
identified 40 centers of excellence to deliver quality training. In 2008, over 4290 counselors were trained with a 12-day induction
training module. Similarly, 3282 out of 4462 laboratory technicians have taken a five-day induction training in NACO-identified
State reference laboratories. The quality of the testing program is improving, as shown by a continuing decline in the drop-out rate
between pre-test, test and post test counseling.
To ensure quality of HIV testing an External Quality Assessment Scheme (EQAS) is implemented in most states in which all
ICTCs participate. A quality assessment of the national reference laboratories was carried out in July 2008 by USG: findings from
this study will guide NACO in further strengthening the quality of HIV testing.
A major concern identified by NACO is that high-risk populations are not accessing public-sector CT services. One possible
reason for the low utilization of CT services is assumed to be the discriminatory attitude of health workers towards FSW and
MSM. NACO is developing systems for referral linkages between NGOs implementing prevention programs and the ICTCs to
increase coverage of CT services for MARPs. ICTCs conduct a sensitization program every year for their staff on issues such as
stigma and discrimination against MARPs and people living with HIV/AIDS (PLHA). From January to March 2008, over 14,000
male referrals to CT centers from MARP prevention programs were tested throughout the country and the positivity rate was
14.3%. This high reported rate underscores the importance of scaling up CT services among MARPs and establishing linkages for
care and treatment to those tested positive.
In most settings, instituting routine provider-initiated counseling and testing (PICT) can prevent missed opportunities to diagnose
and counsel individuals attending health facilities and facilitate access to HIV-related services. In a concentrated epidemic such as
India's, a high priority is provider-initiated CT in STI clinics, health clinics for high-risk populations, TB clinics and ANC centers. In
line with WHO guidance, NACO has introduced PICT in TB, STI and ANC clinics in over 200 high prevalence districts. WHO and
UNAIDS have issued new guidance on PICT in health facilities as a means to significantly increase access to prevention, care
and treatment services. In India, however, a high level of routine HIV testing is also requested by private practitioners and
hospitals with referrals to laboratories where quality assurance is non-existent. This is a cause of concern, and NACO is planning
to establish regulatory measures to control non-priority testing.
According to available reports, 40% of those tested positive at the ICTC centers do not reach ART centers. NACO is addressing
this issue by strengthening the linkages between ICTCs and ART centers through establishment of a patient feedback system.
Coordination and Other Donor Support: The entire funding for CT programs in India comes from the Global Fund (Rounds 2, 3,
and 6). USG supports a national program officer on CT who assists the national program in curriculum development and
organizing trainings for ICTC counselors. Additionally, the technical support units in the USG priority states support the SACS in
conducting ICTC team training programs.
Current USG Support: USG is playing an important role in creating and expanding a variety of CT approaches tailored to different
populations. The USG provides direct support to 263 facilities delivering CT services in Tamil Nadu (TN), Maharashtra, Karnataka
and Andhra Pradesh (AP). This includes private sector services, services for MARPs and placement of nurses trained in HIV CT
in community-based primary health care centers (PHC).
The USG-supported APAC project, in collaboration with the Tamil Nadu State AIDS Control Society (TNSACS), is increasing
access to user-friendly CT services for MARPs. As part of this effort, the counselor and the lab technician from the government
ICTC visit the APAC intervention site once a week to provide CT services to MARPs. Mobile CT, first used to reach rural villages
in TN, has been adapted and scaled up by TNSACS and currently there are 20 mobile CT teams covering all 22 high prevalence
districts. Based on the successful experience of TN, mobile CT is now being adapted nationally to expand CT services to high-risk
rural populations. At the Government Hospital for Thoracic Medicine (GHTM) in TN and the Chest Hospital in Hyderabad in AP,
USG supports the Indian Network of Positive People to manage Family Counseling Centers at GHTM. This model contributed to
national recognition of the importance of post-test and follow-up counseling in positive prevention for PLHAs. PLHA involvement
has now been scaled up in the ART centers supported by the Global Fund in high prevalence states.
Other models work with the private sector, which overall has not been involved in the provision of CT services. USG has
partnered with 19 private medical hospitals in TN and 15 private medical colleges in AP to expand access to and strengthen the
quality of private sector CT services. The USG-supported Christian Health Association of India (CHAI) program has successfully
demonstrated the expansion of CT services through partnership with the PHC program in the high prevalence districts of AP. The
program strategy included placement of a nurse (initially funded by CHAI) and capacity building of the PHC team in providing user
friendly CT services to high-risk individuals. Ongoing supervision by CHAI is an important component of the model. NACO has
adopted this model in scaling-up CT services through integration with the NRHM program in the 24-hour PHCs.
A critical gap is low demand for services at the 4,567 ICTCs resulting in low service uptake. Hence, NACO recommended that the
Avert project in Maharashtra State develop a demonstration program on community mobilization to increase the uptake of ICTC
services in six districts and assist the state and national programs in scaling-up lessons learned through this effort. In FY08, USG
will support six programs that will utilize link workers to increase access to CT services. The link workers will work with community
-based structures such as Self Help Groups (SHGs), youth clubs and community leaders to mobilize high-risk individuals in
villages to test; motivate partners of PLHA, including positive pregnant women, to test; and facilitate access to user-friendly
USG FY09 Support: USG will provide technical support to SACS in USG-supported focus states in establishing systems to
achieve significant coverage of CT services down to the sub-district level. This will support NACO's plans to expand CT reach
through approaches that include: scaling up PICT services, reaching the high-risk rural population, strengthening linkages with
the TB program and prevention programs; and expanding CT services through PPPs. NACO also aims to ensure the quality of
HIV testing, including availability of quality test kits, and support demand generation for CT services.
1. USG will provide technical assistance (TA) to NACO and SACS to standardize the quality and consistency of counseling
services, develop and/or adapt technical standard operating procedures and a quality assurance/quality improvement framework,
and train CT staff.
(a) USG will provide TA to NACO to strengthen the national counseling curricula, including training in post-test counseling,
confidentiality, and family counseling.
(b) In Tamil Nadu (TN), USG is demonstrating a quality improvement model of the government ICTC program through onsite
capacity building and supportive supervision. NACO plans to learn from this model and scale it up nationally to improve the quality
and uptake of ICTC services. In Maharashtra, the USG-supported Technical Support Unit (TSU) will provide TA to the SACS in
planning and conducting training for 600 ICTC staff. In AP, based on the lessons learned from the primary health care CT
program, USG will assist the national program in scaling-up CT services through the 24 hour PHCs and integrating with the
NRHM including developing operational guidelines for implementation. In Karnataka, USG will establish six model CT centers
which will serve as learning sites for the 565 ICTCs supported by SACS.
(c) USG will provide TA to SACS in its focus states to develop plans for different approaches to increase coverage and quality of
CT services. This will include hiring experts to help SACS design PICT models; strengthening supply chain logistics; enhancing
systems to ensure quality counseling; and developing model CT centers as learning sites for the SACS. To increase uptake of CT
services by MARPS, in TN, TNSACS will conduct weekly clinics for MARPS for 30 USG-supported prevention programs. In
Maharashtra, the TSU will assist the SACS to develop referral linkages for MARPS with NGOs implementing prevention programs
to increase CT uptake.
2. USG will continue to develop and promote the expansion of private-sector models for quality CT. In the six states where USG
is supporting the TSU, TA will be provided to the SACS in expanding the PPP program to scale-up CT services. The TSUs will
support planning, selection of preferred private providers, capacity building and monitoring the quality of services. USG will also
strengthen the collaboration with 19 private medical hospitals in TN and 15 private medical colleges in AP to expand access to
and strengthen the quality of private sector CT services.
3. USG will expand community mobilization and targeted demand generation for CT services in the focus states and nationally. In
FY09, the Avert will provide TA to the SACS in Maharashtra and Goa to implement community mobilization programs to increase
CT uptake and will share best practices with NACO and USG partners.
4. USG will provide technical support to SACS on positive prevention and follow-up counseling: In FY09 USG will provide TA to
the SACS in the focus states in training counselors of ICTCs and ART centers on positive prevention strategies. The TN SACS
plans to train over 780 counselors across the state on use of the Prevention with Positives Follow up Counseling Tool Kit
(prepared by a USG partner). The toolkit has a standardized curriculum that covers advanced issues of living with HIV/AIDS,
including stigma and discrimination, disclosure, mental health safer sex, care and prevention. A complementary training is also
planned for health care providers.
5. USG will address gender concerns in CT: USG partners will develop and implement community outreach strategies to address
stigma and discrimination against women who test positive. This includes working with positive networks and SHGs to tackle
problems faced by positive women such as forced estrangement from their marital homes, physical and psychological abuse, loss
of property rights and custody of their child.
Table 3.3.14:
National estimates indicate that less than 10% of people living with HIV know their status. Even among
MARPs the percentage reported having been counseled and tested is low. Only 38% of female sex
workers reported of ever having had an HIV test. Among MSMs, the proportion reporting of ever having
had an HIV test ranges from three to 69 percent among the different states.
Tamil Nadu has a good infrastructure for Counseling and Testing services. The State has 780 Integrated
and Counseling and Testing Centres (ICTC) (with the majority located in government hospitals), and more
than 2 million individuals are being tested annually. These include antenatal women and their spouse, TB
patients and STI patients.
In COP 09, only activities 3 & 5 in COP 08 will be continued.
ACTIVITY 1: Improving Access to CT Services for Most-at-Risk and Bridge Populations
This activity will not continued as NACO has suggested the project to utilize the government counseling and
testing centres. The project and the Tamil Nadu State AIDS Control Society have already worked out a
plan by which a team of ICTC staff (one counselor and lab technician) will visit the project supported MARP
intervention sites on a weekly basis (on a fixed day) for provision of CT services. This ensures sustainability
and greater utilization of the Govt. ICTCs. The experiences will be documented and shared with NACO and
other State AIDS Control Societies.
ACTIVITY 2: Improving Access to CT in Rural Areas in Selected High-Prevalence Districts
This activity is being dropped since TNSACS has adopted the concept of mobile CT services from APAC,
and plans to scale it for the entire state. APAC will provide technical assistance to TNSACS for effective roll
-out of the mobile CT services.
ACTIVITY 3: Capacity Building of Counselors and Lab Technicians
Will continue as in COP 08.
ACTIVITY 4: Facility Assessment of Public and Private Sector CT Centers
This activity will not be undertaken as this is not a recurring activity and is planned only twice in the next five
years.
The following change is planned for activity 5:
ACTIVITY 5: Technical Assistance to the State AIDS Control Societies
This activity will now have an expanded role. Based on a request from the Tamil Nadu State AIDS Control
Society (TNSACS) the project will support a consortium of agencies to provide technical assistance and
improve the quality of CT services in the state. These agencies will: a) provide onsite support to the
government ICTCs for quality assurance and adherence to national protocols; b) establish systems within
TNSACS for collation, analysis and timely feedback of monthly reports from ICTCs; c) strengthen cross
referral linkages between ICTCs and prevention, care, support and treatment partners in public and private
care settings; d) assess and grade ICTC; and e) document and disseminate best practices among ICTCs at
the state and national level.
National estimates indicate that less than 10% of people living with HIV know their status. Most-at-risk-
populations (MARPs) and bridge populations do not access public sector counseling and testing centers
due to inconvenient timing, distance and lack of privacy. The AIDS Prevention and Control (APAC) project
will support activities to increase access to counseling and testing services for MARPs, bridge and other
selected sub-populations at risk through a network of NGO-based and private-hospital-based counseling
and testing (CT) centers. The project will increase access to CT services in rural areas of high-prevalence
districts through innovative approaches such as mobile CT. The project will encourage CT services in the
private sector and build the capacity of counselors and lab technicians to provide quality CT services in
accordance with the national guidelines. As the Technical Support Unit for the states of Tamil Nadu and
Kerala, APAC will also support an assessment of public sector CT centers to improve quality and client
friendly services, explore accreditation of private CT centers and strengthen systems for CT.
for MARPs, has expanded its efforts over the last few years to support a more comprehensive approach to
HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in controlling HIV prevalence
(prevalence among antenatal women has dropped from 1.13% in 2001 to 0.5% in 2005) and the APAC
project has significantly contributed to this success. The National AIDS Control Organization (NACO) has
technical support to the State AIDS Control Societies (SACS) of Tamil Nadu, Puducherry and Kerala by
setting up a Technical Support Unit at Tamil Nadu and Kerala, consisting of a core team of
improving efficiency and quality. APAC also serves as the vice-chair on the national Technical Working
Counseling and Testing (CT) is an integral part of the prevention, care and treatment initiatives of APAC. In
FY06, APAC supported NGOs to establish user-friendly CT centers that are easily accessible to MARPs
and bridge populations. APAC also supported district-level communication campaigns on the theme of
"Know your Status" and introduced mobile CT units to reach rural areas and inaccessible urban areas in
selected high-prevalence districts. The evaluation of the campaigns confirmed that the initiative increased
Activity Narrative: access to CT. Over 24,000 individuals were provided CT services over a period of two months. Based on a
request from the Tamil Nadu State AIDS Control Society (TNSACS), APAC conducted the first state-wide
assessment of public and private sector CT centers. The findings include: lack of adequate infrastructure,
the sub-optimal quality of counseling, issues of confidentiality, and weak referral linkages and follow-up. The
activities proposed by APAC in FY08 are based on this assessment and will continue to support the national
and state priority of increasing access to CT services for MARPs, bridge and other selected at-risk
In a recent development, National AIDS Control Organization (NACO) and Tamil Nadu State AIDS Control
Society (TANSACS) have taken a decision that the project should withdraw its support to 25 NGOs
implementing CT services in the targeted intervention programs as the CT services to the MARPs will now
be offered by the government run ICTCs in these districts. However, the project will continue to support the
19 private hospitals for the CT services.
In FY08, APAC will continue support to 16 NGO based CT centers in selected high- prevalence districts that
will primarily cater to MARPs and bridge populations. In addition, in these high prevalence districts APAC
will also support the establishment of CT centers at 19 private hospitals to enable MARPs, bridge
populations, pregnant women, TB patients, and the general public who choose to use private facilities for
health care, to access CT services. NGOs supported by APAC for prevention activities will promote these
services and create demand for CT through interpersonal communication and mid-media activities. The 19
private hospitals will also provide PMTCT, TB/HIV management and palliative care services including
ARVs. Linkages for palliative care will be established with care and treatment NGOs, networks of people
living with HIV/AIDS, and private and public sector hospitals. Through this initiative, APAC expects to
counsel and test 32,000 individuals. The HIV test kits for NGO-run CT centers will be leveraged from
TNSACS.
In selected high-prevalence districts, APAC will support mobile CT units to extend services to rural areas
which have limited access to CT services. The project will establish linkages with the Government Primary
Health Centers, Link Workers (two Link Workers to be appointed under NACP 3 for every village having
5000 population in High-Prevalence Districts) to promote access to CT services. This activity is based on
learning from APAC's previous experience of supporting mobile units and will be implemented in
coordination with other USG partners and TNSACS. APAC will also develop operational guidelines for the
mobile units and quality control mechanism will be an inherent part of the protocol. APAC will assess the
impact of the mobile CT units for addressing gaps, cost effectiveness, quality of services, follow-up, and,
linkages to care and treatment. Through this initiative, 4000 individuals will be counseled and tested. The
entire process will be documented and the findings disseminated to SACS, NACO and other agencies for
learning and replication.
APAC will support one state-of-art training institute to provide training to counselors on CT, consistent with
the national guidelines. This institute will also undertake field assessments to assess the quality of services
provided at NGO run centers, private hospital based centers and will also provide onsite training to
counselors. The counselors will go through periodic refresher trainings for improving quality of service
provision. Examples of the training components for counselors and lab technicians include: risk
assessment, pre/post test counseling, universal precautions and waste management. Apart from these
topics, the counselors will be trained to counsel on handling specific situations such as counseling
unmarried individuals who test positive, counseling discordant couples, antenatal women and their spouse,
MARPs, infected children, drug adherence, and positive prevention. The training institute will support the
development of reporting formats, counseling case sheets and other Quality control and Monitoring
documents.
A regional experience sharing workshop will be organized by the APAC project for the counselors
representing different agencies from all the southern states of India. The three-day program, with an
estimated presence of 250 Counselors, will provide an opportunity for the counselors to share their
experience, learnings and challenges. APAC will also support one training institute to train lab technicians
on CT services. The training curriculum will include testing procedures, confidentiality and ethics, universal
precautions, waste management, and Quality assurance. APAC will also explore the feasibility of
collaborating with the Directorate of Medical Education in Tamil Nadu to include a special training on
HIV/AIDS testing to the budding lab technicians passing out from public and private paramedical
institutions.
ACTIVITY 4:Facility Assessment of Public and Private Sector CT Centers
In FY 08, APAC will support another assessment of CT centers in public and private settings. This will
include areas such as facility assessment, quality of service provision, and follow up. The findings of the
assessment will be disseminated to stakeholders and policy makers.
The third phase of the National AIDS Control Program has planned for counseling and testing 21 million
individuals in the next five years. As part of its role as the TSU for the state of Tamil Nadu and Kerala, the
APAC project will provide Technical Assistance to the SACS to improve quality of counseling and demand
generation in line with the findings of the CT assessment study carried out by the project. The project will
assist the SACS in strengthening counseling protocols, possible accreditation of private CT centers and
linkages after testing. The project will work closely with the SACS to develop specific information materials
such as counseling aids for sero-discordant couples, positive children, and MARPs.
Continuing Activity: 14159
14159 6153.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $325,500
10828 6153.07 U.S. Agency for Voluntary Health 5604 3949.07 $588,000
6153 6153.06 U.S. Agency for Voluntary Health 3949 3949.06 $707,650
Except for Activity 2, all activities planned in COP 08 will be continued in COP 09. The reason for not
supporting Activity 2 is because BSS is planned once every alternate year and will not be undertaken in
COP 09.
In COP 09, the prime partner will also support the following new activity:
ACTIVITY 4: Establishment of the Strategic Information and Support Unit (SISU)
The Tamil Nadu State AIDS Control Society (TNSACS) has requested APAC to provide technical support
for: a) data mining of past records; b) introduction of data quality assurance at the reporting unit level; c)
collating data of different donors to ensure the Three Ones Principle; and d) build capacity of SACS officials
and in the District AIDS Prevention and Control Units (DAPCUs) on data analysis for evidence based
programming and influencing policy change. This is a recent development and APAC has already initiated
work on this area. The unit will also collect gender specific information (mostly sex disaggregated data),
private sector, linkages and offer strategic information support to TNSACS and other stakeholders in the
state.
The National AIDS Control Organization (NACO) has emphasized the need for evidence-based
interventions. The AIDS Prevention and Control (APAC) project has extensive expertise in this area. In
FY08 APAC will continue to support initiatives to build the capacity of its NGO partners on Management
Information Systems (MIS) and strategic information, and will conduct behavioral and facility assessments.
As the Technical Support Unit (TSU) for the states of Tamil Nadu, Puducherry, and Kerala, APAC will
strengthen the MIS of the State AIDS Control Societies (SACS) and the District AIDS Prevention and
Control Units (DAPCUs) to collect, analyze and effectively use field data for program planning and
monitoring.
provide technical support to the SACS of Tamil Nadu, Puducherry and Kerala by setting up a Technical
Support Unit in Tamil Nadu and Kerala, consisting of a core team of consultants/experts co-located with the
SACS, with a mandate to assist the SACS in scaling-up programs, improving efficiency and quality. APAC
also serves as the vice-chair of the national Technical Working Group on Targeted Interventions.
APAC has extensive experience in establishing systems and conducting assessments that provide strategic
information that helps to guide evidence-based planning for the state of Tamil Nadu and the APAC project.
In its twelve years of experience, APAC has conducted a large number of assessments and studies,
examples of which include: a) eleven rounds of behavioral surveillance surveys (BSS); b) two rounds of STI
prevalence studies; c) two rounds of health care provider assessments; d) condom quality assessments; e)
assessment of public and private sector VCT centers; and f) mapping of MARPs. Most of these
assessments have been used by SACS and NACO for program planning and decision making. APAC
supports the SACS in implementing the UNAIDS "Three Ones Principle" of a unified monitoring and
evaluation (M&E) framework and has played a significant role in the implementation of one M&E system in
Tamil Nadu. APAC has trained SACS officials from other states on strategic information and many of its
systems and procedures have been adopted by SACS and NACO.
ACTIVITY 1: Capacity Building of NGOs on Data Quality Assurance
In FY08, the APAC project will continue to support efforts to build the capacity of sub-partners on MIS,
develop data quality assurance protocols and checklists, and share/disseminate project information to
SACS and other stakeholders as part of its commitment to the "Three Ones Principle". The project will
continue to adopt existing approaches such as participatory site visits, experience-sharing meetings, and
cluster-level meetings to get more detailed information on field activities and to enhance the quality of
information and interventions. Training on data analysis and data use will be provided to NGO staff.
APAC will also continue to support the state's Geographic Information System (GIS), which was developed
using F06 funds, to collect and update information pertaining to health and more specifically HIV/AIDS. The
GIS will help APAC and other policy makers in the state to make better decisions based on evidence.
ACTIVITY 2: Behavioral Surveillance and Other Assessments
APAC will support another round of state level BSS to understand the behavior of MARPs and other
selected populations in the states of Tamil Nadu and Puducherry. In addition, the project will support
assessments such as mapping MARPs, district health facility resource mapping and other assessments that
will provide data to support the project and the state in planning evidence-based interventions.
ACTIVITY 3: Technical Assistance to the State on Strategic Information
APAC will build the SACS' capacity to carry out data quality assurance at the field level and strengthen
institutions that are involved in training NGOs and other agencies on MIS. As a TSU, APAC will strengthen
the MIS of the SACS and DAPCUs for greater coordination of data collation, analysis and use. The project
will strengthen the Strategic Information and Management Unit located within SACS to be able to analyze
Activity Narrative: data more effectively and make program-related decisions. Need-based assessments that help with state-
level planning by assessing the impact of interventions will also be supported. APAC will share examples of
best practices (such as multi-faceted monitoring strategies) in Strategic Information (SI) and monitoring and
evaluation (M&E) with the SACS. APAC also will play a critical role in promoting the implementation of
"Three Ones" Principles by all partners in the states, through establishing donor coordination committees for
SI/M&E.
Continuing Activity: 14161
14161 6156.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $396,000
10831 6156.07 U.S. Agency for Voluntary Health 5604 3949.07 $392,000
6156 6156.06 U.S. Agency for Voluntary Health 3949 3949.06 $794,000
Program Budget Code: 18 - OHSS Health Systems Strengthening
Total Planned Funding for Program Budget Code: $6,835,866
Overview: The ambitious roll-out of the third phase of the National AIDS Control Program (NACP-III) launched in early July 2007,
has increased the demand for USG assistance in India in several technical and cross-cutting areas including health systems
strengthening (HSS). The USG team makes important contributions to strengthening health systems in India by placing advisors
at the national and state level in key technical areas and participating with other donors in program development.
One of the goals of NACP-III is to decentralize HIV/AIDS management and control to the district level. This will be done through
the establishment of District AIDS Control Units (DAPCUs) that will provide managerial and financial oversight of the HIV/AIDS
programs. The State AIDS Control Societies (SACS) will continue to lead the planning, coordination and monitoring of activities in
the states but the DAPCUs will be the nodal agencies for coordinating activities. The goal of NACP-III is that the DAPCUs will, by
2012, be absorbed into the National Rural Health Mission (NRHM), established in 2007 with similar goals to decentralize and
integrate all health programs at the district level. Strengthening the DAPCUs will therefore contribute to stronger overall health
systems at the district level.
The National AIDS Control Organization (NACO) is overhauling its management and financial systems and has appointed a Joint
Secretary and Finance Director to oversee administration and fiduciary management. It has also developed and released
procurement and financial guidelines on its website and will soon be hiring a fulltime procurement specialist. USG is supporting
NACO in strengthening management and financial systems at the state and district level. However, responding to ad hoc
requests from NACO for support has been challenging. What is needed is a clear needs assessment and implementation plan for
future USG support.
Coordination and Other Donor Activities: The World Bank, DFID, USG and other donors reviewed and endorsed NACP-III in
2006. The World Bank and DFID also take the lead in the annual Joint Implementation Reviews of NACP-III, in which USG
participates. UNICEF continues to support PMTCT policy development, and provides advice to the Ministry of Education for in-
school HIV/AIDS programs and to the Department of Women and Child Development for OVC policies and programs. UNDP is
the lead agency for mainstreaming programs, with USG emerging as its key partner for mainstreaming HIV/AIDS with the private
sector. UNIFEM is the nodal agency to mainstream gender across various sectors and the World Food Program (WFP) provides
policy level support for nutrition and HIV/AIDS.
USG is a member of the India Country Coordinating Mechanism (CCM) of the Global Fund, several national Technical Working
Groups, the Technical Panel for the Bill and Melinda Gates Foundation, and the Technical Panel for the Clinton Foundation's
training program for private sector providers and public sector nurses. USG is a key member of the NACO-led Steering
Committee of donor partners, a forum for multilateral and bilateral partners, as well as of the State Project Steering Committees in
the four priority USG states. USG represents the bilateral donors on the India-CCM of the Global Fund and, in partnership with
GTZ, the European Commission and other bilateral donors such as DFID, supports the functioning and capacity-building of the
India CCM Secretariat, specifically including technical assistance for staffing, proposal development, and meetings for the private
sector.
Current USG Support: Technical Support Units (TSU) are a new entity under NACP-III established to give technical support to the
SACS. The TSUs provide technical assistance (TA) to the SACS for managing grants to non-governmental (NGO) and
community-based organizations (CBOs) to implement programs. TA is given in critical areas such as program management,
targeted interventions, capacity building, mainstreaming and public-private partnerships. USG was asked to establish TSUs in
Tamil Nadu, Maharashtra, Goa, Kerala, Puducherry, Uttar Pradesh and Uttarakhand, where USG has a history of program
support. This is the highest number of TSUs supported by any donor. In Andhra Pradesh and Karnataka, USG contributes by
providing assistance for district action plans, policies and guidelines.
USG continues to play an active role in the roll-out of NACP-III in its capacity as a member of the Donor Steering Committee as
well as through various national-level Technical Working Groups. Examples from FY08 include USG membership in the national
committees that facilitated the award of a nation-wide franchise to expand STI services, and the implementation and monitoring
across 13 states of the link-worker scheme piloted by USG. Additionally, USG's work in piloting task shifting through the nurse-
practitioner model at Primary Health Centers in Andhra Pradesh (AP) has facilitated the scale up of Integrated Counseling and
Testing Centers (ICTCs) in the State. USG has also supported the development of state and district-level plans in select states
and districts as part of the decentralization process. In AP, USG supports District Program Managers (DPMs) in 10 districts; these
positions will be absorbed into the future DAPCUs.
Policy and advocacy activities include development of a national policy guiding the role of private sector in HIV/AIDS services
under NACP-III. USG was also responsible for the country's first group insurance scheme from the private sector for positive
persons, which was launched by the Director-General of NACO, and is now being considered for adoption by various state
governments and at the national level. USG continues to advocate for a stronger focus on OVC in national and state programs,
enhanced support for the Greater Involvement of People with AIDS (GIPA), strengthening monitoring and evaluation (M&E) and
data systems, and ensuring that the special needs of women and vulnerable populations are adequately addressed.
USG also provides TA for the implementation of protocols and operational guidelines. USG worked in close association with
UNICEF to mainstream HIV/AIDS activities for infected and affected OVC into activities of the Ministry of Women and Child
Development (MWCD). This was informed by the Policy on Children and HIV/AIDS released jointly by NACO, MWCD and
UNICEF in May 2007, for which USG provided substantial technical support. Additionally, in close association with UNDP, USG
facilitated the compilation of an assessment of public-private-partnerships in HIV/AIDS for NACO. The assessment will help in
determining the current scope and depth of private sector engagement in HIV/AIDS prevention, care and treatment services,
including workplace programs.
At the technical level, USG supports NACP-III by funding 40 key personnel at NACO in the following areas: CT, PMTCT, ART,
care and support services, surveillance and M&E. In addition, the USG provides funding for staff (epidemiologists and M&E
officers) in several states to strengthen the national strategic information system. USG also supports technical specialists at state
level in such areas as workplace interventions, TB-HIV coordination, ART, and behavior change communication. Additional TA
support to NACO in technical areas included designing the methodology for mapping high-risk groups. Other contributions
include development of the state communication strategy for the Karnataka State AIDS Control Society and design of the
communication plan for the nation-wide Red Ribbon Express project, a 12-compartment train that has been traversing India over
the past 10 months.
USG FY09 Focus: In response to NACP-III's emphasis on repositioning donor support for systems strengthening, in FY09 USG
will speed up a transition from direct support for field-level implementation to providing more technical and management
assistance at higher levels to NACO and the SACS. At the India PEPFAR Program Review debrief, the Government of India
articulated the need for a USG role in key areas such as health systems strengthening, management of STI franchising, supply
chain management and human capacity development. There will be a focus on the following:
1. Systems strengthening and building human and technical capacity
i) At national level: USG plans to support the national Technical Support Unit, a new entity intended to build capacity and
strengthen systems of NACO's $2.5 billion NACP-III. USG will support the Team Leader and three key personnel in Human
Capacity Development, M&E and Strategic Program Management. The USG program will also continue to participate in
Technical Working Groups, taking the lead in several areas, including working with the private sector. USG will continue
collaboration with the Lawyers Collective to facilitate the inclusion in the Draft HIV/AIDS Legislative Bill of the recommendations of
the policy guidance on children and HIV/AIDS. USG will continue to provide leadership for in-service human capacity
development programs for professionals including government and NGO personnel through the USG-supported field leadership
training program.
ii) At state level: USG will continue to support the TSUs in Tamil Nadu, Maharashtra, Goa, Kerala, Uttar Pradesh and
Uttarakhand, which will focus on TA for human capacity development and district level integration activities. USG will also provide
technical assistance to SACS in the four USG priority states, particularly in prevention interventions with MARPs, counseling and
testing, Strategic Information (SI), OVC and health systems strengthening.
iii) Building capacity at sub-state level to strengthen a decentralized response: USG will provide technical support to build the
management and technical capacity of DAPCUs with a focus on program management, coordination and SI.
iv) NGO and civil society level: USG will continue to build the institutional capacity of local NGOs and CBOs, including faith-based
organizations, in program and financial management as well as in establishing M&E systems, including routine Data Quality
Assessment. USG will also support the TSUs to build capacity of the SACS' implementing partners to deliver high-quality
prevention and care programs.
2. Mainstreaming programs: USG will continue to support mainstreaming activities through partnerships with government
ministries such as the Ministries of Women and Child Development, Human Resource Development, Rural Development, Youth
and Sports, Social Justice and Welfare, and the National Rural Health Mission to integrate HIV/AIDS issues in their systems at the
national and state level. These activities will complement the support from the lead donor agencies in those areas. As part of the
Mainstreaming Taskforce, USG will assist efforts to mainstream GIPA as well as gender in priority ministries under NACP-III.
3. Strengthening PLHA networks: USG will continue to strengthen PLHA networks and support implementation of the GIPA Plan
(developed in 2007 with USG support). The plan proposes to increase the role of positive persons at the state and district level in
strategic planning, implementation and monitoring, including advocacy to address stigma and discrimination. USG will support TA
to SACS in the USG priority states to incorporate GIPA in state plans, appoint State GIPA Advisors, develop a toolkit for positive
prevention and support national and state level trainings for GIPA. Following the recommendation of the PEPFAR program
review, USG support to the Indian Network of Positive People (INP+) will be reviewed to align with PEPFAR priorities as well as
with those of NACP-III in terms of strategic institutional capacity building.
4. CCM Secretariat: Enhancing the effectiveness of the India Global Fund CCM Secretariat, which has limited resources and
staffing, will continue to be a priority. USG is ready to support strengthened M&E capability for the Secretariat (such as an M&E
officer and/or TA) to consolidate the M&E frameworks of all Global Fund Rounds currently underway, however final agreement on
the specific components of USG support is still under discussion with NACO. In addition, USG will continue to support the human
capacity development of CCM members from civil society. USG will also assist in the development of future high quality proposals
for TB and HIV/AIDS to the Global Fund.
5. Strengthening private sector systems: As a lead donor for mainstreaming activities in the private sector, USG will facilitate and
support NACO in the implementation of the national PPP policy and guidelines. USG provided TA in developing the policy
guidance and in developing operational guidelines for a PPP Trust that will manage all PPP activities under NACP-III. The Trust
will have a menu of options for private sector engagement in key areas of care, support and treatment. USG will also continue to
support models of private sector partnerships that provide cost-effective prevention and treatment services for workers in the
organized and unorganized sectors, linked to government services and through the private medical colleges that offer these
services. USG will also facilitate scaling-up the first group insurance scheme in the private sector for HIV-positive persons. In
FY09, USG will also provide technical assistance for the strategic scale-up of female condoms across India.
Specific Benchmarks/Outcomes:
1. National TSU supported at NACO
2. Development of district action plans in selected districts from USG priority states.
3. Staff specialists provided to support Global Fund CCM.
4. Development of National Policy and Operational plan to mainstream private sector engagement through PPP under NACP-3
5. Communication strategic plan developed for KN SACS.
6. Operational plan for Indian Network of Positive People (INP+) to implement GIPA strategy in USG priority states.
7. National symposium with public and private insurance sector for long-term engagement of sustainable health insurance for
positive people.
Annex: PPP document
Table 3.3.18:
ACTIVITY UNCHANGED FROM FY 2008
The third phase of the National AIDS Control Program (NACP-3) has underscored the need for system
strengthening and developing appropriate policies/guidelines to facilitate the scale up of high quality
HIV/AIDS activities. Several new polices and systems have been developed, such as the policy for orphans
and vulnerable children (OVC), the ART policy, and policies related to decentralized program management.
Other operational guidelines such as guidelines for NGOs on targeted interventions, guidelines for TSUs
are in the process of being finalized with USG playing an important role. National implementation of NACP-
3 is a major challenge for the GOI and will require extensive strengthening of infrastructure, management
systems and staff skills at all levels. In FY08, the AIDS Prevention and Control (APAC) project will support
system strengthening and policy change initiatives, primarily at the State level, but also at the national level
through technical assistance and demonstrating best practices. As the Technical Support Unit (TSU) for the
states of Tamil Nadu and Kerala, APAC will play a critical role in strengthening state systems at various
levels in the public and private sector. In the public sector, the project will support the State AIDS Control
Societies (SACS) and District AIDS Prevention and Control Units (DAPCUs) to strengthen existing program
management systems and develop new systems as required. APAC will support specific initiatives with faith
-based organizations, the Lawyers' Collective, PLHA networks and political leadership to influence policy
change. APAC will also work with a number of associations in the private sector to develop/strengthen their
systems to integrate HIV/AIDS activities into their ongoing programs.
With the establishment of Technical Support Unit under the project, the reach will increase for institutional
capacity building and community mobilization in the three states - Tamil Nadu, Puducherry and Kerala.
Kerala by setting up a Technical Support Unit in Tamil Nadu and Kerala, consisting of a core team of
APAC in its twelve years of experience has played a significant role in influencing decision- makers to
support policy change. It has worked with the state government, the Confederation of Indian Industries (CII),
faith-based organizations and physicians' associations to bring about policy change and strengthen the
organizational systems of these institutions. In FY08, APAC will continue to support these initiatives and
expand to work with newer groups on system strengthening, mainstreaming and promoting policy change.
ACTIVITY 1: Systems Strengthening of State-Level Public and Private Sector Agencies
The APAC project has been identified by NACO as the TSU for the SACS of Tamil Nadu, Puducherry and
Kerala. The primary objective of the TSU is to strengthen State systems to manage HIV/AID and build the
capacity of SACS in various areas. As the TSU, APAC will support a unit of 6-8 consultants/advisors, co-
located with the SACS in Tamil Nadu and Kerala. The team will assist the SACS in identifying and
organizing the technical expertise available in the state to strengthen the State's to respond to a well
designed, evidence-based technical assistance (TA) plan. Areas for TA from the TSU include strategic
planning, project management (including the selection, management and monitoring of NGOs), monitoring
and evaluation, capacity building, training, human resource planning and management, increased private
sector engagement, and mainstreaming. The TSU will also assist the SACS in developing systems to
support planning and implementation of HIV/AIDS activities implemented by the new DAPCUs., who will
play a critical role in coordinating and monitoring district-level HIV/AIDS activities.
The TSU will also assist in system development and building the capacity of other agencies such as
industry associations, associations of trucking companies, and physicians' associations to develop and
implement workplace policies and increase their engagement in HIV/AIDS activities.
ACTIVITY 2: Supporting Faith-Based Organizations to Develop and Implement HIV/AIDS Policies
APAC has initiated advocacy programs among the 17 dioceses of the Tamil Nadu Bishops' Council (TNBC)
and provided training for bishops and religious sisters in implementing the HIV/AIDS policy developed by
Catholic Bishops' Conference of India (with USG assistance). In FY08, the project will continue its support
to TNBC to strengthen the implementation of their HIV/AIDS policy in their educational, health and religious
institutions. In FY08, APAC will support Hindu and Muslim religious institutions to develop and implement
HIV/AIDS policies that support HIV/AIDS programs. In high-prevalence districts, committed religious leaders
will be identified and their capacity built to promote HIV/AIDS prevention messages and support for
individuals infected and affected by HIV/AIDS. APAC will also support one regional experience-sharing
workshop for showcasing and cross-learning about faith/spiritual initiatives.
ACTIVITY 3: Promoting the Rights of Women PLHA through Capacity Building and Systems Strengthening
of Legal Support Institutions
Women are more vulnerable to HIV/AIDS, exploitation, and in many cases their legal rights have been
compromised. Instances of women PLHA being denied property and basic rights have been reported across
the country. In the high-prevalence districts of Tamil Nadu, the APAC project will support a women's
Activity Narrative: lawyers' collective to advocate for and support the rights of women (particularly of marginalized, infected
and affected women). In these districts, through the lawyers collective, a panel of women lawyers will be
trained and supported to take up issues related to the rights of women PLHA. Linkages between NGOs,
CBOs, PLHA networks, and the women's lawyers' collective will also be established.
ACTIVITY 4: Systems Strengthening of District PLHA Networks
In FY06, APAC supported the Indian Network of Positive People (INP+) to build the systems and capacity of
district PLHA networks. SACS and other agencies have also supported PLHA networks to strengthen their
governance and management and technical capacity. In FY08, APAC will support an initiative to assess the
existing gaps in the capacity of PLHA networks. Based on the findings, the project will support one strong
PLHA network to build the systems and capacity of other district networks in areas such as project
management, monitoring and evaluation, human resource planning, and financial management. The
project will also support the PLHA network to advocate with government and other stakeholders to develop
PLHA-friendly policies.
ACTIVITY 5: Training and Advocacy with Legislative Assembly Members
In FY08, APAC will support a public sector institution to work with Legislative Assembly members to
educate them on HIV/AIDS issues and on the need to develop/amend policies that will facilitate the
implementation of robust, evidence-based HIV/AIDS programs and the protection of PLHA rights.
Continuing Activity: 14162
14162 6157.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $481,900
10832 6157.07 U.S. Agency for Voluntary Health 5604 3949.07 $245,000
6157 6157.06 U.S. Agency for Voluntary Health 3949 3949.06 $260,700
Estimated amount of funding that is planned for Human Capacity Development $128,047
