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
The objective of this activity is to support the Armed Forces Medical Service's (AFMS) expanding HIV/AIDS
prevention program. This will be achieved by providing support for the production and distribution of IEC
materials for the armed forces and support to the Training of Trainers (TOT) program for secondary school
children in Ministry of Defense (MOD) schools. These efforts build on past successes of the production and
distribution of IEC material for the armed forces and continue support for HIV/AIDS prevention training for
MOD secondary school students. Given the high priority that AFMS places on HIV prevention programs,
this activity is a priority for the foreseeable future.
BACKGROUND
The Department of Defense (DOD) in collaboration with the US Pacific Command/Center of Excellence
(PACOM/COE) has supported the Indian Armed Forces Medical Services (AFMS) since 2004 in building
their capacity to provide HIV/AIDS prevention, care and treatment services to military personnel, and their
families. The geographical focus covers the capital city New Delhi; Shillong, in the North East where there is
a generalized epidemic; and in Mumbai and Pune in the high prevalence State of Maharashtra. As with
many militaries worldwide, the Indian Armed Forces personnel are an at-risk population since soldiers are
generally young, mobile, separated from their families, and exposed to commercial sex workers. With a
troop strength of nearly 1.3 million, troop turnover, and an annual recruitment of 80,000 new recruits and
their accompanying family dependents who are new to the military community, it is critical for the AFMS to
develop a sustained HIV prevention, care and treatment program which can be accessed by military
personnel and their families.
To reach the wider military community with Abstinence and Be Faithful (AB) prevention messages, AFMS
plans to extend HIV prevention education to focus on high-risk groups such as new recruits, soldiers in
unaccompanied posts, soldiers in areas of conflict and dependent adolescents of active duty soldiers. We
expect IEC materials to continue to play a role as AFMS expands the reach of its prevention activities, and
continues to extend HIV/AIDS prevention activities to the MOD secondary schools the in coming years.
ACTIVITIES AND EXPECTED RESULTS
This is a continuing activity from FY08 that is being modified as a result of a mid-program review and the
pending results of an AFMS knowledge, attitude and practice (KAP) survey. IEC materials will be produced
and distributed to support the broader objectives of AFMS's HIV prevention program.
ACTIVITY 1: Production and Distribution of IEC Materials Emphasizing AB Messages
AFMS has trained and will continue to train peer leaders and counselors who facilitate the dissemination of
IEC materials in conjunction with counseling and discussion of life skills, including the importance of
abstinence and/or fidelity, addressing gender stereotypes, male norms and behaviors, reduction in violence
as well as stigma and discrimination. This is an activity that has been specifically requested by AFMS.
These materials are expected to reach over 40,000 soldiers through 93 IEC nodes as well as through peer
educators and Integrated Counseling and Testing Centers.
AFMS will update the IEC materials based on a curriculum with a proven ability to reach soldiers and their
families across India. The program will support the production and distribution of these materials.
Additionally, AFMS will cost share to expand the TOT program to secondary school children in MOD
schools. The life skills TOT program for secondary school children has been developed by AFMS in
consultation with MOD school leaders, the National AIDS Control Organization (NACO) and local non-
governmental organizations. The curriculum will be based on principles whose efficiency has been proven.
ACTIVITY 2: TOT Peer Education Workshops
Building on the HIV prevention education component for MOD-operated schools (funded by PEPFAR
FY08), AFMS will coordinate and execute TOT workshops designed for adolescents, focusing on life skills,
gender stereotypes, and addressing male norms and behaviors to reach a minimum of 500 secondary-
school children. In order to reach 500 school children, AFMS will train a minimum of 50 secondary school
children to be master peer educators. These 50 master trainers will then train an additional 10 students.
This is an activity that has been specifically requested by AFMS.
New/Continuing Activity: Continuing Activity
Continuing Activity: 14677
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
14677 11520.08 Department of Armed Forces 6905 3974.08 $70,000
Defense Medical Services
11520 11520.07 Department of Armed Forces 5795 3974.07 $30,000
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Reducing violence and coercion
Military Populations
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.02:
The objective of this continuing activity is to create a core group of Master Peer Leader Educators whose
work spreads HIV/AIDS education within the Indian Armed Forces (IAF) and throughout soldiers' native
communities as well. Peer leader education activities extend beyond improved knowledge and awareness
to focus on changing norms of male behavior, reducing sexual violence and coercion and decreasing
stigmatization and discrimination. This is accomplished through Training of Trainers (TOT) workshops,
which will build on the success of workshops held over previous years. These workshops are an essential
part of the Armed Forces Medical Service's (AFMS) HIV/AIDS prevention program and the DOD partnership
with AFMS, and it is expected that HIV/AIDS peer leader education will continue for the foreseeable future.
In addition, this activity is linked with the continued procurement of condoms by DOD.
families. The geographical focus covers the capital city New Delhi; Shillong, in the North East, where there
is a generalized epidemic; and Mumbai and Pune in the high prevalence State of Maharashtra. As with
personnel and their families. This includes developing and sustaining a large and widespread cadre of peer
leaders to bring prevention education to high-risk populations within the military.
DOD has supported AFMS since 2004 in building its human capacity to provide HIV/AIDS prevention, care
and treatment services. A major component of this effort has been support for TOT workshops in peer
leader education. The main objectives of increasing support for TOT workshops and Master Peer Educators
are to increase coverage, develop capacity and ensure sustainability of the prevention program. Prevention
is the mainstay and ‘backbone' of AFMS' war on HIV/AIDS transmission and is identified as a top priority for
the AFMS as well as for the USG PEPFAR team.
HVOP builds the human resources capacity of AFMS through peer leader education workshops and
ensures the availability of condoms.
ACTIVITY 1: Training of Trainer (TOT) Workshops
The AFMS will execute five TOT workshops that will train over 300 Master Peer Leader Educators. Each
Master Peer Educator will then train an additional 10 peer educators for a total of 3,000 peer educators.
This learning will ‘cascade' down through the peer leaders reaching at least 30,000 soldiers, dependents,
and civilians. The modules and IEC materials for peer leader education trainings are military specific,
based on successful materials with proven efficiency and that conform to national guidelines. To support
and ensure proper implementation of workshops, AFMS conducts pre and post-workshop knowledge
assessments. Workshop participants will be provided with IEC materials to use and distribute when they
return to their respective postings and speak on HIV/AIDS. It is expected that these workshops will reach
the desired amount of people. Follow-up reviews will inform whether the desired effect of reaching beyond
the peer leaders and their peers has been achieved.
Past workshops have included skits performed by local NGOs that demonstrate the roles and
responsibilities of peer leaders, visits to local hospitals and clinics, testimonials of People living with HIV and
AIDS (PLWHA) to reduce stigmatization and discrimination, practice sessions where peer educators
practice being peer leaders, and question and answer sessions where soldiers are given real life choices
and decisions facing soldiers and their dependents. Workshops also use videos and media to reinforce key
messages and behavioral change objectives.
The workshops are designed to have an impact far beyond their immediate participants. First, those trained
as Master Peer Leader Educators are specifically assigned to train 10 others when they return to their
bases and these 10 each train another 10. Additionally, HIV/AIDS prevention activities have an all-India
impact as soldiers come from all areas of India and are instructed to take Behavioral Change
Communication (BCC) messages back to their local communities and villages.
Continuing Activity: 14678
14678 6248.08 Department of Armed Forces 6905 3974.08 $60,000
11510 6248.07 Department of Armed Forces 5795 3974.07 $135,000
6248 6248.06 Department of Armed Forces 3974 3974.06 $125,000
* Increasing gender equity in HIV/AIDS programs
Table 3.3.03:
PACOM/COE, with the support of the Office of Defense Cooperation (ODC) will facilitate the procurement of
condoms to augment the other AFMS prevention activities. Condom supplies will be given to the AFMS for
distribution, especially to military facilities in high prevalence areas. The activity is linked with the peer
leader education activities, the counseling and testing activities, and the adult care and treatment programs
and with the training workshops.
ACTIVITY 1: Condom Procurement
Through its continued commitment to HIV prevention, the AFMS supports appropriate, correct, and
consistent condom use to promote HIV prevention. PACOM/COE, with the support of the Office of Defense
Cooperation (ODC) will facilitate the procurement of condoms to augment the other AFMS prevention
activities. Condoms will be procured and distributed to military facilities and/or units. Condom supplies will
be given to the AFMS for distribution, especially to military facilities in high prevalence areas. At least 25
facilities and/or military units will receive condoms.
Continuing Activity: 15079
15079 15079.08 Department of US Department of 7033 3976.08 $60,000
Defense Defence/Pacific
Command
Program Budget Code: 04 - HMBL Biomedical Prevention: Blood Safety
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
Introduction
The PEPFAR/India program is not working in the areas of Blood Safety or Male Circumcision. Blood Safety is addressed by the
national program under phase three of the National HIV/AIDS Control Program (NACP-III). Male circumcision is not part of the
national program; it would not be appropriate for USG to address this issue in India.
Injection Safety
Overview: India, with its large health care system, generates a significant amount of bio-medical waste each year. The
Government of India (GOI) estimates that 800 million injections take place in health care facilities each year in India and up to 2.0
kg of waste is generated per day per in-patient bed, some of which is infectious. More than 70% of patients visiting a primary
health care provider receive at least one injection at that visit. Bio-medical waste generated during diagnosis, treatment and
immunization processes in healthcare establishments includes sharps, human tissue or body parts and other infectious materials,
which have the potential to transmit various infectious agents (such as HIV and Hepatitis).
Healthcare workers (HCWs) are at particular risk of disease transmission via bio-medical waste due to their repeated exposure to
this potentially infectious material. In addition, medical waste that is improperly segregated and disposed of can contaminate non-
infectious waste and thereby transmit disease to waste-disposal personnel and others that may come in contact with it (such as
ragpickers). There are very limited data on the amount of infections that occur via bio-medical waste through unsafe injection
practices in India, where an estimated 20% of all syringes are from recycled sources. In most developing countries such
transmission has accounted for an increase in health care costs, morbidity and deaths every year. With the increasing availability
of care for PLHA in India through HIV counseling and testing centers, community care centers, and ART and link-ART centers,
biomedical waste management and infection control measures need to be practiced by HCWs, especially those involved in patient
testing and treatment activities.
NACO and SACS have recognized the urgent need to address the issue of injection safety in all health care services. NACP-III
specifically recognizes the risks associated with Biomedical Prevention/Injection Safety and highlights workplace safety issues
including biomedical waste management and infection control measures to be practiced by healthcare workers. The GOI is
working to collect evidence of infections associated with medical injections, and is actively attempting to promote safe injection
practices and policies.
Coordination and Other Donor Support: The World Health Organization (WHO) and the USAID-funded project BASICS, in
cooperation with the Safe Injection Global Network (SIGN), have developed a rapid assessment and response guide to assess
the extent of safe and unsafe injection practices and to identify key problem areas. This tool allows practitioners to quickly assess
the frequency and safety of injections through a sample survey of people who prescribe and administer injections to patients. The
National HIV/AIDS Control Organization (NACO) and the State AIDS Control Societies (SACS) will work in coordination with the
Directorates of Medical Education, Public Health, and Medical Services to train HCWs providing services to PLHAs.
USG FY09 Support: This is the first year in which USG will fund specific activities in this program area. The USG will support the
GOI in the prevention of HIV (and other infectious agents) transmission via bio-medical materials and waste. This will include the
implementation and operation of the GOI's Bio-Medical Waste Rules (2006) that were developed to provide health facilities with
clear and practical guidelines for the appropriate handling and disposal of bio-medical waste.
Based on these guidelines, the USG will support implementing partners to build the capacity of health care workers to properly
handle and dispose of bio-medical waste. To achieve this, the USG has developed a training curriculum for nurses and other
HCWs who play an important role in waste management and disposal at health facilities (such as clinicians and disposal staff).
Relevant topics in the curriculum include: policy development, appropriate segregation and disposal of medical waste (including
infectious equipment), universal precautions, and developing standard operating procedures related to infection safety in the work
-place. The training curriculum has been piloted at a large, tertiary care facility in South India and will be expanded to additional
facilities this year through a ‘training of trainers' model. To date, over 80 HCWs have been trained. In FY09, the USG will seek to
collaborate with appropriate GOI partners (the Directorate of Medical Education, State AIDS Control Societies, NACO) for the roll-
out of this training to other facilities, including ART and other HIV care and treatment centers and to ensure the sustainability of
this approach.
Injecting and Non-injecting Drug Users (IDU and NIDU)
Overview: India with an estimated 2.47 million people living with HIV has the third largest epidemic globally, next only to South
Africa and Nigeria. Despite the large number of infections, India continues to be a concentrated HIV epidemic with a 0.36%
national adult prevalence. HIV prevalence among men is higher (0.43%) than in women (0.29%). National averages mask the
large regional variations in HIV prevalence. The HIV burden continues to be skewed towards six high-prevalence states that
account for nearly 65% of the total infections in the country. Almost a third of the 600 districts in the country report an over 1% HIV
rate among antenatal clinic (ANC) attendees and in five percent of districts the ANC prevalence exceeds 3%.
Most-at-risk populations (MARPs), inevitably have higher seroprevalence rates. HIV prevalence among Injecting Drug Users
(IDUs) is the highest at 6.9%. The National AIDS Control Organization (NACO) estimates that there are 220,000 IDUs in the
country. The presence of IDUs is no longer limited to the North-East region and many large towns in India report having IDU
populations. It is estimated that nearly 40% of IDUs in the country are covered through current interventions. The IDU
interventions in the country primarily focus on HIV/AIDS awareness, condom promotion, needle/syringe exchange, abscess
management, and behavior change communication messages.
In the last two years, NACO has supported many new initiatives to address IDU populations. Significant among them are: a)
setting up a NACO regional office in Assam to cater to the needs of IDUs and People Living with HIV/AIDS (PLHA) in the North
East, b) supporting a country-wide mapping of IDUs and c) developing guidelines for IDU interventions (as part of high-risk group
guidelines). Also in a recent and major development, the Government of India has approved oral substitution therapy (OST) for
injecting drug users and plans to provide Buprenorphine to more than 10,000 by March 2009 and to an additional 30,000 IDUs by
2012. The introduction of Buprenorphine is a major policy change and can have significant impact on the quality of life of IDUs
and on controlling the spread of HIV among them.
Coordination and Other Donor Support: NACO and SACS are the lead players in HIV/AIDS interventions among IDUs. The
Ministry of Social Justice and Empowerment (MSJE) also works with IDUs and supports 200 NGO-managed Counselling, De-
addiction and Rehabilitation Centers. NACO supports the counselors in these MSJE-supported centers. The United Nations
Office of Drugs and Crime also supports assessments on drug use. The Bill and Melinda Gates Foundation and Australian Aid are
also engaged in supporting interventions among IDUs. USG engagement in IDU programs is limited and is confined primarily to
Tamil Nadu.
Current USG Support: Compared to other programs and agencies, USG's engagement in IDU programs is very limited. In Tamil
Nadu, USG prime partners support NGOs and CBOs for interventions among IDUs. The programs create HIV/AIDS awareness,
promote condom use, treat STI patients, create demand for counseling and testing services and refer HIV-positive IDUs to care,
support and treatment services. Safe needles and syringes are being sourced from the government and other agencies. More
than 240 IDUs have been reached through USG programs in the last year.
In Tamil Nadu, Puducherry and Kerala, USG prime partners are also engaged in mapping and assessing IDU needs. This will
provide vital information to the states for planning the required number of IDU interventions and modifying programs to suit the
needs of the target community. USG-supported Technical Support Units also provide critical inputs to the SCS in identifying and
building the capacity of NGO and CBO partners for IDU interventions. In Tamil Nadu a panel of consultants/experts has been
formed to provide technical and programmatic inputs to partners involved in IDU interventions.
There are many challenges in the IDU intervention programs which need to be addressed as a priority. Saturating coverage of
IDUs, advocacy with law enforcement for an enabling environment, and addressing the regular partners and spouses of IDUs to
reduce HIV transmission and vulnerability to HIV are some of the major issues. The possibility that other types of drug users will
shift to injecting drug use is high but has not been addressed so far.
USG FY09 Support: USG-supported TSUs will continue to provide technical assistance to the SACS for: saturating coverage of
IDUs, quality assurance of IDU programs; coordination with MSJE for de-addiction programs, and strengthening the supply chain
management system. Greater emphasis will be given to reaching out to the sexual partners of IDUs and to promote safe sexual
practices.
In Tamil Nadu, USG will identify one NGO/CBO and build its capacity to provide comprehensive services to IDUs and to function
as a learning site on IDU interventions. In selected high-prevalence districts of Tamil Nadu, where the number of IDUs is small
and does not warrant a full-time NGO/CBO program, the USG partner will demonstrate a composite intervention model, whereby
the capacity of the agency engaged in MARPs interventions will be built to identify and reach IDUs with core services and link
them to other prevention and care programs. USG will also support SACS in documenting and disseminating experience and
challenges in rolling-out the OST program among IDUs.
Program Budget Code: 05 - HMIN Biomedical Prevention: Injection Safety
Total Planned Funding for Program Budget Code: $10,000
Table 3.3.05:
Activities under Adult Care focus on strengthening the human resource capacity of the Indian Armed Forces
Medical Services (AFMS) to provide a high quality of health care and support to HIV-positive soldiers and to
ensure that the AFMS has the critical medical supplies available while providing care and treatment
services. These activities are a continuing collaboration between the US Department of Defense (DOD)
and the AFMS to improve the human capacity to address HIV care and treatment at military medical
facilities and ensuring the availability of key medical supplies. The US Pacific Command (PACOM)/Center
for Excellence (COE) in collaboration with the US Embassy, Office of Defense Cooperation (ODC), New
Delhi will continue to work closely with the Indian AFMS to improve and enhance the skills of healthcare
providers, (including doctors) to manage, care, treat, and monitor HIV patients who are on antiretroviral
treatment (ARV). In consultation with the AFMS, the ODC will procure the medical supplies.
The US DOD in collaboration with the US PACOM/COE has supported the Indian AFMS since 2004 to build
the Indian military capacity to provide HIV/AIDS prevention, care and treatment services to military
personnel and their families, with a geographical focus that covers the capital city, New Delhi; Shillong, in
the North East where there is a generalized AIDS epidemic; and in Mumbai and Pune. Both Mumbai and
Pune are located in the state of Maharashtra, known for its high prevalence of HIV/AIDS. The Indian Armed
Forces inducts 80,000 new recruits annually. As with many militaries worldwide, the Indian Armed Forces
personnel are an at-risk population since soldiers are generally young, mobile, separated from their families,
and exposed to commercial sex workers. With troop strength of nearly 1.3 million, troop turnover, and
annual recruitment of 80,000 new recruits and their accompanying family dependents, new to the military
community, it is critical for the AFMS to develop a sustained, comprehensive HIV prevention program that
includes a care and treatment component.
The goal of the training workshops in treatment, care and support is to build the human resource capacity of
military medical officers, nurses, and paramilitary medical personnel so that they are better able to care for
and treat HIV-positive military staff and their families. Past HIV care and treatment workshops focused on
topics that included medical adherence, post diagnosis counseling and psychological support.
ACTIVITY 1: HIV/AIDS Treatment and Care Workshop for Healthcare Providers
AFMS will continue to develop, refine, and implement the HIV care and treatment trainings. Two training
workshops will be executed. These four-day workshops will focus on recent trends in prevention and
treatment strategies for HIV patients in the civilian and military sectors. As in previous training, workshops
program will includes sessions on "Antiretroviral Therapy Case Studies," "Monitoring Antiretroviral Therapy:
Practices and Problems, " "Emerging Toxicity Syndromes in HIV in HIV Infection, " "Recent Concepts in
Drug Resistance and Strategies to Maximize Drug Compliance." Building on past workshops, with FY09
funds, AFMS plans to carry out similar workshops for healthcare providers who did not attend the previous
two workshops. At least 60 military medical providers will be trained.
Continuing Activity: 14679
14679 11521.08 Department of Armed Forces 6905 3974.08 $30,000
11521 11521.07 Department of Armed Forces 5795 3974.07 $55,000
Table 3.3.08:
Activities under Adult Treatment focus on strengthening the human resource capacity of the Indian Armed
Forces Medical Services (AFMS) to provide a high quality of treatment to HIV-positive soldiers and to
ensure that the AFMS has the critical medical supplies available while providing treatment and care
providers, including doctors, to manage, care, treat, and monitor HIV patients who are on antiretroviral
US DOD in collaboration with the US PACOM/COE has supported the Indian AFMS since 2004 to build the
Indian military capacity to provide HIV/AIDS prevention, care and treatment services to military personnel
and their families, with a geographical focus that covers the capital city, New Delhi; Shillong, in the North
East where there is a generalized AIDS epidemic; and in Mumbai and Pune. Both Mumbai and Pune are
located in the state of Maharashtra, known for its high prevalence of HIV/AIDS. The Indian Armed Forces
inducts 80,000 new recruits annually. As with many militaries worldwide, the Indian Armed Forces
includes a treatment and care component.
This activity area supports the training workshops in treatment, care and support that will be carried out by
the AFMS. The purpose is to build the human resource capacity of military medical officers, nurses, and
paramilitary medical personnel so that they are better able to care for and treat HIV-positive military staff
and their families. The workshops are described in the related AFMS activity narratives. This activity
focuses on the provision of supplies to support care and treatment by AFMS.
ACTIVITY 1: Procurement of Disposable Medical Supplies for AFMS Medical Facilities
In consultation and coordination with the AFMS, the ODC will facilitate the procurement of disposable
medical supplies, including CD4 and Opportunistic Infection kits so providers will have critical medical
supplies for patient treatment and care. Once procured, the medical supplies will be given to the AFMS to
distribute to military medical facilities. AFMS will report on the military medical facilities that benefit from the
supplies and on usage. Funds will also support technical support and travel as required. At least four
military medical facilities will benefit from these supplies.
Continuing Activity: 15078
15078 15078.08 Department of US Department of 7033 3976.08 $80,000
Table 3.3.09:
Forces Medical Services (AFMS) to provide a high quality of health care and support to HIV-positive
soldiers and to ensure that the AFMS has the critical medical supplies available while providing care and
treatment services. These activities are a continuing collaboration between the US Department of Defense
(DOD) and the AFMS to improve the human capacity to address HIV care and treatment at military medical
Continuing Activity: 14681
14681 11522.08 Department of Armed Forces 6905 3974.08 $30,000
11522 11522.07 Department of Armed Forces 5795 3974.07 $55,000
Program Budget Code: 10 - PDCS Care: Pediatric Care and Support
Total Planned Funding for Program Budget Code: $291,290
Overview: It is estimated that nearly four percent (94,000) of the total 2.47 million people living with HIV in India are children
(National AIDS Control Organization [NACO], 2007) with around 24,000 children (25%) requiring anti-retroviral therapy (ART). As
of June 2008, 32,000 children living with HIV/AIDS (CLHA) have been registered at the 158 ART centers across the country with
current coverage of children on ART at 40% (9,545 children). A total of 40,000 CLHA are planned to be covered by the end of the
third phase of the National AIDS Control Program (NACP-III) in March 2012.
HIV infection follows a more aggressive course among infants and children than among adults, with 30% dying by age one and
50% by two years of age without access to life-saving drugs, including ART and preventive interventions such as cotrimoxazole
(Lancet, 2004). Most deaths in children can be avoided through early diagnosis of HIV and timely provision of effective care and
treatment for common childhood illnesses and opportunistic infections, and provision of ART. It is estimated that in India about
32,000 infants are infected every year through mother-to-child transmission. With India accounting for 35% of the developing
world's low birth-weight babies and 40 % of child malnutrition , it is essential to reach, identify and diagnose any child who is
exposed to HIV/AIDS. Additionally, there is a need to protect the child from infection and, if found infected, provide treatment with
any nutritional supplement that may be required.
Children infected and affected by HIV/AIDS are often forced to drop out of school to care for sick parents or to join the workforce
to earn for their families. Depending on the economic condition of the family, the children may end up being part of the large
number of children from marginalized communities in India such as street children, children of sex workers, ragpickers, and
children using substances. These are vulnerable children and adolescents at risk of contracting HIV. This situation requires a
systemic change that will make it possible to respond to the needs of these children from the time of conception to the age of 18.
In India, the state of ‘orphanhood' is only recognized when the child loses both parents. However, among the majority of the
population (which is 70% rural), the extended family system persists and those children who lose their parent/s eventually get
absorbed into these family units. Most of the children who end up in alternative care systems like institutions or adoption are
children who may have infected parents (dead or alive) but have been abandoned due to stigma attached to the cause of birth,
chronic disease or the lack of capacity of the parents/caretakers to take care of their children.
NACP-III proposes to reach out to the maximum number of infected children to ensure that the ones eligible for ART are provided
with pediatric AIDS services. Specific strategies and guidelines have been developed to address the three areas related to
children and AIDS: prevention of mother-to-child transmission (PMTCT), provision of pediatric AIDS treatment, and prevention of
infection among adolescents.
A Pediatric ART Initiative was launched in November 2006, supported by the Clinton Foundation. The Foundation also supports
NACO in improving access to diagnostic services and viral load testing for the national expansion to second-line ART. In addition
to revamping the computerized MIS at the ART Centers, the Clinton Foundation is also supporting NACO to implement a
computerized patient record system for pediatric cases registered at the ART centers (the system has now been extended to adult
cases). Pending government approval, NACO has now allocated a budget of $1.2 million to integrate nutrition as a part of care
and support under NACP-III for CLHA on ART. Seven ART centers have been upgraded as regional Pediatric Centers of
Excellence that will provide comprehensive specialized services to CLHA. These centers are also expected to be nodal points for
research in pediatric care.
The most important challenge to India's pediatric care and treatment program is the poor follow-up of pregnant women under the
PMTCT program which has hindered early infant diagnosis and subsequent initiation of ART for infants who test positive. In a
recent study, 10% of those provided PMTCT services reported their infants were not administered any medicine after delivery,
indicating poor follow-up after initial prophylaxis for the mother (Population Council, 2007). Lack of PCR testing facilities,
especially in high-burden districts has also been a critical limiting factor to carrying out early infant diagnosis that would have
increased the coverage of CLHA on ART. Adherence to pediatric ART and follow-up with CLHA caretakers for treatment and
adherence education is also a challenge.
Coordination and Other Donor Support: UNICEF and the Clinton Foundation are the lead agencies and key technical partners for
NACO in the implementation of pediatric care and treatment respectively. USG, Save the Children, FHI, CARE and India
HIV/AIDS Alliance are the other donors supporting pediatric care programs in India. USG-funded programs in Tamil Nadu,
Karnataka, Maharashtra and Andhra Pradesh (AP) have contributed significantly to identification, referrals and follow-up of
pediatric care and treatment cases.
In AP, the state government has merged two private foundation partnerships to form a five-year, $14 million public-private
partnership called the Balasahyoga Project to provide community and facility-based services including food security for children
infected and affected with HIV/AIDS in 23 districts. The key players in this consortium are the Children's Investment Fund
Foundation (CIFF), the Elton John AIDS Foundation, FHI, CARE, the Clinton Foundation, India HIV/AIDS Alliance and the Global
Fund Round 6 funds.
As part of the National Task Force for Children Affected by HIV/AIDS, USG reviews programs and policies on OVC, including
pediatric care and support issues. The Lawyers Collective has been involved in reviewing HIV/AIDS legislation related to children.
USG is currently collaborating with the Lawyers Collective (tasked with drafting the country's first HIV/AIDS Bill) to incorporate in
the Bill the policy and guidance on children and HIV/AIDS that was approved by NACO.
Current USG Support: The USG-supported pediatric care and treatment portfolio has been a modest program with a focus on
supporting referrals and linkages with pediatric ART centers. Facilities offering adult care and treatment such as the community
care centers (CCC) and the PMTCT programs as well as testing centers that offer family testing serve as the main entry points for
identification of children in need of pediatric care and treatment services. USG programs reach the following target ‘child'
populations through the pediatric care and treatment programs: OVC, children of MARPs, and children of registered adult PLHA
attending care and treatment services through CCC/Integrated Positive Prevention and Care Centers/District level networks. In
USG priority states, USG supports link workers and peer counselors who facilitate outreach activities for identification, early
diagnosis, referral and follow-up of children living with HIV/AIDS on ART. These programs support linkages with the OVC and
community and home-based care programs. In Tamil Nadu, USG supports clinical trainings for health care providers specializing
in pediatric care and treatment, including laboratory support for infant diagnosis.
USG FY09 Funds Support: In FY09, USG support for pediatric care and treatment will continue to be modest and move towards
TA-related activities such as human capacity development of health care providers. USG support in direct interventions will be
limited to ensuring referral and linkages with the pediatric ART centers and leveraging support from Clinton Foundation for
pediatric ART and from the Government of India for transport and nutritional assistance for the larger USG-supported OVC
programs, which include children on ART.
Table 3.3.10:
DOD will continue to support VCT training for HIV counselors, including procurement of HIV test kits and
other disposal medical supplies. This will provide supplies to support a new VCT activity in the FY09 COP:
funding will be provided to the Armed Forces Medical Service (AFMS) to assist in maintaining and
expanding its Integrated Counseling and Testing Centers (ICTCs). Support for the ICTCs will bridge the
budget gap until AFMS can fully finance these centers in FY 2013; support will help to offset the costs of
limited expansion of the ICTCs to key military service hospitals.
AFMS has conducted several successful counseling workshops, supported by PEPFAR in FY06, FY07, and
FY08. Over 185 military personnel and civilian staff serving the military community have been trained. As
military staff is mobile and routinely reassigned, continued training is required to build the skills of new
personnel, and in some cases to refresh the knowledge base of others. Working in collaboration with US
Pacific Command (PACOM)/Center for Excellence in Disaster Management and Humanitarian Assistance
(COE) and in consultation with the AFMS, the US Embassy/Office of Defense Cooperation (ODC) in New
Delhi has procured tests kits and other medical supplies in previous years with PEPFAR funds. These
activities remain an important part of the military to military partnership in the VCT arena and will continue in
FY09.
Support of AFMS' ICTCs is a new activity. Programming in this area reflects a significant change in the
DOD component of PEPFAR COP FY09. The additional money requested for FY09 will be used to further
develop the human resource capacity of AFMS by training and supporting staff at existing and additional
ICTCS. We expect that the 20 existing centers will remain open at full operating capacity and at least 10
new centers will be opened. We expect AFMS to gradually increase its share of funding until it eventually
retakes full control by FY 2013.
This increase has been proposed in consultation with AFMS and reflects growth in the program and a plan
to eventually transition the program to full ownership by AFMS by FY 2013. In FY09, $220,000 of PEPFAR
funds will support training and the ICTCs; $30,000 will be used for the procurement of test kits and other
disposable medical supplies. In FY 2010, DOD will propose decreasing the HVCT program area by
$50,000 a year until AFMS has full budgetary ownership of its ICTCs in FY 2013. This transition is
necessary because MOD's budgeting process has not been responsive enough to respond to this shortfall
in the short term. AFMS is confident that the MOD budgeting process will respond according to the new
schedule. ICTCs are such a central part of the shared goals of AFMS and PEPFAR that it is essential to
keep them developing according to existing plans despite this temporary setback.
ACTIVITY 1: Procurement of Test Kits and Supplies
Working with COE and in consultation with AFMS, ODC will coordinate the procurement of rapid test kits
and medical supplies; AFMS will receive the medical supplies and distribute throughout the military health
care system. At least, eight military facilities will receive test kits and supplies.
Continuing Activity: 15071
15071 15071.08 Department of US Department of 7033 3976.08 $30,000
Table 3.3.14:
DOD will continue to support VCT training for HIV counselors and procurement of HIV test kits and other
disposal medical supplies. The COP FY09 will also support a new VCT activity: funding will be provided to
the Armed Forces Medical Service (AFMS) to assist in maintaining and expanding its Integrated Counseling
and Testing Centers (ICTCs). Support for the ICTCs will bridge the budget gap until AFMS can fully finance
these centers in FY 2013; support will help to offset the costs of limited expansion of the ICTCs to key
military service hospitals.
ACTIVITY 1: Counseling and Testing In-Service Workshop
AFMS will execute one counseling and testing in-service workshop. As note, military staff is mobile and
routinely reassigned, and continued training is required to build the skills of new personnel, and to refresh
the knowledge base of others. At least 45 counselors, serving the military community will receive this
training.
ACTIVITY 2: Support for Salaries of ICTC Staff
DOD will cost share the salaries of ICTC staff with AFMS, through ODC/DOD support to AFMS as a prime
partner. Twenty existing ICTCs will be supported and at least 10 more ICTCs will be opened with cost-
shared resources.
The request to support the ICTCS is due to a major shift in National AIDS Control Organization (NACO)
funding. NACO previously funded the salaries and training of the AFMS' ICTC staff., however, as part of its
drive to mainstream HIV/AIDS program activities within relevant ministries, AFMS no longer receives NACO
funds to carry out HIV/AIDS prevention, care, and treatment activities. Consequently, no staff support is
provided for the AFMS's ICTCs. The AFMS identified support for the existing ICTCs and the planned
expansion of these centers as a priority for developing and maintaining a successful military HIV/AIDS
prevention program. Therefore, the DOD PEPFAR program proposes providing significant support to the
AFMS to help offset the costs the ICTCs for a limited time. This will allow the ICTCs to continue to provide
services at full capacity, as the AFMS develops a plan to fully fund them and initiates a limited expansion of
these centers within key military hospitals.
While AFMS will still cover some of the costs of the ICTCs, the increased support is essential in sustaining
the present level of service and ability to provide essential HIV testing, counseling and care. Without
increasing support, ICTCs will face an uncertain fate, which will significantly setback AFMS' HIV/AIDS
program as a whole. ICTCs are often the first step in determining HIV status, receiving and distributing IEC
and BCC materials to service members and, as required, linking into AFMS' care and treatment activities.
Support and eventual expansion of ICTCs to the military service hospitals will broaden access to voluntary
counseling and testing (VCT) while also increasing demand for and awareness of HIV/AIDS prevention.
Activity Narrative: These activities contribute to PEPFAR goals by improving access to and quality of VCT services in order to
identify HIV-positive persons, increasing the number of health care workers trained in the provision of
Parent Mother to Child Transmission (PMTCT) services, increasing the number of service outlets providing
HIV-related care and support, increasing the number of individuals who receive counseling and testing for
HIV, increasing the number of individuals trained in counseling and testing, and strengthening the overall
heath system of the Indian Armed Forces.
Continuing Activity: 14680
14680 6249.08 Department of Armed Forces 6905 3974.08 $30,000
11511 6249.07 Department of Armed Forces 5795 3974.07 $80,000
6249 6249.06 Department of Armed Forces 3974 3974.06 $60,000
The objective of this program area is to support the Armed Forces Medical Service (AFMS) in maintaining a
comprehensive HIV laboratory capability within its health care system. This will be accomplished through
the purchase of disposable laboratory supplies such as reagents and maintenance/service support for
previously purchased equipment. This will build upon previous success in helping AFMS establish its
current level of laboratory capabilities. The program will strive to transfer equipment titles to AFMS and
seek alternative support to ensure laboratory maintenance and laboratory supplies.
The Department of Defense (DOD) in collaboration with the US Pacific Command/ Center of Excellence
generally young, mobile, separated from their families, and exposed to commercial sex workers. With troop
strength of nearly 1.3 million, troop turnover, and annual recruitment of 80,000 new recruits and their
accompanying family dependents, new to the military community, it is critical for the AFMS to develop a
sustained HIV prevention, care and treatment program which can be accessed by military personnel and
their families.
DOD has been working to improve the AFMS laboratory infrastructure since FY04 when the DOD HIV/AIDS
Prevention Program (DHAPP) funded the initial military-military HIV/AIDS program in India. The recent
visioning exercise, as well as the priority areas that AFMS has identified for DOD, resulted in a decision to
decrease the amount of lab equipment purchased while still providing funds for the short-term procurement
of kits and consumables and maintenance of the equipment. Funding in previous years has allowed the
DOD PEPFAR program in India, through the purchase of equipment, to assist AFMS in establishing and
improving a comprehensive HIV laboratory capacity within its health care delivery system. The number of
military laboratories with the capacity to support diagnostic testing and clinical monitoring of HIV/AIDS has
increased to over 10 different sites. DOD support has allowed for procurement of critical HIV lab equipment
and disposable supplies and, in doing so, both filled the gaps in AFMS's program while also building a
successful military-to-military partnership.
The procurement of much needed laboratory equipment and consumables for use in AFMS facilities has
continued for several years. This activity has evolved and matured to the point where new equipment is no
longer a priority, but maintaining existing equipment is a present challenge because DOD still holds the
titles to the laboratory equipment. This prevents AFMS from handling the maintenance itself. (The USG
hand-receipt laboratory equipment is housed at AFMS laboratories and is used by AFMS staff in support of
HIV/AIDS prevention.)
The biggest challenge this program faces is transferring the titles of previously purchased laboratory
equipment to AFMS. There are a number of bureaucratic obstacles to this on both the US and Indian sides.
Steps are being taken to remove these obstacles, but until this is done stopgap measures will be required to
keep the equipment functioning. Nonetheless, we do anticipate overcoming these obstacles within the next
two years for all procured equipment and transitioning this program to full AFMS control, while continuing to
fill the gap in needed kits and consumables from PEPFAR funds.
ACTIVITY 1: Procurement
Working in consultation with the AFMS, the ODC will procure items such as FACS Count Reagent Kits and
other disposable supplies required for continued equipment operation.
ACTIVITY 2: Laboratory Equipment Maintenance
It is expected that this activity will keep all previously purchased equipment operating at full capacity to
allow AFMS to maintain the effectiveness of its HIV testing operation.
The long-term goal is to transfer the titles of all equipment to AFMS, but until that time it is crucial that the
equipment is maintained and serviced so that the labs remain fully operable. In working to transfer
ownership, DOD seeks to ensure that all equipment is in working order. Working in consultation with the
AFMS, the ODC will procure laboratory equipment maintenance service contracts that will extend the life of
previously procured equipment.
AFMS cannot repair or maintain equipment that it does not own due to MOD constraints. Of the requested
$40,000, $10,000 will cover the cost of maintenance and $30,000 will go to short-term procurement.
Continuing Activity: 15072
15072 15072.08 Department of US Department of 7033 3976.08 $130,000
Table 3.3.16:
NEW ACTIVITY NARRATIVE: CONTINUING ACTIVITY
The objectives of this activity are to monitor and assess the effectiveness of the ongoing military HIV/AIDS
prevention program, identify areas requiring additional support and greater attention by the Armed Forces
Medical Service (AFMS) to improve its data collection and analysis capabilities. Support will be provided for
the development, design, and implementation of a further mid-program review. A first mid-program review
is currently underway, and its results will inform and guide the development and implementation of this
second review, which will be implemented in 2011. Although this is not an annual request, it is anticipated
that there will be additional efforts to collect and analyze data regarding the overall DOD PEPFAR India
program to ensure that program activities are achieving expected results.
(PACOM/COE ) has supported the Indian Armed Forces Medical Services (AFMS) since 2004 in building
This activity will allow for a further mid-program review by funding a KAP survey to be implemented in 2011,
similar to the one being conducted in late 2008. The results of this review will allow DOD and AFMS to
assess the effectiveness of specific DOD PEPFAR/India program activities and help guide future
programming. This activity builds upon and further develops AFMS's capacities to monitor, evaluate, and
manage information, as well as perform situational analysis and evidence-based planning. These
capacities improve health system management, and strengthen information systems and AFMS's overall
monitoring and evaluation.
ACTIVITY 1: AFMS Behavioral Survey
In coordination with ODC and PACOM/COE, AFMS will conduct a behavioral survey aimed at developing
the ability to follow health status, knowledge, attitude and practices (KAP). This will be similar to the survey
implemented in August 2008, at the time of the review of the PEPFAR program with AFMS. While this will
be an approved COP FY09 activity, the KAP survey will be executed in 2011.
One challenge that this activity faces is the sensitivity of the survey findings. The Indian Armed Forces are
not eager to share information concerning their readiness and other related issues for security reasons.
This challenge can be overcome through maintaining the strong, trusting relationship with key leaders at
AFMS that the ODC and PACOM /COE currently have. Obtaining agreement on how survey data will be
released and used prior to survey review will be facilitated by the ODC and PACOM/COE. While these
surveys are not an annual request, it is anticipated that they or similar reviews will be used again at some
point in the future.
ACTIVITY 2: Monitoring and Reporting
PACOM/COE and ODC will monitor and report on the implementation of the military component of the
PEPFAR program. Some information will be taken from response to the KAP survey which will ask survey
participants about IEC materials reach, utilization, comprehension, and peer education sessions. Monitoring
and reporting on technical assistance will also be carried out.
Three results are expected from the Strategic Information program component. First, it will help measure
the impact of various prevention, care and treatment interventions conducted over the past three years.
Second, it will identify areas needing additional support. Finally, it will contribute to the sustainability of the
program by further increasing awareness of and commitment to the importance of regular data collection,
monitoring, reporting, and evidence-based planning.
Emphasis Areas: Military populations
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.17:
The objective of this activity is to provide the resources necessary for the successful management and
oversight of the DOD PEPFAR India program. This activity provides managerial, administrative, and
technical support to the DOD PEPFAR program in India through a part-time program manager working out
of US Pacific Command (USPACOM) as well as a part-time in-country Program Management Assistant
(PMA).
The USPACOM HIV/AIDS Strategy builds upon and leverages its established working relationships with
military partners and civilian experts and its access to technical expertise in the field to prevent the
transmission of HIV in the Asia Pacific/South East Asia/ South Asia region. Through its facilitation and
training experience, PACOM aims to catalyze regional cooperation and collaboration that will afford military
coalition partners the ability to address HIV/AIDS within their respective militaries and their countries, and,
where possible, within their border and internal security forces and other uniformed services. In India, this
translates to a strategy that supports and augments the Indian military's evolving comprehensive HIV/AIDS
prevention program by building and improving human resources and laboratory capacity to mitigate
HIV/AIDS within the Indian military. PACOM's executive agent for HIV/AIDS is the Center for Excellence in
Disaster Management and Humanitarian Assistance (COE). In India, COE works in coordination and
consultation with the Office of Defense Cooperation (ODC), US Embassy/New Delhi to implement a direct
military-to-military HIV/AIDS prevention program with the Indian Armed Forces Medical Service (AFMS).
This activity provides funding for the following:
• Program Manager: This position is located at the PACOM/COE headquarters in Honolulu, Hawaii, the
home of the US Pacific Command, and provides overall program management, guidance, and technical
support, as well as coordinates and prepares documents, such as Letters of Agreement, reports of training
activities, and annual reporting requirements, as well coordinates commodity procurement as required.
• Program Management Assistant (PMA): This position is located in the ODC /New Delhi Embassy and
ensures execution of DOD activities under the PEPFAR program, including coordination and facilitation of
commodity procurement at Post, monitoring of activities and assisting in preparing reporting requirements
and other program documents. The PMA assists the ODC Chief and Deputy Chief in PEPFAR country
team coordination as needed. The PMA attends PEPFAR Country Team meetings and represents the
DOD in these meetings when the ODC uniformed staff is not present. The PMA also liaises with AFMS.
• Office equipment, supplies and travel, including ICASS costs as required.
It is anticipated that the management and staffing requirements for the DOD PEPFAR program will remain
unchanged for the foreseeable future.
USPACOM, through a part-time program manager at COE, will provide overall program management,
guidance and technical assistance. The program manager develops and coordinates necessary
documents to ensure participation of all DOD parties as well as works with the COE Budget office and ODC
to monitor and track funds. A part-time, in-country PMA works directly with the ODC to provide on the
ground program management, liaise with AFMS, facilitate and coordinate commodity procurement, and
ensure overall execution of DOD activities under the PEPFAR program as well as tracking, monitoring and
following-up of activities. Funding also supports office equipment, supplies and travel, including ICASS
costs. It is expected that this activity will allow the DOD PEPFAR program to have the human and material
resources necessary for the successful management, planning, and monitoring of all program activities,
including preparing and meeting reporting requirements.
Continuing Activity: 15070
15070 6258.08 Department of US Department of 7033 3976.08 $77,300
11519 6258.07 Department of US Department of 5796 3976.07 $80,000
6258 6258.06 Department of US Department of 3976 3976.06 $69,000
