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
CONTINUING ACTIVITY - NEW ACTIVITY NARRATIVE
SUMMARY
Red Ribbon Club (RRC) is an on-campus and voluntary educational intervention among college youth in
Tamil Nadu that started in 2005. It is implemented with the twin objectives of reducing HIV infection among
youth by raising their risk perception and preparing youth as peer educators and agents of change. Each
RRC is made up of 10-50 college student volunteers motivated to some degree to address HIV and other
sexual health issues among their age group and/or community. CDC, in partnership with TNSACS and the
state Ministry of Higher Education, supports this program by placing 30 district-level field officers (one per
40 RRCs), 5 regional managers, and one state-level director under TNSACS with technical support coming
from CDC. TNSACS, via NACO and state funding, provides seed funds to each RRC to help facilitate HIV
prevention and stigma-reduction programs both in the colleges and outside in the nearby communities.
CDC support includes curriculum development, training and monitoring and evaluation of RRC activities. In
FY09 and FY10, there will be efforts to mainstream these activities with the GOI Department of Higher
Education and Department of Youth Affairs.
BACKGROUND
The Tamil Nadu State HIV/AIDS Control Society (TNSACS) is the implementing body for India's National
AIDS Control Organization (NACO) in the southern state of Tamil Nadu, a high HIV-burden state. TNSACS,
which is headed by a senior officer from the Indian Administrative Service (IAS), is the state-level authority
for HIV-related policy formation, activity and partner coordination, and program implementation, as well as
monitoring, reporting, and evaluating on all activities related to the HIV epidemic in the state. In 1991,
TNSACS was the first state HIV agency to be formed in the country and has continued to serve as a model
for other such agencies around the country.
In 2002, HHS/CDC developed a formal relationship with TNSACS and in 2003 began providing fiscal and
technical support. The USG continues to play a strategic role in the operations of TNSACS. The strong
historical and technical relationship between TNSACS and the USG has allowed the USG to leverage the
entire budget of TNSACS (approximately $20 million in FY08) effectively. This relationship is also strategic
as jointly funded projects are likely to be replicated throughout the country since TNSACS is regarded as
the leading state HIV agency in India. The technical support provided to TNSACS by the USG has been
one of the successful models of donor support in the country. The extent, form, and specificity of our
support was discussed with NACO, which resulted in the creation of the new Technical Support Unit in
Tamil Nadu that works directly with the USG advisors based at TNSACS.
ACTIVITIES AND EXPECTED RESULTS
The Red Ribbon Club (RRC) program is an ideal social support platform for youth to understand the myths
and misconceptions about sexual health in the context of HIV and gain skills in decision making for
protecting their health. There are Red Ribbon Clubs (RRCs) in 961 colleges in Tamil Nadu State, with a
volunteer strength of above 57,660, reaching over 150,000 students in various higher educational
institutions (and an undocumented number of out-of-school youth through community programs). RRC
volunteers undergo training using the Celebrating Life curriculum, which is a ten hour package that
addresses socio-cultural influences and vulnerabilities to HIV particular to both young adult men and women
to HIV. In FY08, this program was endorsed by NACO and adopted as a national strategy and adopted in
NACP3. In FY09, plans will be developed to mainstream this program within the Ministry of Education so
that there is a sustained mechanism to address HIV/AIDS in this vulnerable age group.
ACTIVITY 1: Celebrating Life: Curriculum on Sex and Sexuality
The curriculum has been rolled out with urban and rural college youth with supervision by USG-supported
RRC Regional Managers and Field Officers. It includes topics on adolescent vulnerability, HIV/AIDS and
STI, gender-based issues/vulnerabilities, life skills and sexual rights and responsibilities. Nearly 537 three-
hour Primer and 259 ten-hour curricula have been rolled out in 961 colleges from FY06-08 and the program
will continue through FY10, with the addition of 100 more RRCs in Law, Agriculture, Medical and
Paramedical (pre-service) colleges which were not targeted previously.
NACO has endorsed the Celebrating Life curriculum by including it in the NACP3 Operational Guidelines.
USG and TNSACS will provide TA to NACO in the finalization of the guideline by incorporating lessons
learned in the field. Additionally, USG and TNSACS will advocate for mainstreaming the RRC Program and
curriculum within the Department of Higher Education and Department of Youth Affairs. Regional Managers
will help TNSACS train 961 RRC Program officers at district level on the three-hour curriculum and give
them an orientation to RRC. Emphasis will also be on identifying trainers from within colleges for training
college students and peer educators, in order to create college-based ownership of the program.
By ensuring more trainers are available from within colleges, support provided through field officers will be
gradually reduced, which will reflect in the reorganization of the program and the efforts to mainstream it
into the GOI throughout FY09 and FY10.
ACTIVITY 2: Peer Education Training and Convention
In addition to peer leaders' conventions, RRC Regional managers and RRC Field Officers will focus on
strengthening the team of Peer Educators in every RRC. A curriculum will be prepared, piloted, and
implemented for training the peer educators to enable them to organize three to six campaigns in their
colleges every year. Each peer educator will reach 10 to 30 peers through peer education. The peer
educators training will focus on transitioning the program implementation and reporting to the college
students.
ACTIVITY 3: Networking
In order to increase the reach of the HIV/AIDS program to young adults, TNSACS has started interactive
sessions of community people with college youth through RRCs. College youth will interact with: a) PLHA
to orient them on stigma and discrimination issues, b) transgenders to understand the issues faced by
sexual minorities, and c) IDUs to understand HIV transmission through a non-sexual route. ICTC
Activity Narrative: counselors will also visit colleges to encourage counseling and testing.
ACTIVITY 4: Community Outreach by RRCs
In FY09 the RRC District Managers and RRC Regional Managers will reach out to 35,000 RRC members
with the Celebrating Life Curriculum and to 15,000 Peer Educators on skills training. The Peer Educators
will further reach out to 150,000 peers. Peer Educators will also reach out to youth outside the college
campus through village awareness campaigns and programs on radio and TV, and street theater
performances. Community blood donation drives are another way by which RRC staff will reach out to the
community and spread messages of safe blood donation. Collaborations will be made with the National
Service Scheme (NSS) so that peer educators (who may also be NSS volunteers) are allowed to conduct
sessions on HIV/AIDS. This innovative plan will reach out to more than 100,000 NSS volunteers. This will
continue through FY10.
ACTIVITY 5: Monitoring and Evaluation of RRC Programs
Program indicators and reporting formats will be further streamlined and efforts to capture the impact made
by the peer educators. There will also be a focus on establishing a formal reporting system for colleges for
RRC activities (at least on a six monthly basis). Field level staff will be trained to capture these indicators.
USG and TNSACS will continue to advocate for routine HIV risk assessments among 18-23 year olds in
school and out of school through surveys like BSS. A formal evaluation of the impact of RRC training on
sexual risk perceptions, self efficacy to make informed sexual decisions, and behavior change is planned for
FY09.
ACTIVITY 6: Targeted "Pilot" Programs for High Risk Youth
Through the peer educators, youth with high-risk behavior will be identified and referred to counselors in
order to encourage counseling and testing. This will continue through FY10.
New/Continuing Activity: Continuing Activity
Continuing Activity: 14667
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
14667 HHS/Centers for Tamil Nadu AIDS 6902 3958.08 $100,000
Disease Control & Control Society
Prevention
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
* Increasing women's legal rights
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $75,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.02:
The Tamil Nadu State AIDS Control Society (TNSACS) will continue to support an innovative program that
reaches an estimated 5.2 million women through women's self-help groups (SHG), working in partnership
with the Tamil Nadu Women's Development Corporation. The potential of SHG to address health issues is
great, but previously has not been used as a channel for education and behavior change. The USG will
continue to provide guidance for this training program, delivered by the government, which reaches women
with comprehensive SHG messages, including the development of sexual negotiation and communication
skills, and where to seek services for HIV counseling and testing and STI treatment.
for HIV-related policy formation, activity and partner coordination, program implementation, as well as
In 2002, USG developed a formal relationship with TNSACS and in 2003 began providing fiscal and
technical support. The USG continues to play a strategic role in the operations of TNSACS despite
contributing only 3% of the TNSACS budget. The strong historical and technical relationship between
TNSACS and the USG has allowed the USG to leverage the entire budget of TNSACS (approximately $20
million in FY08) effectively. This relationship is also strategic as jointly funded projects are likely to be
replicated throughout the country as TNSACS is regarded as the leading state HIV agency in India. The
technical support provided to TNSACS by the USG has been one of the successful models of donor support
for the country. The extent, form, and specificity of our support was discussed with NACO, which resulted
in the creation of the new Technical Support Unit in Tamil Nadu that works directly with the USG advisors
based at TNSACS.
Self Help Groups (SHGs) have promoted microfinance by rural women for the past twenty years in India. In
the state of Tamil Nadu, population 62 million, and where an estimated 150,000 PLHA live, there is a
voluntary SHG membership of 5.2 million women. SHGs are village-level groups of women aged 18 to 60
years formally organized for economic and social empowerment. Each group has a membership between
12 and 20, and elects its own leader for administration, representation, advocacy and capacity building
called an ‘animator'. The government-owned Tamil Nadu Women's Development Corporation (TNWDC)
coordinates the functioning of all SHGs.
SHG groups meet regularly to discuss fiscal and social issues. This process has had a significant impact
on gender equality issues in Tamil Nadu, with the SHG movement helping women to become financially
independent and socially and politically organized. The potential of SHGs to influence health issues has not
been focused upon, but logically makes sense based on the fact that health outcomes are heavily
influences by social and gender issues. HIV and reproductive health are obvious examples of this.
TNSACS, USG, and TNWDC developed a strategy to reach women in SHG to educate them and mobilize
them on sexual and reproductive health, with an emphasis on HIV. Beginning in FY06, the collaborative
team tapped into the existing government SHG network, and initiated a training process, including use of
pictorial flip books, guided discussions, problem-solving techniques, games, and "homework." Women thus
develop skills to address their sexual health concerns and seek services related to HIV/AIDS and STI. The
main objectives of the intervention are to: develop sexual negotiation and communication skills in women;
increase their knowledge about HIV/AIDS and STI; equip them with information on how and where to seek
care, support, and testing for HIV/AIDS and STI; and promote and increase their intention to be change
agents in the community.
CDC staff and consultants developed the training material, including its overall messages, storyline, and
delivery style. USG funds were used to pilot test the curriculum/materials, print the training materials
(50,000 flipbooks), hire the project manager, and conduct a documentation process. TNSACS provided
resources for training, logistics, and monitoring. The multi-layered training program includes 4 stages;
selection and training of master trainers, selection and training of Panchayat-level trainers, training of
individual SHG animators, and training of SHG members. In the first phase more than 700,000 women were
reached at a cost of less than $1 per women. USG leveraged $520,000 from the government for this
intervention.
To further support the SHG intervention in FY08, TNSACS initiated an external, formal evaluation and
recent baseline results indicate that 30-40% of SHG women believe that STIs are passed through modes
other than sexual contact. Additionally, about 8% of women reported STI symptoms in the past 90 days,
and of 30% of the respondent who reported perceiving themselves at risk for HIV, almost 15% reported
themselves at high or medium risk. Anecdotal reports suggest that many SHGs are taking the training
seriously and are mobilizing the community to respond to sexual rights and gender issues. Male
counterparts in these communities are now asking to be trained as well, and this complementary
intervention will be initiated in FY09. More objectively, preliminary analyses of TNSACS HIV testing data
show a greater than expected increase in HIV testing over the past 6 months in the districts where this
massive program has been completed compared to non-SHG intervention districts.
USG will continue to support this innovative program for the above cited reasons. The recently National
Health and Family Survey (NHFS) data of 2007 found that HIV prevalence in Tamil Nadu (the only state that
showed this) was 1.5 times higher in women than men for unclear reasons. This suggests that women are
a vulnerable population group in Tamil Nadu and must be reached and empowered in effective, holistic, and
Activity Narrative: cost-efficient ways. In FY08, this program was adopted into the NACP-III guidelines and was sanctioned
dedicated funds so that this vulnerable population has a sustained mechanism to address HIV/AIDS,
allowing USG funds in support of this program to be greatly reduced.
ACTIVITY 1: Consultant to Manage the SHG Prevention Intervention
This activity will continue from FY08 and the consultant will continue to manage, monitor and supervise the
SHG Prevention Intervention in coordination with the Tamil Nadu Corporation for Development of Women
(TNCDW). Additionally, this year the SHG consultant will manage the supply and technical revision of
training materials. In the next fiscal year, the consultant will play an active role in monitoring the progress
and relevance of the contracted impact evaluation of the program (TNSACS funded). In the next phase of
the trainings, the consultant will coordinate the four tiered Training of Trainers in 3 high prevalence districts:
Dindigul, Salem and Krishnagiri.
Additionally, in FY09 the consultant will ensure that that three key community outreach activities will occur in
FY09-FY10. These activities are critical in sustaining the program at community level and include the
observance of World AIDS Day; addressing Stigma and Discrimination against those affected/infected with
HIV on Women's Day; and supporting health-seeking behavior (for Integrated Counseling and Testing,
VCT, ART, STI) as a community. It is expected that these activities will reach out to 482,000 women in 3
districts.
ACTIVITY 2: Support for the Implementation and Expansion of SHG Program
In FY08, USG and TNSACS successfully mainstreamed the SHG program and leveraged funds from NACO
for the continuation of the program. As a result, USG funds will no longer be required for this activity and
funding was reduced in this program area. However, USG will continue to support TNSACS in tailoring the
training curriculum to the needs of SHG women, based on the recent baseline results of the SHG
evaluation. Additionally, with FY09 funds TNSACS plans for advocacy activities and by FY10, the
consultant will have developed a sustainability plan involving the relevant government agency, TNCDW, to
support the program from its own budget. The justification for expansion of HIV prevention programs
through SHGs has been further supported by recent data from a baseline study contracted by TNSACS
(with non-USG funds) that suggest that women in SHGs are, indeed, highly vulnerable to STI and HIV. At
least one workshop will be organized across the four high-prevalence southern states for disseminating
models of HIV prevention within the context of SHGs.
ACTIVITY 3: Training Program for Men
As written in FY08, a complementary training program for men (the male community members of the SHG
women) will be conducted in FY09 in the same districts as the women's SHG program. This will be a pilot
activity which will be carried out with TNSACS funding. The trainings address male norms and behaviors in
the context of HIV. The SHG consultant will take the lead in preparing the complementary modular training
program.
Continuing Activity: 14668
14668 HHS/Centers for Tamil Nadu AIDS 6902 3958.08 $40,000
* Reducing violence and coercion
Estimated amount of funding that is planned for Human Capacity Development $10,000
Table 3.3.03:
NEW ACTIVITY NARRATIVE
The recently revised National AIDS Control Organization (NACO) estimates that 2.5 million people in India
are living with HIV; meeting the demand for care and support for these PLHA is a growing concern in India.
To address this issue, TNSACS aims to train Health Care Providers on key aspects of Positive Prevention,
specifically training on the Follow-up Counseling toolkit. The complex physical, psychological and social
vulnerabilities associated with being a PLHA necessitate the integration of other key health care providers
into the counseling infrastructure. This training will be complementary to other PLHA-services-related
trainings conducted by TNSACS (including advanced counseling training on Positive Prevention for all
counselors in the state (at the Integrated Counseling and Testing Centers, the ART Centers and the
Community Care Centers (CCCs), TB screening and referral, OI prophylaxis treatment and referral, and
counseling on nutrition and psychosocial support). This program area will support on-going USG-funded
activities listed under the Counseling and Testing, ART, Prevention of Mother-to-Child Transmission,
TB/HIV, and Health Systems Strengthening.
replicated throughout the country since TNSACS is regarded as the leading state HIV agency in India. The
ACTIVITY 1: Health Care Provider Training on Prevention with Positives/Follow-up Counseling
Although counselors are often the first point of contact with the health care system and play a pivotal role in
linking PLHA to critical services, other health care staff, such as nurses, physicians, and dieticians, play an
important role in the health of a PLHA. TNSACS plans to train about 300 ART center, Link ART center and
CCC staff on the usage of the Prevention with Positives Follow-up Counseling Toolkit, prepared by the
Indian Clinical Epidemiology Network (IndiaCLEN) with financial and technical support from USG. The
toolkit has a standardized curriculum (prepared with USG support to ITECH in FY08) that covers advanced
issues of living with HIV/AIDS—including adherence, disclosure, safer sex, care, prevention, and mental
health issues. This training will last for two days and will provide an orientation on the significance of and
need for Positive Prevention from an epidemiological, biological, and social perspective.
By orienting a cadre of health care providers who have repeated and regular contact with PLHA, USG will
create a top-down (knowledge and referral by health care providers to counselors) and bottom-up (demand
from PLHA to counselor) environment that is supportive for counselors to use the Follow-up Counseling
Toolkit with PLHA and link them to care. Complementary to the currently available HIV counseling
materials, these tools provide practical guidance for counselors to use during client sessions, to which
PLHA will be referred by the other health care staff. However, to maximize the potential of this phase of
counseling, a more comprehensive infrastructure will be developed for counselors. These activities are
highlighted in the Counseling and Testing narrative.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.08:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
ACTIVITY 1: Addition to ART Consultants to TNSACS
TNSACS plans to increase the ART services by expanding its network of ART centers to 35 and creating 68
Link ART centers, which will help in decentralizing the ART services further. During this expansion,
TNSACS will be required to ensure the quality of care delivered through these centers and also ensure that
proper linkages are maintained with Integrated Counseling and Testing Centers, Community Care Centers
and District AIDS Prevention and Control Unit staff.
USG will provide technical expertise to monitor and supervise the ART program. It will also actively support
skills building - both technical and managerial - of the staff involved, through a needs-based approach on a
regular basis. Additionally, it will build the skills of the program staff to analyze their data more effectively to
provide better quality care and support services to the patients.
FY 2008 NARRATIVE
To assist this program, HHS/CDC will support the placement of an ART technical office within the Tamil
Nadu State AIDS Control Society (TNSACS), and two other consultants to support ART. These officers will
be responsible for guiding the implementation of the State's ART program in 26 ART centers, to achieve
TNSACS' target of 14,400 new clients for ART in FY08. The consultants will also be responsible for training
and monitoring and evaluation for the State's ART program.
contributing 3% of the TNSACS budget. The strong historical and technical relationship between TNSACS
and the USG has allowed the USG to leverage the entire budget of TNSACS ($16 million in FY07)
effectively. This relationship is also strategic as jointly funded projects are likely to be replicated throughout
the country as TNSACS is regarded as the leading state HIV agency in India. The technical support
provided to TNSACS by the USG has been one of the successful models of donor support for the country.
The extent, form, and specificity of USG support is now being discussed with NACO in relation to the
creation of the new Technical Support Unit in Tamil Nadu (also to be supported by the USG) and how that
will interact with the USG advisors currently in TNSACS.
ACTIVITY 1: ART Consultants to TNSACS
In FY08, HHS/CDC, in collaboration with TNSACS, will support the placement of one full time ART
consultant and two other consultants supporting ART as part of their broader job responsibilities in
TNSACS. These consultants, who will be located within TNSACS' main office or their southern regional
office, will support the expansion and monitoring of the Tamil Nadu ART program. The strategic plan,
developed by TNSACS and the National HIV/AIDS Control Organization (NACO), calls for establishing 26
ART centers in FY08 (from 19 in FY07). Currently, there are 22,000 patients receiving ART treatment in
TNSACS facilities. TNSACS has a target to newly initiate 14,400 clients on ART in FY08.
These HHS/CDC-supported consultants will be responsible for developing and implementing training for
ART health-care personnel, program monitoring and evaluation, and partner coordination (with the Global
Fund, WHO, NGOs) at the state level.
In collaboration with NACO and USG partners (such as PHMI, I-TECH), TNSACS will also be responsible
for piloting innovative system-level improvements such as accreditation systems, down referral systems,
and public-private partnerships and documenting their feasibility and effectiveness in Tamil Nadu.
HHS/CDC believes that placing ART technical officers within TNSACS is a strategically appropriate activity
which will result in improved efficiency and efficacy as the ART program expands rapidly.
Continuing Activity: 14671
14671 HHS/Centers for Tamil Nadu AIDS 6902 3958.08 $20,000
Health-related Wraparound Programs
* TB
Estimated amount of funding that is planned for Human Capacity Development $20,000
Table 3.3.09:
The Tamil Nadu State HIV/AIDS Control Society (TNSACS) works in collaboration with the Revised
National Tuberculosis Control Program (RNTCP) to provide quality TB/HIV care for co-infected persons.
There are 760 Integrated Counseling and Testing Centers (ICTCs) located in government Primary Health
Centers (PHCs), taluk and district hospitals, each staffed by a laboratory technician and counselor. ICTCs
work with the Designated Microscopy Centers (DMCs) for TB within the hospital premises. In some places
DMCs are adjacent to the ICTC to ensure patients are screened for TB and vice versa. The referral of
patients between the two centers is facilitated by an outreach worker.
ART centers are located in either the district general hospital or the medical college of the district.
Screening for TB is done at the DMC within the hospital and all PLHA are referred for TB screening as part
of the ART workup and during follow-up if they have chest symptoms. With the rapid scale-up of the ART
centers and the increasing number of persons accessing these services, the system needs increased
capacity to meet the needs of additional co-infected patients. Coordination at the field is adequate but
systems need to be improved to ensure all information is used to improve care and support to PLHAs. USG
will support activities in human capacity development and strengthening of the existing systems by
identifying gaps, improving linkages and collaboration, and establishing an information system.
TANSACS is the implementing body for India's National AIDS Control Organization (NACO) in Tamil Nadu,
a high HIV-burden state. TNSACS, which is headed by a senior officer from the Indian Administrative
Service (IAS), is the state-level authority for HIV-related policy formation, activity and partner coordination,
program implementation, as well as monitoring, reporting, and evaluating on all activities related to the HIV
epidemic in the state. In 1991, TNSACS was the first state HIV agency to be formed in the country and has
continued to serve as a model for other such agencies around the country.
technical support. The USG continues to play a strategic role in the operations of TNSACS, contributing
only 3% of the TNSACS budget. The strong historical and technical relationship between TNSACS and the
USG has allowed the USG to leverage the entire budget of TNSACS (approximately $20 million in FY08)
effectively. This relationship is also strategic as jointly funded projects in Tamil Nadu are often models that
are later replicated throughout the country. The technical support provided to TNSACS by USG has been
one of the successful models of donor TA in the country. The extent, form, and specificity of our support
was discussed with NACO, which resulted in the creation of the new Technical Support Unit in Tamil Nadu
that works directly with the USG advisors based at TNSACS.
ACTIVITY 1: Needs Assessment of Health Care Providers and TB/HIV Patients
Focused discussions will be held with health care providers of both the government and private sector
through workshops to identify training and program implementation needs. While both the RNTCP and
ICTCs function to optimal capacity independently, there is an opportunity to improve and streamline the
coordination of the two to ensure adequate linkage for PLHA with TB. At least two workshops will be
conducted with all stakeholders to discuss better convergence between TB and HIV activities.
Whether the needs of TB/HIV patients are met will be explored informally in view of the rapid increase in
health care facilities and services. The findings will enable USG to support TNSACS to improve access to
health services and monitor the quality of the expanded services.
ACTIVITY 2: Capacity Building in TB/HIV in Collaboration with RNTCP
TNSACS, in collaboration with RNTCP, provides TB/HIV training to its health care staff. A two day modular
training for medical officers and one day training for laboratory technicians and counselors at ICTCs, and
nurses and pharmacists at PHCs and government hospitals includes sessions on TB/HIV co-infection and
management. These programs are ongoing due to the rapid turnover of medial officers, laboratory
technicians and counselors in the public health system for which technical assistance is provided. At least
two six-hour orientation programs covering basic TB/HIV knowledge and skills in care according to the
national standards will be conducted for health personnel in the private sector. Technical assistance will be
provided for dissemination workshops to update field staff on ongoing programmatic and technical issues
and changes. These activities will be transitioned to the Technical Support Unit (TSU) of TANSACS.
ACTIVITY 3: Strengthen Linkages between ICTC, ART Centers and the RNTCP
Designated Microscopy Centers (DMC), DOT centers
Patients with TB/HIV co-infection receive ART from the ART center located at the district level once every
month and anti-TB treatment (ATT) from a DOT provider/DOT center close to their homes on an alternate
day basis. Linkage between the ART center and the DOT center is essential to ensure that all persons with
TB/HIV co-infection receive ART and ATT and are monitored to adherence of both treatment regimens.
The program will train staff at both centers and establish a system whereby both treatments are monitored
and follow-up is ensured. Feedback of patients on DOTS at a local site and an ART enter will be made
possible only through well-functioning linkages between the two systems which will be supported by USG in
The General Hospital for Thoracic Medicine (GHTM), Tambaram, in Tamil Nadu has been recognized as a
site for implementation of the DOTS PLUS program of RNTCP. This requires that in-patient care of all TB-
diagnosed patients includes MDR TB and second line treatment regimens. Well functioning mechanisms
are needed to ensure TB/HIV co-infected patients on second line regimens are closely followed up and
monitored.
ACTIVITY 4: Establish a Model TB/HIV Referral and Feedback System
Activity Narrative: GHTM provides HIV diagnosis and care for patients coming from all districts in Tamil Nadu and from the
neighboring state of Andhra Pradesh (AP). While 65% of all patients diagnosed with HIV at GHTM are from
Tamil Nadu, less than 10% live in the vicinity and thus have to be referred for TB treatment to a local DOT
center. Patients are also referred to district ART centers, but many continue to receive ART from GHTM for
a variety of reasons, including familiarity and quality of care. Many pre-ART patients visit GHTM for follow-
up advice and services. Many of such patients from AP are now being referred back to their state for both
ATT and ART, as new ART centers are established.
The TB/HIV Information System (THIS) at GHTM will be strengthened to monitor districts in Tamil Nadu to
ensure all patients detected are referred to ATT at the appropriate DOT center, and that referral to ART
centers are regular (including feedback on adherence monitoring and follow-up of those on pre-ART and
ART at GHTM). The system will also monitor referrals made to Andhra Pradesh, in partnership with the
Andhra Pradesh State AIDS Control Society (APSACS).
ACTIVITY 5: Strengthen and Improve State Level TB/HIV Information System
The TNSACS database is a computerized record system that provides information on patients registered at
the ICTCs and ART centers in the state. Data are routinely collected in the field and compiled and reported
monthly by the counselors. Referrals between RNTCP and ICTC for TB/HIV co-infection are also captured
and reported by THIS. USG will provide technical assistance to TNSACS M&E staff in using the THIS data
for making program-related policy and implementation decisions.
Estimated amount of funding that is planned for Human Capacity Development $14,000
Table 3.3.12:
To address this issue, TNSACS aims to train Counselors (ICTC, VCT, ART) on the Follow-up Counseling
toolkit. The complex physical, psychological and social vulnerabilities associated with being a PLHA
necessitate the integration of other Positive Prevention into the counseling infrastructure. This training will
be complementary to other PLHA-services related trainings conducted by TNSACS (trainings include
advanced counseling training on Positive Prevention for Health Care Providers in the state (ICTC, ART,
CCC staff), TB screening and referral, OI prophylaxis treatment and referral, and counseling on nutrition
and psychosocial support). This program area will support on-going USG-funded activities under HBCS,
CT, PMTCT, TB/HIV, and HSS.
ACTIVITY 1: Counselor Training on Prevention with Positives (PwP)/Follow-up Counseling
Counselors are often the first point of contact with the health care system and play a pivotal role in linking
PLHA to critical care and support services. Since counselors sit at this important intersection of PLHA care
and prevention of secondary infections, TNSACS plans to train approximately 780 counselors across the
state on the usage of the Prevention with Positives Follow up Counseling Toolkit, prepared by the Indian
Clinical Epidemiology Network (IndiaCLEN) with financial and technical support of USG with FY07 funds.
The toolkit has a standardized curriculum (prepared with USG support to ITECH in FY08) that covers
advanced issues of living with HIV/AIDS—including stigma and discrimination, disclosure, safer sex, care,
prevention, and mental health issues. This training will be a 3-5 day training providing skills and tools on
issues specific to PLHA. The significance of Positive Prevention from an epidemiological, biological, and
social perspective is the underlying theme complementary to a training planned for health care providers
(described in the BHCS narratives).
Since ART and CCC counselors will have more frequent and consistent interaction with PLHA clients, the
training may be extended for 2 additional days for this group. The follow-up counseling tools complement
the currently available HIV counseling materials and provide practical guidance to counselors for use during
client sessions. To maximize the potential of this phase of counseling, a more comprehensive network of
linkage will be supported for counselors. These activities are highlighted in the Adult Care and Support
narratives. By focusing on counselors, USG will create a top-down (knowledge and referral by health care
providers to counselors) and bottom-up (demand from PLHA to counselor) environment supportive for
counselors to use the Follow-up Counseling Toolkit with PLHA and better link them to care.
ACTIVITY 2: Technical Workshops for Counselors and Peer Educators
Technical workshops for counselors will enhance the counseling system in Tamil Nadu. TNSACS proposes
twice yearly technical workshops for all counselors to provide an information sharing platform for commonly
asked questions. Currently in the state, districts hold monthly meetings for all counselors that are
administrative in focus. The agenda for the technical workshops will include skills building (refresher) and
discussion of advanced counseling cases using case study methodology. In order for Positive Prevention
concepts to be absorbed and seen by counselors as an effective strategy in reducing the burden of HIV,
advanced counseling issues will be both trained (as in Activity 1) and further analyzed, as outlined above.
CDC will continue to support the appointment of a full-time consultant to manage the Integrated Counseling
and Testing Centers (ICTCs) of the Tamil Nadu State AIDS Control Society (TNSACS). The consultant's
responsibilities cover ensuring that all ICTCs deliver high-quality services in accordance with national
guidelines. This includes monitoring and external quality assurance. In FY08, the consultant will provide
overall supervision for training for nurses, laboratory technicians and health care workers in the private
sector and ensure that all ICTC staff have received refresher training. The consultant will also oversee the
expansion of services for high-risk populations. The results under this program area are the indirect results
of persons reached through systems strengthening for the State program.
contributing 3% of the TNSACS HIV budget. The strong historical and technical relationship between
TNSACS and the USG has allowed the USG to leverage the entire budget of TNSACS ($16 million in FY
'07) effectively. This relationship is also strategic as jointly funded projects are likely to be replicated
throughout the country as TNSACS is regarded as the leading state HIV agency in India. The technical
support provided to TNSACS by the USG has been one of the successful models of donor support for the
country. The extent, form, and specificity of our support is now being discussed with NACO in relation to
the creation of the new Technical Support Unit in Tamil Nadu (also to be supported by USG) and how that
The state currently has 718 functioning counseling and testing (CT) centers. TNSACS will expand
Activity Narrative: counseling and testing sites and numbers during FY08 by mainstreaming CT at the existing 24 hour
government primary health care units. TNSACS will expand CT to 780 more centers during this year and
plans to conduct 885,000 tests during the year. NACO has set a target of 1.6 million tests (including
PMTCT) for Tamil Nadu for FY08-09.
ACTIVITY 1: Standardization of CT in TNSACS Centers
The consultant will facilitate the adoption of national guidelines by the state and ensure they are available in
all centers for standardization of CT. Further the consultant will ensure follow-up counseling modules are
made available to all centers and that all staff in the new CT centers are trained in FY08. He will ensure
refresher training is organized for all staff from the existing centers and will coordinate with the SACS district
level program units for monitoring the centers and for supply of materials.
ACTIVITY 2: Training for Laboratory Technicians, Nurses and Private Sector Staff
In FY08, TNSACS will coordinate the training of 780 laboratory technicians from the expanded facilities in
testing and train 780 nurses in HIV CT using the counseling module prepared by NACO. The nursing staff
will undergo a two week course and technicians will have a one week course in testing and quality
assurance. The course will be organized in batches of 25 with a target to have all staff in the new centers
complete the course. TNSACS will also coordinate and implement the training of 200 private sector health
care workers in HIV CT. The training for counselors will include: basic counseling, testing guidelines, rapid
HIV testing techniques, recording, reporting and the use of follow up counseling modules developed by
HHS/CDC. The laboratory technician's course will cover testing, quality assurance, recording, reporting and
logistics. The existing 1500 (800 counselors and 700 technicians) staff will undergo technical skills refresher
courses during FY08. In FY08, HIV counseling and testing will be provided to an estimated 885,000 non-
ANC clients in Tamil Nadu. This is an indirect result from systems strengthening.
ACTIVITY 3: Monitoring and Supervision
District level officers appointed by TNSACS and coordinated by the HHS/CDC-supported consultant will
monitor all HIV counseling and testing centers. The officer will visit the centers based on need to provide
supervision and technical input and feedback. District level counseling review meetings will be organized
every month by district project managers in the presence of the Joint Director of Health to discuss issues
and solve field problems. Each center will enter their performance data through the web-based monitoring
system and the data will be analyzed at TNSACS and at the district level for management decisions.
ACTIVITY 4: External Quality Assurance
TNSACS, with CDC, will ensure external quality assurance (EQUAS) practice as required by NACO is
complied with by all centers by linking these new centers with the regional reference centers that are linked
to 14 medical colleges in the state. The reference centers will be responsible for training, updating and
mentoring the staff of the new centers in EQUAS
ACTIVITY 5: Expansion of CT to High-Risk Populations
TNSACS, in collaboration with CDC, will support the expansion of HIV CT to high-risk populations (migrant
laborers, commercial sex-workers and clients, prison inmates). The consultant will guide the expansion
which will focus on mobile testing facilities as called for in the recently released strategy of the third phase
of the National AIDS Control Plan. These high-risk populations have traditionally had limited access to HIV
counseling and testing services designed to meet their unique needs, for example with extended hours of
operation, and staff trained to meet the needs of high-risk clients.
Continuing Activity: 14670
14670 HHS/Centers for Tamil Nadu AIDS 6902 3958.08 $15,000
Estimated amount of funding that is planned for Human Capacity Development $15,000
Table 3.3.14:
ACTIVITES AND EXPECTED RESULTS
While USG support to the Government Hospital of Thoracic Medicine, Tambara (GHTM) laboratory
continues, it is important to note that the total number of tests performed at the GHTM laboratory will
continue to come down or remain constant (normally one would expect the test load to increase as patients
on treatment will require regular monitoring), as the hospital is expected to make efforts to transfer patients
to the ART centers nearer to their residence (including new ones being established both in Tamil Nadu and
Andhra Pradesh).
ACTIVITY 1: Support for GHTM Laboratory Services
USG, in collaboration with TNSACS, has supported the development and operation of state of the art
laboratory services at GHTM since 2001. In FY08, a new Lab Manager was appointed to oversee this
laboratory.
In FY09, the Lab Manager will update all Standards of Practice in the lab and help prepare a Quality
Assurance manual. He will also plan and implement basic and refresher trainings of the lab staff, update
their position descriptions and conduct their annual performance assessments. He will develop
teaching/demonstration tools for training on key lab tests. He will play a crucial role in strengthening the
diagnosis of opportunistic infections like cryptococcus meningitis by using newer diagnostics, for which
funds will be leveraged through non-PEPFAR related projects. He will also prepare the lab for earning
International Accreditation like NABL (National Accreditation Board for Testing and Calibration
Laboratories). This will ensure that the lab meets international QA standards. These activities will continue
through FY10.
To create greater ownership by TNSACS of the activities in GHTM Lab, lab consumables previously
procured through USG support will now be fully funded from the Government of India (GOI) budget. In
FY09 and FY10, efforts will be made to leverage funds from the GOI to support the annual maintenance of
the USG procured equipment. This is reflected in reduced funding for laboratory infrastructure in the
COP09 budget.
ACTIVITY 2: Establishing Capacity for TB Diagnostic Culture at GHTM
GHTM is now considered by the National TB Program (RNTCP) as a pilot site for the evaluation and
demonstration of the HAIN'S test for the diagnosis of MDR TB. As a result, GHTM will receive equipment
and lab consumables for the study period of two years. Therefore, financial assistance from USG for TB
diagnostic culture will be greatly reduced, which is reflected in reduced funding in FY09 under this program
activity. Evidence will be generated from the pilot study for incorporating it as routine test in the state run
laboratory - thereby leveraging funds from the state government for conducting and sustaining these tests.
ACTIVITY 3: Development of Laboratory Accreditation Processes
These will be developed for private sector labs that participate in the state's HIV/AIDS program. An
accreditation plan will be developed and used to advocate for a mandatory accreditation policy for all private
laboratories participating in the national HIV/AIDS program. This will continue through FY10.
The USG supported Lab Manager, with the support of the National Reference Laboratories, will help in
enhancing the capacity of the State Reference Laboratories and ICTCs on proficiency testing and on an
External Quality Assessment System (EQAS) for HIV testing and monitoring. This will also help in
preparing the state owned labs for the accreditation process.
Since 2004 HHS/CDC, in collaboration with the Tamil Nadu AIDS Control Society (TNSACS), has
supported the development and operations of state of the art laboratory services at the Government
Hospital of Thoracic Medicine, Tambaram (GHTM). In FY08, this will include support for a senior laboratory
manager to oversee laboratory services and five laboratory technicians. USG will also expand GHTM's
laboratory capacity to include TB/HIV diagnostic culture. A third activity will be to support a consultant within
TNSACS to expand an accreditation process for laboratories in Tamil Nadu state, particularly targeted at
the private and NGO sectors.
The Tamil Nadu State AIDS Control Society (TNSACS) is the implementing body for India's National AIDS
Control Organization (NACO) in the southern state of Tamil Nadu, a high HIV-burden state. TNSACS,
In 2002, CDC developed a formal relationship with TNSACS and in 2003 began providing fiscal and
The extent, form, and specificity of our support is now being discussed with NACO in relation to the creation
of the new Technical Support Unit in Tamil Nadu (also to be supported by USG) and how that will interact
with the USG advisors currently in TNSACS.
Activity Narrative: ACTIVITIES AND EXPECTED RESULTS
Since 2004 USG/CDC, in collaboration with TNSACS, has supported the development and operations of
state of the art laboratory services at the Government Hospital of Thoracic Medicine, Tambaram (GHTM).
The support is particularly strategic as GHTM is the largest HIV care and treatment center in India, currently
caring for over 30,000 HIV-infected patients annually, 6600 of whom are receiving ART. GHTM, with CDC
support has developed into a national HIV training center of excellence. Each year, GHTM performs 25,000
HIV tests, 20,000 CD4 tests, and 150,000 AFB smears to diagnose TB, as well as basic chemistries and
hematology tests for HIV-infected patients. Previous HHS/CDC support has included procurement of
diagnostic equipment, reagents, renovating laboratory space, regular technical assistance, and the
placement of laboratory technicians. As a result, GHTM is recognized as one of the most comprehensive
and high quality laboratory in India.
In FY08, CDC, in collaboration with TNSACS, will support a senior laboratory manager to oversee
laboratory services at GHTM. This laboratory manager will be responsible for quality assurance/quality
control (QA/QC) of GHTM lab services, ensuring timely generation of test results, record keeping and
reporting, expanding services, and lab staff management. This senior manager will also assist developing a
QA/QC training program for private sector laboratories involved in HIV diagnosis, care, and treatment. S/He
will report directly to TNSACS with direct technical assistance from HHS/CDC.
HHS/CDC will also support TNSACS in the placement of five laboratory technicians to assist with the high
volume of lab tests at GHTM. To ensure sustainability, TNSACS will assume an increasing proportion of
lab costs at GHTM (i.e. reagents) in FY08 with an agreement to assume total costs (i.e. personnel) in
subsequent years.
In FY08, CDC, in collaboration with TNSACS, will support the implementation of TB diagnostic culture
capacity at GHTM. As stated previously, GHTM cares for over 30,000 HIV-infected patients each year with
TB being their most common cause of morbidity and mortality. GHTM, which was established originally as
a TB sanatorium, is a certified TB DOTS treatment center, diagnosing and/or treating over 63,000 cases of
TB among HIV-infected clients from 2002 to 2006. The availability of TB culture will allow GHTM to provide
a more rapid and accurate diagnosis of smear AFB negative and extra-pulmonary TB, which are common
among HIV-infective patients with TB disease. The availability of TB diagnostic culture capacity will also
allow for diagnoses of treatment-resistant forms of TB. HHS/CDC and TNSACS will procure the TB culture
equipment with TNSACS assuming the annual costs of the reagents and maintenance.
USG has recently begun developing laboratory accreditation processes in the private/NGO sector in Tamil
Nadu. The objective of this process is to ensure high quality and accurate HIV laboratory services in the
private sector. Private facilities receiving this accreditation will be eligible to receive HIV diagnostic and
treatment support from the Government of India at a reduced price which will be passed on the patient.
Initial findings from this program have been promising with 25 private, high-volume HIV testing centers
enrolling themselves in late FY07.
In FY08, HHS/CDC will support a consultant within TNSACS to develop and expand this accreditation
system in Tamil Nadu. Specific activities of this consultant will include developing a transparent and
standardized HIV lab accreditation and certification system, private laboratory assessments, program
monitoring and evaluation, and training TNSACS staff to expand this program.
Continuing Activity: 14672
14672 HHS/Centers for Tamil Nadu AIDS 6902 3958.08 $60,000
Estimated amount of funding that is planned for Human Capacity Development $40,000
Program Budget Code: 17 - HVSI Strategic Information
Total Planned Funding for Program Budget Code: $3,355,696
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
Overview: Strategic information (SI) includes monitoring and evaluation (M&E), surveillance, research, and management
information systems. SI is the cornerstone for reliable evidence-based planning and assessing program impact. The National
AIDS Control Organization (NACO) has given the highest importance to this previously ignored area by including it as one of the
four objectives of the third National AIDS Control Program (NACP-III).
The vision of NACP-III is to go beyond M&E to Strategic Information Management. A central theme in the plan is to decentralize
data collection and data use to the state and district level. With this in mind, NACP III has developed operational guidelines to
establish Strategic Information Management Units (SIMU) at the national and state level, which will bring together M&E,
surveillance, and operational research under one roof. The national SIMU will provide oversight to and coordinate with the state
level on SI activities. The state SIMUs will in turn support the District AIDS Prevention and Control Units (DAPCUs) for functions
ranging across research, monitoring, surveillance, and program evaluation.
The national computerized management information system (CMIS), also to be supported by the national SIMU, was started in
the 1990s to generate monthly and annual reports from service delivery information collected at state and district levels. The
national SIMU will revamp the existing CMIS to facilitate tracking Global Fund inputs; it will also capture PLHA data from smart
cards and will interface with other financial and contractual data systems. With over 8,500 primary reporting units, it provides a
relatively comprehensive and representative picture of the state of the epidemic in India. Core indicators with definitional and data
source clarifications have been developed by NACO, infrastructural improvements have been effected through upgrading
computers and net-connectivity, state epidemiologists and M&E officers have been hired, and training and capacity-building plans
for these officers are underway to encourage decentralized data collection and use. A quarterly news bulletin, outlining latest data
and trends is published and disseminated for public use.
NACO continues to improve and expand the HIV surveillance system. To track the epidemic, it uses HIV sero-surveillance for
different populations in 1,122 sentinel sites, a periodic national behavioral surveillance survey in a sample of general and high-risk
populations, AIDS case reporting from all states, and surveillance for STIs from more than 900 facilities across the country,. The
number of sentinel surveillance sites increased from 320 sites in 2001 to 1134 in 2007 (these include 646 antenatal clinic (ANC)
sites, 137 female sex worker (FSW) sites, 248 STI clinic sites, 52 IDU and 40 MSM sites). Each district now has at least one
sentinel site. The data have helped classify India's 611 districts into 4 epidemic categories: A,B,C and D, with priority given to the
A districts, which have a prevalence of over 1% in ANC attendees.
The Government of India (GOI) with help from developmental partners including USG, recently held a consultation to discuss the
weaknesses and limitations of the surveillance system: such as: insufficient coverage of sites in states, inadequate sample sizes,
under-reporting of AIDS and STI cases, and lack of analyses of data. The national M&E working group, consisting of M&E experts
from all development partners including USG, will take a leading role in addressing the recommendations from the consultation.
India revised its HIV prevalence estimates last year using the results from the National Family Health Survey 3 (NFHS-3). This
survey, conducted with USG support, included HIV biologic and behavioral indicators for the general population. This was further
complemented by an Integrated Biological and Behavioral Survey (IBBS) of female sex workers, MSM and long distance truck
drivers funded by the Bill and Melinda Gates Foundation (BMGF) for their focus districts. Triangulation of this data resulted in a
revised national HIV-prevalence estimate, from 0.91% to 0.36%, with the estimated number of HIV-positive people revised from
5.2 million to 2.47 million. USG played an important role by providing technical expertise in analysis and interpretation of the new
data.
Challenges: Some underlying challenges still remain. Data is still largely public-sector oriented, since data from the majority of the
private sector still do not flow into the CMIS. There is a shortage of staff and infrastructure for managing SIMUs at state level.
While the completeness and accuracy of CMIS is improving, utilization of generated data remains low and the capacity to utilize SI
varies across states and is largely lacking. The Joint Implementation Review of the national program (conducted every 6 months,
with the World Bank, DFID, USG, BMGF and other donors participating) pointed out the need to have more inclusive reporting
units, and the need for the Global Fund, BMGF and bilateral programs to feed into the national CMIS. Data quality was also an
issue in both reviews.
Other Donor Support: The GFATM, World Bank, DFID, BMGF and Clinton Foundation are some of the major contributors to the
$2.5 billion NACP III. USG contributes 6% of the total value of the plan. Provision of technical assistance (TA) to the government
is however, largely limited to BMGF and the USG. BMGF and USG have jointly supported many SI staff at the national and state
level and undertaken capacity-building efforts. The two organizations may also support the planned National Technical Support
Unit (NTSU). The NTSU will have an SI officer, responsible for working with the national SIMU to coordinate SI on HIV/AIDS
nation-wide. The Clinton Foundation has developed a pediatric care and treatment reporting system and the national government
is looking at its integration into the CMIS. As noted above, the USG was a key partner in leveraging donor support and providing
TA for NFHS-3, the first population-based HIV prevalence survey in India.
Current USG Support: USG has been identified as a technical resource for the national government in spearheading its SI
initiatives. The USG is rapidly gaining credibility for building capacity at all levels in strengthening data collection, M&E, and
management information systems. USG was a major contributor to the surveillance consultation of April 2008 and provided many
suggestions to strengthen the surveillance systems. USG was a lead participant in the National M&E Working Group to develop
national level program indicators and significantly contributed to developing the operational manual for strategic information
management, for use by multi-level SI units. USG has provided intensive TA and resources to develop the management
information system (MIS) at the General Hospital for Thoracic Medicine, Tamil Nadu. Many USG partners train and build the
capacity of SACS M&E staff, either through consultant support or directly. USG has organized training in triangulation, data
analysis and use for state M&E officers and epidemiologists.
At the state level, USG has helped the Tamil Nadu State AIDS Control Society (TNSACS) to form a state-level M&E Working
Group that allowed major donors to agree to a common set of indicators for joint tracking. USG has also helped initiate
Geographic Information System mapping in TN and in FY09 will convene a similar GIS Working Group in Maharashtra for
collating and presenting data in user-friendly form. USG also carried out extensive mapping of private health care facilities and
providers in TN and continues to provide day to day support for testing new initiatives and program ideas.
At the PEPFAR/India level, several activities were undertaken in 2008 to strengthen evidence-based planning and M&E. 1) A
training on SI was organized for all PEPFAR partners who came together for the first time to discuss indicators, the reporting
framework, performance management plans and problematic indicators. There are varying capacities among partners and
partnerships have been forged among them to help them tap into existing resources and expertise. 2) The PEPFAR team
conducted a structured, field-based program review, which made recommendations to improve implementation and performance.
In FY09, the PEPFAR/India Technical Working Groups will work towards completing these deliverables. The Department of
Defense separately undertook a visioning exercise and plans to take action on recommendations. 3) USG/India also conducted a
portfolio review of its current prime partners, especially those poised to receive 2009 funding. SI areas identified for further action
were: gauging SI needs for different states and working with national and state governments to respond to clear and present
gaps, encouraging scientific exchanges among partners and other developmental partners, data analysis of demonstration
projects, measuring the impact of media campaigns, disseminating good and better practices, carrying out a DQA of partners, and
the need for M&E strengthening plans for partners.
USG FY 09 Support:
Capacity building at National Level: USG will carry out a strategic planning exercise with NACO, conducting a needs assessment
and developing a plan for specific activities and timelines. The areas for potential TA are: 1) follow-up on triangulation workshops
held in FY08 for data triangulation, analysis and use for state M&E officers and epidemiologists; 2) support to the national M&E
Working Group to operationalize the recommendations, including improving data quality; 3) M&E support for developing a
laboratory-specific results framework; 4) short-term TA on HIV prevalence estimates and projections and trend analysis; 5) TA for
sentinel surveillance through improvements in sampling methods and analysis; 6) feasibility assessment for a biological and
behavioral surveillance in place of the national BSS; and 7) assistance in incidence analysis. USG will also support the national
TSU to strengthen their capacity to provide technical support to the state level TSUs, which will have dedicated SI personnel.
USG will continue to be involved in strengthening the Global Fund CCM Secretariat's M&E capacity, and provide support for the
agreement to use the national monitoring system to report Global Fund results. USG will also continue to explore partnership
opportunities with the National Institute of Health's US-India Bilateral Collaboration Research Partnership, which commits
significant extramural funds for HIV/AIDS research in India.
Capacity Building for SACS and DAPCUs: USG will assist the SACS to collect, analyze, interpret and use surveillance and
programmatic information by supporting training in M&E of the SACS staff, the DAPCU and other district level staff, and the staff
of the six USG-supported TSUs, who will be mentored to take a guiding role in M&E for those states. USG plans to identify the
decision-makers and data handlers at the district level and enhance their capacities to use data effectively in planning,
implementing, monitoring, and evaluating health programs. USG partners will provide TA in establishing MIS capacities as per
NACO guidelines in the states of Karnataka and Maharashtra under Community Care Centers supported under Global Fund
Round 6.
USG will continue to provide crucial provisional staff support at the national and state level, including epidemiologists, M&E
officers, and program officers
Strengthening state-level reporting: USG has been recognized as a leading expert in the areas of Health MIS and Human
Resource Information Systems. In Maharashtra, Tamil Nadu, Andhra Pradesh and Karnataka, many USG partners are helping to
strengthen or establish a system of decentralized, district level data management and use. In Karnataka, USG has piloted a web-
based MIS at district level that directly links field information with the CMIS. USG will also explore strengthening SI systems in the
North-Eastern states where SI capacity is lacking. In some focus states USG is helping to convene a state-level M&E group that
will regulate harmonized reporting from all partners
Evidence-based planning: Data quality assessments will be conducted for local and state-level partners. Detailed training reviews
are planned to improve training and mentoring methodologies. USG partners will also convene meetings to facilitate exchange of
innovative methodologies and best practices. A USG partner will assist NACO and SACS to collect data for prioritizing industrial
sectors that have at-risk workers. Another partner will provide TA to establish standard data collection methods and capacity
building plans for implementing PMTCT with private sector partners. Insurance plans for PLHAs, funded by USG, will be
evaluated to study the feasibility of extending this to all PLHAs in the country. USG plans to work with positive networks to
strengthen their reporting and data management.
Program assessments: USG plans to support formative assessments and qualitative research at the project/partner level to
assess outcomes and guide future programming. Assessments of the private sector PMTCT models, the link workers scheme
recently piloted by USG and adopted by NACO, the factors influencing the vulnerability of children to HIV, the free and social
marketing program in Maharashtra and Goa, and factors affecting health-seeking behavior among high-risk groups will be
conducted. The integrated Behavior Change Communication (BCC) program focused on increasing condom usage in high-risk
areas and the female condom program will be evaluated, while a partner will carry out operations research on Condom Lubricant
Quality.
Strengthening PEPFAR M&E systems: Alignment with national systems: To support the Three Ones, USG will explore
harmonizing the PEPFAR program-level indicators and results framework with the NACO dashboard indicators to minimize
duplication of efforts. PEPFAR partners: USG will train its partners and sub-partners in the collection, collation, management and
reporting of field-level data and will conduct a data quality assessment of partners' data systems to validate protocols for data
reporting. Recommendations from the assessment will be implemented to strengthen partner data quality and reporting systems.
In-house staff: USG will strengthen the skills of new and current SI staff and in-country professionals on the three SI pillars (M&E,
surveillance, and HMIS), through training and technical assistance from other PEPFAR countries.
Table 3.3.17:
USG will continue to support a Strategic Information (SI)/Monitoring and Evaluation (M&E) officer within
TNSACS to oversee and coordinate timely and high quality data collection, analysis, and reporting. USG will
also provide assistance to the TB/HIV Information System (T/HIS) at the General Hospital of Thoracic
Medicine, Tambaram (GHTM).
ACTIVITY 1: Strengthening TNSACS Management Information System (MIS)
While USG will continue to support an M&E Consultant who manages the MIS in TNSACS, efforts will be
more focused on building the capacity of the newly functional/recruited program divisional staff in TNSACS
so that they can monitor data collection and analysis and provide timely feedback to the field staff. The
M&E consultant will also continue to build the capacity of the 112 NGOs working in prevention and care
programs funded by TNSACS. The consultant will carry out refresher training on SI for the relevant staff
(approximately 1100) at Integrated Counseling and Testing Centers, ART centers, Community Care
Centers, blood banks, and NGOs. The consultant will further build the capacity of the newly recruited
regular M&E staff so that they can assume some of his responsibilities by FY10.
Additionally, the USG will provide support to the consultant in further refining the annual sentinel
surveillance process in Tamil Nadu and will help in addressing more at-risk populations. This activity will
continue through FY10. There will be a greater focus on the analysis of existing data to create a scientific
body of evidence to assist in program planning.
ACTIVITY 2: Capacity Building for District AIDS Prevention and Control Units (DAPCUs)
As the DAPCUs are established, USG will provide technical assistance to build the SI capacity of these
teams in collaboration with TNSACS and APAC. Additionally, USG will work closely with TNSACS to build
the SI capacity of the District Health Officers, who will be required to oversee the HIV/AIDS programs in
their districts.
ACTIVITY 3: Support to GHTM, Tambaram
While some of the recurring infrastructural support costs in maintaining the TB/HIV Information System
(T/HIS) will be taken over by the hospital, USG will continue to support the basic operation of T/HIS by
placing data-entry and supervisory personnel at GHTM in FY09. However, USG/TNSACS will initiate a
mainstreaming plan with the Director of Medical Education and the District Collector of Kancheepuram (two
other state government bodies) in order to transfer these costs to the government in FY10. USG technical
focus will remain on the analysis of existing data to create a scientific body of evidence to assist in program
planning.
USG will support the placement of a Strategic Information (SI)/Monitoring and Evaluation (M&E) officer
within the Tamil Nadu State AIDS Control Society (TNSACS) to oversee and coordinate timely and high
quality data collection, data analysis, and data reporting. The consultant will be responsible for oversight of
the state Management Information System (MIS) and for supervising the state surveillance system. USG
will also support capacity-building for the District AIDS Prevention and Control Units (DAPCUs), including
training in SI/M&E. Assistance will also continue to support the TB/HIV Information System at the General
Hospital for Thoracic Medicine, Tambaram, Chennai (GHTM).
and the USG has allowed the USG to leverage the entire budget of TNSACS ($16 million in FY '07)
In FY08, CDC will support TNSACS' management information system (MIS). This web-based MIS regularly
collects standardized data from 1187 government and non-government supported sites. These include
blood banks, HIV care and support centers, STD treatment centers, PMTCT clinics, integrated HIV
counseling and testing centers (ICTCs), and targeted intervention (TI) sites. CDC will support the
placement of a SI/M&E officer within TNSACS to oversee and coordinate timely and high quality data
collection, data analysis, and data reporting. These data, via the MIS, are then reported to the National
AIDS Control Organization (NACO). CDC will also provide technical support to this officer and considers
Activity Narrative: the placement of this officer a strategic activity to leverage support for larger activities that will be supported
by TNSACS itself.
This state-level consultant will continue to be responsible for managing the annual sentinel surveillance
process in Tamil Nadu, including the analysis of the data and writing of a state surveillance report published
each year. In FY08, this consultant will advocate for ways to strengthen the sentinel surveillance system
especially the component that addresses most at-risk populations.
Funding and technical support will be provided to support capacity building of the DAPCUs, units that are to
be funded under Phase 3 of the National AIDS Control Program (NACP-3). The objective of capacitating
the DAPCUs is to decentralize program implementation and management down to the district level
(population: 2-2.5 million per district). Currently, Tamil Nadu has recruited and trained DAPCU staff at one
level, the District Program Managers (DPMs). As the DAPCU concept materializes, an additional 1-4 staff
will be hired under the DPM. DPMs have been placed in all 30 districts to supervise and strengthen HIV
prevention, care, and treatment services in those districts. Specific activities of the DAPCU will include; 1)
ICTC supervision; 2) field-level staff training and mentoring; 3) technical support to district government
officials in charge of health and social programming; 4) establishment of linkage systems between
prevention programs, ICTCs, and the ART center; 5) coordination of all district level partners and activities;
6) technical inputs into communication and condom social marketing campaigns; and 7) monitoring and
evaluation of all district-level HIV services.
CDC will play a technical role in training DAPCU staff on basic public health principles, field management
skills, HIV prevention strategies, HIV care and treatment operational guidelines, and monitoring and
evaluation skills. The exact training calendar will be determined in collaboration with TNSACS, APAC (as
the technical support unit for Tamil Nadu), and other technical agencies working in Tamil Nadu. This
activity will be undertaken with a USG partner, Public Health Management Institute (PHMI), located in
Hyderabad, Andhra Pradesh.
ACTIVITY 3: Support to the Government Hospital for Thoracic Medicine, Tambaram (GHTM)
In FY08 CDC, in collaboration with TNSACS, will provide technical, human, and financial support to the
TB/HIV Information System (T/HIS) at the Government Hospital for Thoracic Medicine, Tambaram (GHTM),
India's largest HIV care hospital. T/HIS is a comprehensive electronic database that holds longitudinal
patient records of over 370,000 (10 million patient interactions) patients at GHTM. The development and
implementation of T/HIS has been supported by CDC and TNSACS for the past five years (software
development, hardware (computers, printers, local area network), and personnel).
In FY08, CDC and TNSACS, will support basic maintenance of T/HIS by placing data-entry and supervisory
personnel at GHTM. These personnel will be responsible for entering accurate patient data into T/HIS,
network administration, and timely reporting to GHTM, and to TNSACS. Support will also be provided for
hardware upgrades, paper for patient records, network connectivity, and basic system upkeep (cleaning,
uninterrupted power). Technical support will be provided by CDC in the areas of data quality assurance and
data analysis. CDC will continue to strive for increased local (that is, GHTM and TNSACS) operational
control and support of T/HIS by decreasing overall financial support in FY08 relative to FY07.
Continuing Activity: 14673
14673 HHS/Centers for Tamil Nadu AIDS 6902 3958.08 $90,000
Estimated amount of funding that is planned for Human Capacity Development $105,000
Due to the technical and financial support provided by USG for technical consultants in TNSACS, TNSACS
has been able to demonstrate and document successful program management and implementation, which
has led to the leveraging of national-level funds by TNSACS to directly fund and regularize in the State
program the activities/support activities (partially or fully). This has benefited the mainstreaming of
programs like the SHG prevention intervention, monitoring for Integrated Counseling and Testing (ICT) and
Prevention of Mother-to-Child Transmission programs, Red Ribbon Club, RRC programs, and M&E.
The following activities proposed in COP08 have been taken over by TNSACS using non-USG funds: (1)
Coordination and Strengthening of Counseling and Testing Activities, (3) State-Wide Capacity Building and
Training for Health Care Personnel, (4) Public Health Training for District Collectors, and (6) Consortium of
HIV/AIDS Stakeholders. As a result, USG has been able to use the funds for newer, more vital activities in
TNSACS as is seen by the reduced budgets in this program area for COP09.
Activities 2, 5, and 7 in the FY08 COP have been modified as shown below:
As mentioned in the SI program area, USG will continue to provide technical support to TNSACS and TSU
for capacity building of the DAPCUs. TNSACS with technical support from USG, will conduct workshops to
develop skills of District Health Officials for understanding HIV/AIDS and monitoring the programs, which
will soon be their responsibility.
ACTIVITY 5: State-to-State Information-Sharing Workshops
USG in collaboration with TNSACS will invite all HIV/AIDS implementers in India's high prevalence southern
states for a "Best Practices Workshop" which will collectively help in learning evidence-based practices, and
promote replication in other areas. At least two such workshops will be organized every year to disseminate
the knowledge. This will provide opportunity to develop skills for good scientific writing and documentation,
and epidemiological and public health skills.
ACTIVITY 7: Laboratory Accreditation Processes
This activity's title has been changed to, "Capacity Building of Laboratory, Including Accreditation
Processes."
USG will not only support the development of accreditation process for private sector laboratories that
participate in the state's HIV/AIDS program but will also build capacity to streamline the accreditation
process.
USG and TNSACS, in collaboration with the GHTM Lab Manager and National Reference Laboratories
(NRLs) in the state, will help in enhancing the capacity of the State Reference Laboratories (SRLs) and the
Integrated Counseling and Testing Centers in the state on proficiency testing and on the External Quality
Assessment System (EQAS) for HIV testing and monitoring. This will also help in preparing the state
owned labs for the accreditation process.
Twelve USG-funded consultants are placed within various program areas of the Tamil Nadu State AIDS
Control Society (TNSACS) to provide strategic and technical leadership. These positions will continue to be
supported in FY08. Specific activities will include coordination and strengthening the state counseling and
testing program, developing laboratory accreditation processes for the private/NGO sector, capacity building
for the District AIDS Prevention and Control Units and for health care personnel; supporting inter-state
information exchange, and an in-state stakeholders' consortium.
TNSACS is the implementing body for India's National AIDS Control Organization (NACO) in the southern
state of Tamil Nadu, a high HIV-burden state. TNSACS, which is headed by a senior officer from the Indian
Administrative Service (IAS), is the state-level authority for HIV-related policy formation, activity and partner
coordination, program implementation, as well as monitoring, reporting, and evaluating on all activities
related to the HIV epidemic in the state. In 1991, TNSACS was the first state HIV agency to be formed in
the country and has continued to serve as a model for other such agencies.
the country. The technical support provided to TNSACS by the USG has been one of the successful models
of donor support for the country. The extent, form, and specificity of our support is now being discussed with
NACO in relation to the creation of the new Technical Support Unit in Tamil Nadu (also to be supported by
USG) and how that will interact with the USG advisors currently in TNSACS.
Consultants funded by HHS/CDC are placed in various program areas of TNSACS to provide strategic and
technical leadership. To date, HHS/CDC has provided 12 consultants to TNSACS who work under the
guidance of the TNSACS Project Director (PD). These positions will continue to be supported in FY08 as
they fulfill a key system strengthening need at TNSACS through state-level supervision, policy and guideline
development, program monitoring and evaluation, and strategic planning. They will receive mentoring from
Activity Narrative: HHS/CDC staff. It is expected that TNSACS will assume responsibility for these consultants in subsequent
years.
ACTIVITY 1: Coordination and Strengthening of Counseling and Testing Activities
TNSACS has established 718 integrated counseling and testing centers (ICTC) in Primary Health Centers
(PHC), select district headquarters hospitals, and medical colleges to facilitate the ‘integration' of HIV
counseling and testing (CT) services, with the objective of increasing CT accessibility for those clients most
in need of CT. The centers have been provided with trained counselors, test kits, and laboratory
technicians. TNSACS, as the state HIV coordinating body, has the responsibility to ensure appropriate HIV
CT practice, standardized data recording and reporting, human capacity development of ICTC staff, and
program monitoring and evaluation. HHS/CDC will support the placement of an ICTC technical officer within
TNSACS to coordinate and strengthen these ICTC activities in the state. Additional activities that will be
supported by this officer include establishing an appraisal system that ensures optimal placement of ICTCs,
expanding provider-initiated HIV CT services into other health-care settings (TB, ANC, STI, in-patient
centers), improving the ICTC supply chain management system, and strengthening the state ICTC quality
assurance/control system.
Funding and technical support will be provided to support the capacity building of DAPCUs. The objective of
capacitating the DAPCUs is to decentralize program implementation and management down to the district
level (population: 2-2.5 million per district). Currently, Tamil Nadu has recruited and trained DAPCU staff at
one level, the District Program Managers (DPMs). As the DAPCU concept materializes, an additional 1-4
staff will be hired under the DPM. DPMs have been placed in all 30 districts to supervise and strengthen
HIV prevention, care, and treatment services in those districts. Specific activities of the DAPCU will include;
1) ICTC supervision; 2) field-level staff training and mentoring; 3) technical support to district government
prevention programs, ICTCs, and ART center; 5) coordination of all district level partners and activities; 6)
technical inputs into communication and condom social marketing campaigns; and 7) monitoring and
evaluation of all district level HIV services.
HHS/CDC will play a technical role in training DAPCU staff on basic public health principles, field
management skills, HIV prevention strategies, HIV care and treatment operational guidelines, and
monitoring and evaluation skills. The exact training calendar will be determined in collaboration with
TNSACS, APAC (as the technical support unit for Tamil Nadu), and other technical agencies working in
Tamil Nadu. This activity will be undertaken with a USG partner, Public Health Management Institute
(PHMI), located in Hyderabad, Andhra Pradesh.
ACTIVITY 3: State-Wide Capacity Building and Training for Health Care Personnel
HHS/CDC will support a consultant within TNSACS to strategically support and coordinate capacity building
for the different levels of the health system involved in HIV/AIDS services. The consultant will coordinate
with medical college and government hospitals and will be responsible for developing public private
partnerships. In FY08, this consultant will focus on providing technical support to TNSACS-supported ART
centers and community care and support centers in the southern region of Tamil Nadu. This consultant will
work on creating stronger linkages between testing centers, NGO-run care and support centers, and ART
centers placed in government institutions. The consultant will also mentor the 7 DPMs in the region. A
regional training center is being proposed by TNSACS and the Tamil Nadu Health Minister, and if funded
will be developed with assistance from this consultant and HHS/CDC.
ACTIVITY 4: Public Health Training for District Collectors
HHS/CDC has recently received approval from the senior administrative officer of the Government of Tamil
Nadu to conduct a one-day HIV and public health training for all District Collectors, who are the highest
ranking government administrative officials in the district and future state level administrative leaders.
District Collectors oversee all health, development, and social programs in their designated district. The
goal of this training program will be to equip these District Collectors with strong program management and
data-driven decision making skills. The USG, in collaboration with TNSACS, recognizes the importance of
providing these officers with strong HIV program management skills and will support the training of a new
batch of district collectors in FY08 as a strategic system strengthening activity. USG plans to make this
training a routine activity across the four high prevalence southern states.
To facilitate information sharing and collaboration with other state HIV/AIDS Societies (SACs) in FY08,
HHS/CDC will support TNSACS to organize state-to-state sharing workshops for the southern states
(Andhra Pradesh, Karnataka, Kerala, Goa and Pondicherry). Other agencies implementing USG state-level
programs will be invited to share their experiences and to identify best practices and strategies to
addressing HIV/AIDS in their respective states. TNSACS is the ideal SACS to coordinate such workshops
due to their experience and history of success.
ACTIVITY 6: Consortium of HIV/AIDS Stakeholders
In FY08, USG will support TNSACS to establish and lead a consortium of HIV/AIDS stakeholders. There is
an acute need to coordinate the growing number of HIV/AIDS agencies and stakeholders in Tamil Nadu in
order to minimize duplication of activities and geographic coverage and to develop standard materials
(trainings, IEC, recording and reporting) among these partners. TNSACS will coordinate regular meetings
for these partners and will establish standard operating procedures.
private sector. Private facilities receive this accreditation will be eligible to receive HIV diagnostic and
treatment support from the GOI at a reduced price which will be passed on the patient (i.e. customer). Initial
findings from this program have been promising with 25 private, high volume HIV testing centers enrolling
Activity Narrative: themselves in late FY '07. In FY '08, HHS/CDC will support a consultant within TNSACS to develop and
expand this accreditation system in Tamil Nadu. Specific activities of this consultant will include developing
a transparent and standardized HIV lab accreditation and certification system, private laboratory
assessments, program monitoring and evaluation, and training TNSACS staff to expand this program.
Continuing Activity: 14674
14674 HHS/Centers for Tamil Nadu AIDS 6902 3958.08 $69,000
Estimated amount of funding that is planned for Human Capacity Development $35,000
Program Budget Code: 19 - HVMS Management and Staffing
Total Planned Funding for Program Budget Code: $2,803,178
Overview: HIV/AIDS is a priority for the US Mission's health portfolio in India, with the highest budget of any health issue. The US
Ambassador, who leads the President's Emergency Plan for AIDS Relief (PEPFAR) program in India, has delegated day-to-day
leadership to the DCM, who holds quarterly meetings with the agency technical heads and the PEPFAR Coordinator to review
policy and technical issues. A second Embassy-level Committee promotes collaboration and coordination among USG programs
working in HIV, including USG Consulates, USAID, HHS/CDC, the Office of Defense Cooperation (ODC) and other offices of the
Department of State. This committee meets twice a year to exchange information and plan for joint activities such as World AIDS
Day.
The interagency PEPFAR team includes agency technical heads, program managers and key support staff from USAID, CDC,
ODC, and a representative from the Department of State's Political Unit, representing DOL. USAID and ODC in-country staff are
based in Delhi and CDC staff in Delhi, Chennai, and Hyderabad. Day-to-day PEPFAR management is provided by the PEPFAR
Coordinator, the Strategic Information (SI) Advisor and the Program Management Assistant (PMA), appointed in August 2008.
The Coordinator holds weekly DVC meetings with the full staff team to discuss programmatic, technical, and management issues.
The Coordinator and the PMA are hired through USAID; the SI Advisor through CDC.
In the past year, the team revised the arrangement for Technical Working Groups. A Steering Committee was set up, comprising
the PEPFAR Coordinator and agency heads and deputies. The role of the Steering Committee is to guide overall planning and
staffing issues. The proposed State and Technical Working Groups had not been as active as expected, partly because their
functions were expected to be fulfilled through different mechanisms, such as joint interagency technical meetings. At the State
level, agencies developed collaborative working arrangements that differed by State. In Tamil Nadu and Maharashtra, both USAID
and CDC are members of the State AIDS Control Society (SACS) Governing Board. In Karnataka and Andhra Pradesh, the
agencies maintain strong relationships with the SACS and have strengthened interagency communication over the past year.
The team has revised the composition of PEPFAR Technical Working Groups (TWGs), which now consist of TWGs on (1)
Prevention; (2) Care, Treatment and Laboratory Services; (3) Health Systems Strengthening; (4) Strategic Information; (5)
Gender; and (6) Communication. TWGs have been charged to identify priority issues and set a schedule for in-person or virtual
meetings. Partners have been identified to serve on the committees. With more staff support for the PEPFAR Unit we expect to
strengthen the Staffing for Results approach by using the TWGs to focus on quality and policy issues related to technical program
areas.
The USG is represented by USAID on the Donor Steering Committee of the National AIDS Control Organization (NACO), a
committee of donors contributing over $10 million per annum to the national program. Reporting meetings with the Director
General of NACO (DG/NACO) are not yet on a regular schedule, but are arranged to respond to need, such as the meeting to
discuss the concept paper for the Technical Partnership Compact. It is hoped that we can establish a regular schedule for these
meetings, as to date most meetings are with individual agencies to discuss specific technical questions. USG has broad
representation on many NACO Technical Working Groups including those on Mainstreaming/Public-Private Partnerships,
Monitoring and Evaluation, Care and Support, Communication, and Condom Social Marketing. USG has one of two donor
representatives on the Global Fund Country Coordinating Mechanism (CCM); the PEPFAR Coordinator serves as alternate. The
USG term has one more year to run.
Best Practices and Challenges in Interagency Coordination:
Staffing for Results in India has several major objectives: 1) strengthen joint interagency planning based on a sound knowledge of
interagency programs; 2) harmonize relevant program elements (training, communication, technical assistance to the Government
of India [GOI]); and 3) minimize duplication of effort. These objectives contribute to our overall goal of effective support for the
GOI's third National AIDS Control Program (NACP-III).
In the past year, the agencies, particularly USAID and CDC, have made significant progress in strengthening administrative
structures and mechanisms to strengthen joint planning in technical areas. Forming a Steering Committee of interagency heads
has been an effective means of discussing budget and staffing issues and defusing potential conflicts before topics are raised with
the full PEPFAR team. The regular weekly meeting of the full team has strengthened joint planning and exchange. We are also
fortunate that all three agencies were co-located in the Embassy compound, and that USAID/PHN and CDC now occupy office
space on the same floor. We strongly recommend co-location as a best practice in fostering the interagency process.
We have seen results this year, in terms of stronger planning. In early 2008, PEPFAR/India had a mid-term program visioning
exercise and review of the USAID and CDC program, led by a USG team from Washington and Indian consultants. A similar
visioning exercise and review was carried out in July for the DOD program by a team from OGAC, PACOM, and the NHRC in San
Diego. There was a Portfolio Review in August. These meetings resulted in jointly agreed program changes, the most important
being faster transitioning to GOI of programs for the general population, refocusing workplace programs to target higher risk
industries and minimizing duplication of efforts. The two agencies continue to minimize duplication of efforts through regular
coordination meetings at state level. We are now also seeing solid examples of the use of cross-agency expertise: CDC has
called on a USAID partner to develop a joint plan to strengthen positive prevention; a joint mentorship program, for NACO,
initiated by FHI, will call on both CDC and USAID to provide guidance in their areas of technical expertise. Joint site visits and
meetings have taken place, but implementing these activities is difficult because of time pressures and other impediments.
As a team we also face challenges. A major challenge is that we are short-staffed for managing both a large, complex program
and the PEPFAR reporting requirements. The need to have a fully staffed PEPFAR unit is important, but difficult to put into
practice when overall staffing is tight - which can lead to conflicts and role confusion for support staff. Annual visits by the
PEPFAR unit to train groups of grantees in PEPFAR processes are a best practice that has been valuable, but because of staff
shortages and heavy workloads we have minimized these visits. GHCS funding can be difficult to program, given competing
priorities among the different agencies and the lack of objective criteria on which to assess the value of very different programs.
Larger challenges relate to the position of non-focus countries. Because our funding is limited in relation to other donors, we have
less visibility with the GOI, and therefore need to be extremely responsive to GOI requests for technical assistance. This can
impact our ability to maintain a consistent strategic approach. For example, in response to GOI requests and to the shift in our
strategy (under PEPFAR), we are shifting from direct implementation to technical assistance; however, we have been asked to
continue substantial direct implementation in Karnataka, where the program is still relatively new. Long-term strategic and
financial planning is a challenge in these circumstances, when refusal of specific requests could harm the USG's credibility.
A further issue - and one that we are addressing together - is the difference in organizational cultures, particularly in regards to
the budgetary and audit processes. Data from USAID contracts procured in country is difficult to compare with centrally funded
procurement for CDC. The political environment in India also affects programming. For USG/India overall, there are more pressing
diplomatic and bilateral priorities than HIV/AIDS, which, combined with the relatively low level of USG funding compared to major
donors such as DFID and the World Bank, could lessen USG's ability to influence HIV/AIDS policy. Our solution is to promote
USG's technical strengths to GOI, for example through USG's assistance in upgrading the National Reference Laboratory System
and in leading the development of the national strategy for Public-Private Partnerships in HIV/AIDS.
In terms of strategic issues, in response to NACP-III's priorities, the USG role will continue to move from direct implementation to
more emphasis on technical assistance, though this will vary by State. USG supports six of the Technical Support Units, new
organizations set up by NACO to build the capacity of the SACS to manage the expanded HIV/AIDS targeted interventions and
service in the States. In USG focus states where CDC supports technical consultants to the SACS and USAID supports the TSU,
we will monitor agency roles to ensure there is no overlap.
A further challenge is to develop exit plans for the funding we provide for NACO and SACS staff. Agencies will also give particular
attention to developing a joint plan for providing technical assistance to NACO at the district level. In addition, USG's ability to
provide high-quality TA has led to the new challenge of prioritizing NACO's frequent requests for TA, since given our budget
resources, the USG/India program cannot respond to all of them. Internally, major areas that still need strengthening are PEPFAR
documentation, interagency communication, particularly creating and maintaining a PEPFAR/India website, and production of
materials on the PEPFAR/India program. These activities are part of the SOW of the new PEPFAR PMA.
Management and Staffing Pattern by Agency:
USAID: Budget $1,404,000; staff salaries and travel: $1,088,500: administrative costs: $315,500 (IT and ICASS: $197,000; other:
$118,500)
• The Mission Director and Deputy Director take the lead in communication with the Ambassador on the HIV/AIDS program and
provide guidance and approval for USAID's HIV/AIDS activities. The Director of the Office of Population, Health and Nutrition
(PHN) and in her absence her Deputy provide overall supervision, leadership for relations with NACO, and representation on the
Donor Steering Committee, the CCM, and the Technical Panel of the Gates Foundation.
• The Chief, HIV/AIDS Division (Foreign Service National, [FSN]) provides leadership and management support to USAID's
HIV/AIDS program. He is supported by three FSN project management specialists, who are Cognizant Technical Officers (CTOs)
with technical and management oversight of prime partners, and by two project management specialists (FSNs) one to work on
the private sector and technical assistance programs (PSI and FHI) and one as a Technical Advisor on Care and Support. The
PEPFAR team also draws on technical expertise from USAID/PHN staff members in both the HIV/TB and Health Systems
Strengthening divisions.
• The Division is supported by a program management assistant and a secretary, both FSNs. Two communication specialists in
the Program Support Office (one Personal Services Contractor (PSC) and one FSN) support promotion and press activities
related to HIV/AIDS. Two FSN Financial Analysts in the Regional Financial Management Office support financial management
requirements and one FSN acquisition assistant in the Regional Office of Acquisition and Assistance supports contracting
requirements. Support is also given by an FSN staff member in the Program Support Office.
• USAID provides national leadership on Targeted Interventions, IEC, condom social marketing, care and support, and private
sector programs. USAID also manages six Technical Support Units at state level to build the capacity of the SACS. USAID staff
provides technical assistance in program management, capacity building, and technical areas in HIV prevention and care.
PEPFAR HHS/CDC: Budget (for M&S staff only): $903,678; salaries and travel: $479,653; administrative costs: $424,025 (ITSO,
CSCS and ICASS: $231,506; other: $192,519)
• The HHS/CDC Global AIDS Program (GAP) is led by a USDH CDC Country Director and a Deputy Director for Operations
based in New Delhi (the latter position is currently vacant). They are supported by a Finance Specialist, a secretary and a driver,
all Locally Employed Staff (LES). The M&S budget for HHS/CDC also supports three staff in Chennai who spend significant time
on overall management and staffing: a USDH epidemiologist (50% time); an administrative assistant (70%) and a driver (100%),
both LES. CDC technical staff are budgeted under the related program areas.
• CDC's core strength is in providing technical assistance and capacity development activities. CDC requires staff with
administrative and technical experience, often with a medical background and strong expertise in training. Core strengths include
a focus on surveillance, M &E, lab strengthening and evidence based strategic planning for HIV/AIDS activities. CDC provides
technical consultants and support to NACO, the SACS, and input in several technical areas, including ART rollout, CT, PMTCT,
laboratory, care, M&E protocols, national guidelines and training curricula. In the field, CDC is directly involved in providing
technical assistance to partners to improve laboratory and surveillance systems and implement integrated prevention, care and
treatment programs at the state and district level.
DOD: Budget: $45,500
• Commodity procurement, overall program guidance and technical input is provided by the Center of Excellence in Disaster
Management and Humanitarian Assistance (COE), Hawaii, under a contract from the US Pacific Area Command (PACOM).
• The ODC in New Delhi handles liaison with the Armed Forces Medical Services. The program is supervised by the Deputy
Director, ODC. There is a PMA for the PEPFAR program (currently vacant) and a long-term FSN officer also maintains liaison with
AFMS.
• Because the PEPFAR-funded staff position is part-time, there are no ICASS/Overhead costs.
DOL: No staff cost
• Day to day linkages on PEPFAR activities with the prime partner are carried out by the PEPFAR Coordinator, with input from the
Labor and Political Advisor, Department of State, and the U.S. Department of Labor.
Table 3.3.19:
