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: 2010 2011 2012
Implementation Mechanism Narrative
The AIDS Prevention and Control (APAC) Project, a $47.25 million bilateral program, implements HIV/AIDS prevention, care and treatment programs in Tamil Nadu (TN) and Puducherry in partnership with National AIDS Control Organization (NACO) and local State AIDS Control Societies (SACS). APAC played a critical role in engaging civil society in HIV/AIDS programs and established proven systems and strategies for behavior change, service delivery and targeted evaluations, several of which have been adopted by SACS/NACO. APAC in coordination with other agencies has played a pivotal role in controlling the HIV epidemic in TN, which has noted a steady decline in adult prevalence since 2001 (from 1.13%) to 0.25% in 2008.
In the third phase (April 2007 March 2012), APAC reduced its emphasis on direct implementation and is moving towards offering targeted technical assistance (TA). The vision and long-term goal of APAC is to gradually shift away from implementation and to play a more strategic role at a regional and national level, based on core competencies and address critical needs of states and the nation. The long-term vision of APAC aligns with the national and PEPFAR priorities of providing TA and engagement of host governments for increased ownership and sustainability.
APAC works primarily in five technical areas: sexual prevention, adult care and support, orphans and vulnerable children, strategic information, and health systems strengthening. It also addresses several cross-cutting areas including gender, economic strengthening, and human resources for health. It maximizes impact through linkages and integration with other programs. In its third phase, APAC will reach over 20,000 Most-At-Risk-Populations (MARPs - which includes female sex workers and men having sex with men), 10,000 migrants and 5,000 people living with HIV/AIDS (PLHA including 1,000 PLHA who are MARPs) in seven districts of TN and Puducherry. Through this effort APAC will demonstrate saturation of coverage, comprehensive combination prevention and provision of holistic care, support and treatment services.
At a strategic level, APAC has been actively engaged in the design of the third phase of the National AIDS Control Program (NACP-III), preparation of various operational guidelines, and is involved in the Mid-Term Review of NACP-III. APAC has provided guidance to NACO on the Behavior Surveillance Survey and the tools developed by APAC have been adopted by NACO and other agencies for the MTR. NACO has assigned APAC to lead the data triangulation and impact assessment of targeted interventions (TI) for MARPs in TN. As national vice-chair for the technical resource group on targeted interventions, APAC provides innovations and key lessons on MARP interventions and is involved in evaluating other donor programs.
APAC also supports the Technical Support Units (TSU) which provide TA to the SACS of TN, Puducherry and Kerala. The TSUs provide TA in five core areas: strategic planning; targeted interventions for MARPs; capacity building; mainstreaming; and public-private partnerships. The TSUs have played a significant role in scaling-up interventions, improving quality, mainstreaming HIV/AIDS programs and leveraging significant resources.
APAC has also been engaged in several system strengthening initiatives that have a long-term and wider impact on health systems. APAC has partnered with the private medical sector to provide counseling and testing, PMTCT, care, support and treatment for PLHA. This is a major accomplishment, as the private medical sector was not very interested in providing HIV/AIDS services in the past.
APAC has also partnered with leading private companies to promote HIV/AIDS programs. A noteworthy contribution has been the establishment of a toll-free help line to PLHA which was initiated in partnership with a TATA group company and has the potential for national scale-up. APAC is also engaging the Indira Gandhi National Open University (the world's largest distance education service provider) for virtual learning programs on a range of health topics. This opens a new dimension in HIV/AIDS training and can substantively reduce the cost incurred in training programs. APAC also leveraged several million dollars worth of resources from the private and public sectors.
Several assessments are being supported by APAC including a Behavior Surveillance Survey for PLHA, impact assessment of home based care programs, assessment of the secondary level public health sector facilities and a study on changing dynamics of sex work. Many of these are the first of its kind in the country and provide critical inputs to strengthen evidence-based programs and assess impact of interventions.
In COP 10, APAC will continue to focus on the five technical areas. APAC will also support structural interventions to address violence against women and factors that increase vulnerability of female sex workers and men having sex with men. APAC will integrate prevention interventions into government systems and demonstrate models of integration to the national program. APAC will undertake assessments of its various activities and evolve a transition plan in consultation with SACS and NACO. APAC will also organize consultations with the government to evolve the nature of engagement in the coming years at the state, regional and national level.
SUMMARY
The Tamil Nadu State AIDS Control Society (TANSACS) is the lead player for adult care and support programs in the state. HIV prevalence among pregnant women seeking antenatal care in Tamil Nadu (TN) has seen a steady decline since 2001, from 1.13% to 0.26% in 2007. It is estimated that TN has 150,000 People Living with HIV/AIDS (PLHAs), of which 96% are adults (Males 70,000, Females 74,000) and the rest 4% are children below 15 years.
The state has an impressive record in terms of the number of outlets providing care and support services, coverage of PLHAs and utilization of care and support services. Currently there are 35 ART Centers (average one per district), 36 adult Community Care Centers (known as CCCs), 5 Pediatric CCCs and 30 PLHA drop-in-centers. The state plans to support an additional 100 link ART centers (link ART centers are located in existing health facilities at district and sub-district level to make the treatment services more accessible to PLHA. Their primary role is enrollment of PLHA in HIV care, basic investigation, and management of pre-ART and to serve as ART drug distribution points located at the sub-district level). 60% of PLHAs have been identified and registered with the ART center, of which 35,000 are utilizing free ART services.
There are still several challenges that need to be addressed. Nearly 20% of the estimated PLHAs are yet to be identified. Even among those identified, only a small proportion is in regular contact with the care and treatment centers. No concentrated efforts are there to identify HIV positive MARPs and provide them with care and support services. Other gaps include: limited emphasis for positive prevention; stigma and discrimination in health care settings; lackluster engagement of the private medical sector; and lack of standardization in provision of care, support and treatment (CST) services. Data on linkages of HIV positive mothers and infants to CST is also limited.
The AIDS Prevention and Control (APAC) Project, plays a complementary role to TANSACS in adult CST programs. APAC has assisted 18 private hospitals for providing care and support services. These hospitals provide clinical treatment to 4,500 PLHA including conducting surgeries and dealing with medical complications and emergencies. These hospitals are mandated to also provide PMTCT, TB, STI services such that all services for PLHA are provided under one roof. The response has so far been mixed. Counseling, follow-up, adherence to a comprehensive PMTCT package and linkages to TB and other social programs offering care services are major challenges faced by the private sector.
Other CST services supported by APAC include: establishment of a helpline for PLHA; supporting positive networks; conducting assessments; and strengthening systems at care, support and treatment centers. APAC has partnered with Tata Business Support Solutions and has launched a toll-free helpline "Hello (+)" for PLHA. The Hello (+) receives nearly 25,000 calls per month and several states have shown interest in adopting Hello + services. APAC also supports the Positive Women's Network to publish a national-level newsletter for HIV positive women. The newsletter covers current programs for PLHA at state/national level, legal aspects, FAQs and documents case studies.
APAC has pioneered the first Behavior Sentinel Survey (BSS) for PLHAs. The PLHA-BSS collects information on: existing knowledge of HIV/AIDS, care and support services; safe sexual practices; utilization of services; quality of life; and stigma and discrimination issues faced by PLHAs. An assessment of home-based care programs has also been initiated. This study will assess the impact of home-based care on quality of life of PLHAs, minimum package of services for home-based care program, costs, and can provide critical insights to policy makers on home-based care.
APAC also provides technical assistance (TA) to TANSACS by supporting a Data Analysis Team (DAT). The DAT is engaged in analysis of data from ART and CCCs; data triangulation; data quality assurance at ART and CCCs; and undertaking rapid assessments on loss to follow-up and reasons for low reach from ICTC to ART centers. The project is also providing TA to the state for branding ART centers including design of patient education materials.
ACTIVITIES AND EXPECTED RESULTS
In FY 11, APAC aims to address the challenges of identifying HIV-positive MARPs in order to increase uptake of clinical and positive prevention services. APAC will also strengthen provision of comprehensive CST services in private facilities and implement task-shifting by building capacity of nurses to function as counselors. APAC will also provide TA to TANSACS for strengthening existing systems and supporting needs assessments.
ACTIVITY 1: Partnering with the private medical sector to provide comprehensive CST services for PLHA. (Budget $ 323,500)
APAC will support one tertiary care hospital, 17 secondary level hospitals and 63 community-preferred private health care providers to provide quality CST services. These facilities will be sensitized about MARP issues, and emphasis will be given to providing CST services to MARPs in coordination with NGOs and CBOs. APAC will ensure 90% of MARPs in intervention districts are referred for CST services. This initiative will help improve early identification of PLHA among MARPs and provide them with CST services.
The physicians, nurses and paramedical staff will be provided regular mentorship on HIV/AIDS management. This will include management of opportunistic infections, counseling, positive prevention, follow-up, HIV-TB co-infection management, PMTCT and the importance of linkages with NGOs and other care continuum providers in the district. Nurses from these facilities will be trained to provide pre and post test counseling and to counsel HIV-positive pregnant mothers on ART adherence, safe sexual practices, nutritional practices, positive prevention and for referrals of STI, TB patients for HIV testing. Systems will be established for ensuring treatment and patient record keeping and for follow-up of HIV-positive patients and their family members for TB and ART adherence. Through this initiative, 5,000 PLHA will be able to get quality palliative care services at these private sector facilities and 500 PLHAs will be treated for TB. 100 ante/post natal women will benefit from this initiative.
Quality assurance of the program will be ensured by the program officers on a monthly basis. Participatory site visits and data quality assurance reviews would be undertaken once in six months. Operations research will be undertaken to identify gaps in the delivery of services. Facility-based surveys, exit interviews, and mystery client surveys would be conducted to understand the project performance.
This initiative will demonstrate an innovative partnership with the private sector, in which ARV prophylaxis and disposable kits for care would be leveraged from SACS; subsidy would be provided by the physicians for clinical care; STI/OI drugs would be provided by private pharmaceutical companies at subsidized rates; and APAC would support the technical training to health care providers. The lessons learned in engaging the private medical sector for providing comprehensive clinical care for PLHAs and MARP PLHAs would be shared with policy makers and the private medical sector associations for replication, scale-up and adoption.
ACTIVITY 2: Building the Capacity of Private Sector Health Care Providers in Palliative Care (Budget $ 107,900)
APAC will support the Institute of Road Transport Perundurai Medical College Hospital (IRTPMCH), a tertiary care medical institution to build the capacity of private physicians to provide HIV/AIDS care. 200 physicians will be trained through this initiative. IRTPMCH will serve as a learning site for other private and public health facilities and will demonstrate: PLHA-friendly clinical care and support services; computerized patient record management and inter-departmental coordination; follow-up of PLHAs; adult and pediatric ART treatment; systems on supply chain management, universal precautions and waste management; and linkages with NGOs, private and government facilities.
APAC will support the institute's library to house a wide-range of journals, books, videos, slides, audios, guidelines, and other materials on HIV/AIDS adult and pediatric care, support and treatment. APAC will also strengthen the centre's capacity for analyzing patient records, conducting operations research, and publishing articles in peer reviewed journals.
ACTIVITY 3: Technical Assistance (TA) to State AIDS Control Societies (SACS) (Budget included under Health System Strengthening technical area)
APAC will provide TA to SACS to strengthen their systems on HIV/AIDS care and treatment. TA will include training SACS team on palliative care policies and guidelines, technical updates through experts, field visits to care sites, monitoring of CCCs, and TA to public institutions involved in HIV/AIDS care and treatment. Operations research will be undertaken to identify the gaps in delivery of services. Facility-based surveys, mystery client surveys will be conducted to assess the effectiveness of support provided by the TSU. APAC will also conduct the second wave of PLHA-BSS and support the DAT.
APAC will also support TANSACS to enter into a memorandum of understanding with 110 private hospitals in Tamil Nadu for scaling-up PMTCT, STI, and HIV-TB management. On-site supportive supervision would be provided for these private facilities on a quarterly basis for ensuring comprehensive PMTCT services. The best practices in implementing PMTCT program in the private sector would be shared with the SACS and NACO. Efforts will be also made to strengthen the HIV-TB coordination at these 110 private facilities partnering with SACS.
Tamil Nadu (TN) has an estimated 7,000 children infected with HIV. They constitute nearly 5% of the total HIV-positive population in the state. In addition, an estimated 10,000 to 12,000 affected children live in TN. While the state has a strong initiative to prevent mother-to-child transmission and provide pediatric ART, emphasis for non-clinical support has been limited. The basic needs of children such as support for education, nutrition, and livelihood remains unfulfilled or sporadically addressed.
Data on orphans and vulnerable children (OVC) are limited. The state does not have clear and reliable information on the number of affected children and on their orphan status (whether single-orphan, double-orphan). Data disaggregated by age and gender is also not available. A comprehensive needs assessment of OVC has not been undertaken. Yet another major challenge is the limited capacity of counselors and health care providers to counsel children. Stigma and discrimination against children at educational and health care institutions continue to be of concern. The number of NGOs with the capacity to intervene with affected children is also limited.
APAC has been advocating with the Tamil Nadu AIDS Control Society (TANSACS) on the need for strengthening OVC programs in TN. This advocacy has resulted in formation of the state-government supported OVC Trust the first such Trust in any state. The Trust was established in 2009 and the state government through the department of Health and Family Welfare has provided an endowment fund of ($1 million) to initiate the activities of the Trust. APAC provides technical assistance (TA) to the OVC Trust through a team of consultants and supports the OVC secretariat's functions. The consultants are engaged in a size estimation of HIV-affected children and assessing their needs. They contribute to the development of operational guidelines for provision of health and social development programs for OVC and establishing appropriate systems at state and district level for capacity building and monitoring.
During FY'11, APAC will continue to advocate with the state government and NACO for strengthening OVC programs. APAC will coordinate with different departments including Women and Children, Social Welfare, Youth, Education to mainstream HIV/AIDS programs and leverage existing programs/schemes of these departments to benefit OVC. APAC will provide TA to TANSACS, OVC Trust, NGOs and assist in developing customized programs that meet age, gender and orphan-status specific needs. APAC will also document and disseminate the OVC programs experience to NACO for scale-up to other states.
ACTIVITY 1: Technical Assistance (TA) to the state support OVC Trust. Budget ($ 117,000)
In FY 11, APAC will continue to provide technical support to the state OVC Trust. TA will include: a) supporting consultants for refining the Trust's strategy, operationalize its plans and mobilizing private sector resources; b) undertaking studies to assess needs, gaps and effectiveness of Trust activities; c) developing customized packages that meet age, gender and orphan-status specific needs; d) refining operational plans for mainstreaming with other departments and leveraging existing government schemes/programs from other departments to benefit OVC; and e) developing training curriculums for NGOs, counselors and health educators on OVC and child counseling.
APAC will also strengthen monitoring systems and document case studies of beneficiaries. Efforts will be undertaken in partnership with TANSACS to showcase this program as a model to NACO and other state level agencies. The Trust will also seek to give equal attention to girl children by motivating their parents/guardians to send their daughters to school by providing school fees and other educational materials to help them complete secondary education.
ACTIVITY 2: Support to community based demonstration project for OVC. Budget ($ 117,000)
APAC has phased out of most direct implementation of OVC activities, but will continue to support one sub-partner to implement community based OVC programs. Three hundred children will be reached through this activity and will be provided with a minimum of three OVC services as specified by PEPFAR. These activities will include life skills education training for children; provision of medical, nutritional and educational aid; linkages with counseling and testing services; strengthening households to plan for legal and social support for OVC; and strengthen referral linkages with government, the private sector and other stake holders to leverage resources.
The project will serve as a demo project for the state, by building the capacity of other NGOs to undertake OVC programming. Training modules will be developed and NGO staff will be given a comprehensive training and exposure in designing and implementing a comprehensive OVC program. The participants will be trained on practical and scientific methods to implement and monitor the program. The project will offer handholding and on-site support during the initial implementation of the program.
Strategic information (SI), which includes monitoring and evaluation (M&E), surveillance and management information systems, is the cornerstone for reliable evidence-based planning and assessing program impact. M&E is now one of the four objectives of the third National AIDS Control Program (NACP-3), reflecting the growing importance of reliable systems for generating, monitoring, and interpreting data.
There is a plethora of data available at the state and national level. Major data sources include: HIV Sentinel Surveillance (HSS), National Family Health Survey (NFHS), Behavior Surveillance Surveys, Integrated Biological and Behavior Surveys, Mapping data of MARP, Truckers and Migrants. In addition there are monthly reports from targeted intervention projects, PMTCT sites, counseling and testing centers, and ART centers which provide information on service outlets and on the number of beneficiaries. The completeness, accuracy and timely availability of this information are critical for program managers and policy makers.
The AIDS Prevention and Control (APAC) project continues to play a strategic and major role in this area. APAC supports the Technical Support Units (TSU) in Tamil Nadu and Kerala. The TSUs with its mandate for strategic planning has ensured increased coordination of data among different agencies, and has improved the capacity of the State AIDS Control Societies (SACS) to develop evidence-based state and district annual action plans. The TSU continues to provide technical assistance (TA) in this area and is building the capacity of SACS officers to analyze reports and provide timely feedback to the reporting units from the field.
APAC has supported a three-member Data Analysis Team (DAT) to strengthen the capacity of the M&E division of Tamil Nadu State AIDS Control Society (TANSACS). The DAT is engaged in building capacity of the ART medical officers and M&E officers Each DAT team member focuses on a particular component and provides data quality assurance support on targeted intervention for MARP; care, support and treatment; and basic services. The DAT team is also involved in collecting data for the modeling exercise.
On a request from NACO, APAC has completed district profiling of all the districts in Tamil Nadu. The district profiles give a summary of the estimated number of Most-At-Risk-Populations (MARPs) and People Living with HIV/AIDS (PLHA) and their locations within the district, trends in the epidemic, and service availability and utilization for each district. APAC is also undertaking a data triangulation exercise in Tamil Nadu which will further provide information on the gaps in services and drivers of the epidemic and will help NACO to reclassify the categorization of districts based on the epidemic profile and vulnerability.
APAC has also conducted the twelfth round of Behavior Sentinel Survey (BSS) for MARPs and has pioneered the PLHA BSS. The PLHA BSS will assess knowledge, attitude, behavior and exposure of PLHA to interventions. APAC is also undertaking an impact assessment of home-based care programs and has conducted an assessment among PLHA on their willingness to pay for care, support and treatment services. A new study to track changing dynamics of sex work has also been initiated.
APAC has in partnership with TANSACS and the State Health Systems initiated a public health facility assessment in 270 public sector hospitals. The assessment will provide information on the infrastructure and systems of different divisions in these hospitals and asses linkages between different divisions and HIV/AIDS programs. The assessment also includes a patient satisfaction survey of clients in counseling and testing centers, and outpatient and inpatient utilization of PMTCT, STI, ART and TB services. This assessment will provide critical inputs relating to the integration of HIV/AIDS services within maternal and child health, reproductive health and other services.
APAC has also assisted TANSACS to form a state-level M&E Working Group that allowed major donors to agree to a common set of indicators for joint tracking, and meet regularly to share information and policy. In addition APAC initiated Geographic Information System mapping the prevention and care services in TN. APAC also builds the capacity of NGOs and CBOs in epidemiology and biostatistics and has established strong systems including periodic data quality audits to monitor and ensure quality of information from the field.
During FY11, APAC will continue to provide TA on SI to TN. TA will be through placement of consultants at SACS and supporting assessment/studies for evidence-collection and impact assessment. The project will strengthen the capacity of staff of District AIDS Prevention and Control Units in SI specifically on indicators, Data Quality Assurance (DQA), evidence-based planning, analysis of data and providing feedback to field reporting units. APAC will establish working groups that will review study findings and operationalize recommendations through program improvements and policy changes. APAC will also focus on publishing papers in scientific journals and will use its rich experience gained over years to provide TA to other states on strategic information.
Activity 1: TA to SACS and DAPCUs: (Budget; $141,600) APAC will continue to provide TA to SACS and build the capacity of SACS M&E officers for developing annual action plans, monitoring indicators and establishing systems on data quality assurance. The TSU and DAT will manage and analyze the data received from agencies implementing prevention and care programs from the state. The TSU and DAT will also carry out periodic validation exercises to authenticate data. The TSU and DAT will build the capacity of SACS and DAPCU M&E officers to analyze and triangulate data, develop scopes of works for new assessments, and for publication of papers in peer-reviewed journals. APAC will also develop a data- base of research organizations, institutions and experts that could be used by SACS for its various research and M&E programs.
Activity 2: Supporting needs assessments and studies: (Budget $159,300) APAC will continue to take a lead in undertaking studies on prevention, care, support and treatment programs. In FY 11, APAC will conduct the thirteenth round of BSS for MARPs in Tamil Nadu and the second round of BSS for PLHA. APAC will also analyze information coming from its prevention and care programs and support behavioral and biological assessments. All biological assessments will be undertaken only after appropriate ethical clearance from NACO and PEPFAR. For all studies a technical and expert working group comprising of research experts, program managers and policy makers will be constituted to ensure that study findings are converted into policies and actions. APAC will also focus on publishing papers in scientific journals and will use its rich experience gained over years to provide TA to other states on strategic information.
Activity 3: Data Quality Assurance (DQA): (Budget $44,200)
To improve the standards of reporting and recording APAC would standardize reporting formats and explore the option of web-enabled reporting. APAC will also coordinated with TANSACS to link the project data into the existing state GIS. Data quality audits will be undertaken annually to ensure the quality of data being reported by NGO and other partners. In addition regular joint field visits by the program division and M&E division will organized for improved coordination and response. APAC will also support accreditation of NGOs which would ensure greater accountability and quality of reporting. APAC will train 64 staff from eight NGOs in three districts in the areas of data collection.
The third phase of the National AIDS Control Program (NACP-3) has underscored the need for system strengthening and developing appropriate policies/guidelines to facilitate the scale-up of high quality HIV/AIDS activities. The AIDS Prevention and Control (APAC) Project has in the last few years been actively engaged in health systems strengthening at state, district and community levels. Primary focus has been on leadership and governance, improving effectiveness of service delivery and strengthening information systems for improved monitoring and evaluation.
At the state level APAC focuses on strengthening the health systems of the Tamil Nadu State AIDS Control Society (TANSACS), primarily through assistance to the Technical Support Units (TSU) and technical consultants placed at TANSACS. The TSU has strengthened the capacity of SACS officials in both fiduciary and program planning and management. SACS officials are trained on the national operational guidelines and assisted to develop micro-plans for each officer and department. This has increased the efficiency of SACS officers and in timely roll-out of programs.
The TSU team has also built the capacity of State AIDS Control Societies (SACS) to develop and implement a mainstreaming strategy in the states of Tamil Nadu and Kerala, which has resulted in six ministries integrating HIV/AIDS into their annual action plans and the leveraging of nearly two million USD. These ministries have supported establishment of counseling and testing in hospitals and prisons; provided nutritional support for HIV-infected women and orphans and vulnerable children (OVC); provided safe spaces for People Living with HIV/AIDS (PLHA); and supported income generation programs including procurement of products produced by PLHA and Most-At-Risk-Populations (MARPs). Additionally, the TSU have also built the capacity of SACS officials to engage and partner with the private medical sector for PMTCT, CT and care and support services. APAC provides technical assistance and is engaged in building the capacity of TANSACS to establish and manage the state-supported Trust for OVC. The OVC Trust which is chaired by TANSACS has representations from 13 ministries, and the state government has provided an endowment of $1 million to provide health and social welfare programs to OVC. APAC is also building the capacity of state-level lawyers collective in coordination with TANSACS to provide legal aid support for PLHA and MARPs.
At the district level, APAC is involved in building the capacity of the District AIDS Prevention and Control Units (DAPCU) in program and fiduciary management and for inter-departmental coordination to ensure the government health and social welfare programs benefit MARPs and PLHA. At the community level, APAC builds the capacity of community members in leadership, communication, project management and assists them to form community-based organizations. District and state-level peer education associations of MARPs have been formed and capacitated to plan for community development. APAC is also involved in improving the governance of state and district- level PLHA networks.
APAC is building the capacity of the private sector to take a lead role in HIV/AIDS prevention and care services. In a recent development, APAC has partnered with Tata Business Support Solutions (a company that is part of the TATA business conglomerate) and built their capacity to support a toll-free helpline (Hello +) for PLHA. The technical knowledge and expertise gained through this initiative has encouraged TBSS to plan for a pan-India program.
APAC has also identified and built the capacity of a network of private medical sector clinics for provision of HIV/AIDS care, support and treatment. This initiative is a bold approach to engage the private medical sector which has thus far been reluctant to provide HIV services. This initiative has also strengthened their patient record maintenance capacity, inter-departmental coordination, supply chain management systems and linkages with other NGOs and civil society.
APAC is partnering with the Indira Gandhi National Open University (the world largest distance education service provider) and is building their capacity to support virtual learning programs on a range of health topics. This opens a new dimension in HIV/AIDS training and can substantively reduce the cost incurred in training programs.
APAC has in partnership with TANSACS and the State Health Systems initiated a public health facility assessment in 270 public sector hospitals. The assessment provides information on the infrastructure and systems of different divisions in these hospitals and asses linkages between different divisions and HIV/AIDS programs. The assessment will also grade each hospital's performance and the overall district's performance (cumulative performance of all hospitals combined) and establish systems to improve their performance over a period of time. This would facilitate overall health systems development at the state-level.
APAC is also building the capacity of TANSACS to deliver high quality counseling and testing services. APAC will be supporting a counseling hotline facility at TANSACS to provide 24x7 guidance to counselors and strengthening the capacity of district counseling and testing supervisors through on-site support and exchange visits. The counseling and testing (CT) centers will be graded and APAC will support the individual CT center to develop plans to improvement and achieving performance and quality benchmarks.
During FY11, APAC will continue to provide technical assistance on Health Systems Strengthening to Tamil Nadu, Puducherry and Kerala. Technical assistance will be through placement of consultants at SACS, representations in district, state, regional and national level working groups, and supporting new and innovative initiatives that encourage leadership and system strengthening. APAC will support technology initiatives for quicker and improved decision making, health financing, strategy reviews, gender, integration, mainstreaming, building local leadership and task shifting initiatives.
ACTIVITY 1: Health System Strengthening of SACS, DAPCU and other government health departments: (Budget: $911,000)
APAC will continue to support the TSU, Data Analysis Team (DAT), DAPCU and orphans and vulnerable children (OVC) consultants to ensure system strengthening at state and district level. Individual staff assessments at SACS and DAPCU level will be conducted and mentorship plans will be devolved with consultants. APAC will identify established institutions that are capable of building the capacity of SACS and DAPCU officials on a range of project management and technical topics and engage them to provide support, such that technical assistance (TA) can be institutionalized and a phased exit plan for TSU, DAT and OVC consultants can be evolved. APAC will provide TA to SACS on new and emerging areas such as public-private partnerships, integration of HIV/AIDS programs with other health services, and health financing. APAC will also support a three-member consultant team to be located in the State Rural Health Mission Office, State TB Office and Urban Heath Office to facilitate greater coordination between TANSACS and other health offices and improved integration with HIV/AIDS programs.
ACTIVITY 2: System strengthening of positive networks: (Budget $ 221,000)
APAC will undertake an impact assessment of the system strengthening of PLHIV networks supported by APAC and other agencies. The experiences will be shared with SACS and other agencies and a coordinating committee will be established to identity the type of TA and capacity building programs that can best support PLHA networks. The committee will also analyze areas of resource overlap and evolve appropriate mechanisms to ensure greater coordination between agencies. APAC will provide TA to the Positive Women Network to document their experiences, case studies and challenges and disseminate these to policy makers at the national and state level. APAC will also support a professional management firm to formulate business development and sustainability plans for PLHA networks.
ACTIVITY 3: System strengthening in private sector: (Budget $366,800)
APAC will continue to provide TA to the private sector and build their capacity for an enhanced response in HIV/AIDS programming. APAC will partner with well-established private sector organizations to promote public-private partnerships in HIV/AIDS programs and will continue to support TBSS for Hello+ helpline. APAC in coordination with TANSACS will also support accreditation of the private medical sector hospitals engaged in HIV /AIDS care, support and treatment services. APAC will also support pilot initiatives on health financing and explore task shifting options in private hospitals.
ACTIVITY 4: Building Local Leadership (Budget $ 200,000)
APAC along with TANSACS will support capacity building initiatives with the legislative members and women lawyers to advocate HIV/AIDS issues, address stigma, discrimination and protection of legal and human rights of PLHA and MARPs with a greater emphasis on women. APAC will also establish systems in coordination with SACS and donors to support outstanding and emerging leaders for their contributions to health system strengthening initiatives and HIV/AIDS programs.
Tamil Nadu (TN) has an estimated 115,000 most-at-risk-populations (MARPs), which include Female Sex Workers (FSW) 65,000, Men having Sex with Men (MSM) 45,000, and Injecting Drug Users (IDU) - 5,000. Three agencies the TN State AIDS Control Society (TANSACS), AIDS Prevention and Control (APAC) Project, and the Tamil Nadu AIDS Initiative (TAI), support MARP interventions in TN. There is clear geographical demarcation between the agencies to avoid overlaps. Truckers and migrants are the other two priority groups for sexual prevention. HIV prevalence among FSW (3.6%), MSM (6.6%), and IDU (16.8%) continues to be a cause of concern.
Prevention strategies include: a) saturating coverage of MARPs in urban and high-concentration areas through targeted interventions, b) the Link Workers program (Link Workers are volunteers identified from villages to reach MARPs, vulnerable populations and people living with HIV/AIDS (PLHIV) in rural areas to promote prevention messages and for linkages with care, support and treatment services), c) interventions for short-stay single male migrants and long-distance truck drivers through NGOs and mainstreaming with relevant ministries, d) programs for women and youth, and e) increasing access to condoms, STI treatment and counseling and testing services.
APAC has played a very important role in sexual prevention programs These include: mapping of MARPs in TN; saturating coverage of MARPs in seven districts and Puducherry; establishing Technical Support Units (TSU) to provide technical assistance (TA) to State AIDS Control Societies in TN, Puducherry and Kerala; supporting community-preferred clinics (Nakshatra +) for STI services to MARPs; implementing Link Workers program in all high-prevalence districts in TN with resource support from NACO; and conducting studies for evidence and impact assessment.
TN has demonstrated significant progress in covering MARPs population and increasing access to condoms and STI services. HIV prevalence among MARPs in TN is lower than the prevalence among these groups nationally. However, several challenges still persist in sexual prevention. Key challenges include: inconsistent condom use; limited focus on MSM and IDU; lack of a standardized package of prevention services; inadequate systems for early identification and outreach to new MARPs; limited access to and use of counseling, testing, care and support services; minimal engagement of the community in planning, implementation and monitoring of projects; and low emphasis on comprehensive, structural interventions including programs for addressing violence, trafficking, prevention of second-generation sex workers, and linkages to health and development services
During FY'11, APAC will focus on supporting interventions in three districts to demonstrate saturation and comprehensive combination prevention interventions. APAC will also increase its emphasis on providing TA to State AIDS Control Societies (SACS) and District AIDS Prevention and Control Units (DAPCU) through human resource capacity building, strengthening existing project management systems and supporting need-based assessments. The project will also work with SACS and National AIDS Control Organization (NACO) to transition some of its interventions to the state.
ACTIVITY 1: Demonstrating saturation coverage and comprehensive prevention in selected high-prevalence districts.
APAC will support NGOs and CBOs in three districts for interventions with MARPs. The program will ensure 90% coverage of MARP in these districts. APAC will collaborate with NGOs and condom social marketing organizations to ensure access to male and female condoms in all intervention sites. Regular STI screening for MARPs will be ensured through accompanied referrals to Nakshatra + centers and public sector clinics. Periodic NGO and Health Care Provider meetings will also be organized by APAC for improved coordination and sharing of information. APAC will strengthen the capacity of peer educators to provide quality behavior change communication, mobilize community, and train them on leadership, communication and project management. The peer educators and NGO outreach workers will also be trained on identifying and providing support for MARPs who are HIV infected.
APAC will increase access to counseling and testing (CT) services to MARPs through a combination of accompanied referrals to government CT centers and supporting mobile CT teams to visit NGO sites on a fixed schedule. The importance and advantage of early testing will be highlighted by NGOs and Peer Educators during their personal and group interactions. Through these efforts the project aims to ensure 80% of MARP undergo HIV testing annually. The project will register MARP PLHAs and regularly follow-up to ensure care, support and treatment services. APAC will also facilitate in establishing a corpus fund to support MARP PLHAs on alternate occupations, thereby reducing the spread of HIV/AIDS further. APAC will develop a module for positive prevention specific to MARPs and build the capacity of NGOs to provide positive prevention and follow-up counseling. APAC will adapt the CDC tools on positive prevention. The use of peer educators as lay counselors for positive prevention will also be explored.
Community meetings involving MARPs will be undertaken on a monthly basis to share progress, highlight gaps, track sites reporting violence, and identify new entrants to be reached. NGOs and CBOs will be regularly trained on the importance of comprehensive combination prevention and interventions modified to include behavioral, biological and structural programs. A common minimum package on prevention services will be developed and introduced. Other social and health issues faced by MARPs including access to family planning services, adult literacy, alternate income generation etc will be addressed through trainings, advocacy and linkages with the concerned government departments.
A clear strategy for greater involvement and ownership of the community will be developed for each district in coordination with NGOs, and progress will be regularly monitored. APAC will monitor the progress of activities through regular field visits by staff and consultants, and through experience sharing and review meetings. Annual data quality audits of NGOs will also be undertaken.
In-line with national and PEPFAR priorities, APAC has been gradually shifting its focus from implementation to TA and strategic support. A transition plan will be developed by APAC to shift additional direct implementation activities (including transitioning sub-partners involved in MARP and migrant interventions) to SACS funding. A transition committee involving APAC, TANSACS, NACO and other stake holders will be formed to ensure smooth and phased transitioning. The possibilities for transitioning need to be explored in consultation with NACO.
ACTIVITY 2: Technical assistance to SACS to strengthen interventions with MARPs. Budget amount:
APAC will increase its emphasis on TA to SACS. APAC will continue to provide assistance to the TSUs in TN, Puducherry and Kerala. The TSUs will support SACS to develop evidence-based, district and state annual action plans, and will establish systems for enhancing quality, coverage and community ownership. The TSUs will also take a lead role in providing technical assistance on IDU and MSM programs in these three states. APAC in consultation with NACO and SACS will establish benchmarks for capacitating SACS team and for a gradual transitioning of TSU support
APAC will support a team of technical and financial consultants to strengthen the capacity of DAPCUs to plan, implement and monitor the district action plans, through onsite mentorship support and development of guidelines. The consultants will also build the capacity of DAPCU staff to mainstream HIV/AIDS within relevant government ministries/departments and to ensure that health and social schemes benefit MARPs and migrants.
APAC will support a consultant at SACS for data quality assurance in MARPs programs and for coordination between different agencies for ensuring the "Three Ones" principle. The consultants will also identity potential areas for assessment areas among MARPs and migrants. APAC will also build the capacity of the State Training and Resource Centre (STRC) in the areas of comprehensive prevention, community mobilization, project management, social marketing, and application of the national operational guidelines for MARPs and migrant interventions. APAC will support SACS and STRC to establish a repository of tools, training modules, communication materials and research studies on MARPs and migrants at the state level. APAC will also support the state in developing communication strategies and prototypes for communication materials specific to different populations.
APAC will support a team to provide management oversight to the agencies involved in Link Workers Program. APAC will extensively document the MARPs, migrant and Link Worker intervention experience and disseminate experiences and tools to NACO, SACS and other stakeholders. The three districts supported by APAC will be developed as learning sites for other states to learn on saturating coverage, reaching MARP PLHAs, integration with other health services, advocacy, community ownership, and mainstreaming. APAC will also support a state-level migrant association to demonstrate migrant interventions. This will be different from the existing NGO-managed interventions.
APAC will conduct Behavioral Surveillance Surveys and other assessments, to assess gaps and impact of MARPs and migrant programs. APAC will use the study findings to improve the quality of programs and advocating with program planners for policy change.
Injecting Drug Use (IDU) in India has been predominantly identified with the Northeast region of the country. However, recent estimates point to new pockets of IDUs emerging in Kerala, West Bengal, Orissa, Punjab, Chandigarh, Tamil Nadu (TN), Maharashtra and Delhi (Source: NACO SS, 2007). The estimated IDU population in India is approximately 164,820 (Source: Lancet, Mathers et al, 2008) of which nearly 3,000 IDU are estimated to be in TN and 2760 in Kerala (Source: APAC 2008 mapping). HIV prevalence among IDU nationally is 7.2% with TN and Kerala reporting 17% and 8% respectively.
As per national Behavioral Surveillance Survey (2006), 62% of IDU in TN and 11% of IDU in Kerala continue to use used needles/syringes. In TN, nearly 50% of IDU had not sought treatment for STI despite having symptoms and only 21% had consistently used condom with a commercial/non-regular partner. The scenario is still worse in Kerala with only 12% of IDU reporting consistent condom use with their partners. HIV testing is also a cause of concern with only 22% of IDU in TN and 42% in Kerala reporting ever undergoing a HIV test.
NACO has been vigorously pursuing a harm reduction approach to stem the spread of HIV from IDUs to the general population. A major development in the recent past is the approval by the Government of India (GOI) of oral substitution therapy for IDUs. In TN two NGOs have been implementing buprenorphine substitution programs for more than five years, particularly catering to IDUs in Chennai. An additional three such centers have been planned by the Tamil Nadu State AIDS Control Society (TANSACS). Currently one center in Chennai has been accredited by NACO for providing buprenorphine.
Nine NGOs and one CBO are currently implementing prevention programs among IDU in TN. All nine NGOs and the CBO are supported by TANSACS and they reach nearly 60% of the estimated 3,000 IDU population. TANSACS is planning to support additional NGOs to ensure saturation of coverage. The TN government has supported statewide sensitization of police officials at all levels, which has vastly helped in implementation of prevention programs among IDUs in the state. The purpose of this sensitization is to bring about acceptance of harm reduction as a strategy for effectively combating HIV among IDUs and thereby reducing harassment of IDUs and health workers. 5,372 police men and women in TN were sensitized through this initiative. APAC had supported TANSACS in developing the module and training the trainers.
APAC supports sexual prevention interventions in seven districts of TN and Puducherry. Since the number of IDU in APAC intervention districts is small, APAC is using a "composite intervention strategy" i.e., it has trained its sub partners engaged in other sexual prevention to reach IDU in the intervention areas. A total of 230 IDUs were reached through APAC sub-partners. APAC does not support provision of needles or drugs but is involved in behavior change communication, condom promotion, advocacy, referrals for abscess management, counseling and testing, treatment of sexually transmitted infections, and detoxification. APAC also supported the mapping of IDU in TN, Puducherry and Kerala and provides technical assistance to Kerala State AIDS Control Society for implementing IDU programs.
In FY 11, APAC aims to demonstrate models of IDU coverage using a composite intervention strategy. APAC will also provide TA to TANSACS and Kerala State AIDS Control Society for strengthening existing systems and supporting needs assessments for IDU programs.
ACTIVITY 1: Demonstrating IDU programs through composite interventions. Budget amount: $ 78,000
In three districts (Kanyakumari, Kancheepuram and Trichy) APAC will support composite interventions to reach IDU. Through this initiative, APAC will be able to reach 100% of the estimated 220 IDUs in the three districts and demonstrate the effectiveness of composite interventions in sites that have a smaller number of IDU. APAC feels that this is a cost-effective strategy to reach IDU where IDU numbers are not large.
APAC will support comprehensive programs for IDU following NACO guidelines. Services will include: a) information on HIV/AIDS/STI, b) needle/syringe exchange program (NSEP), c) condom distribution, d) abscess management, e) counseling on safe injection practices and safer sex practices, f) advocacy, g) referrals for substitution therapy, h) care and treatment for IDUs who are HIV positive, and I) referrals for de-addition through linkages established with centers supported by Ministry of Social Justice and Empowerment (MSJE). The outreach services will also focus on spouses and sexual partners of IDU, providing referrals for testing, sensitizing on issues related to IDU and other clinical services. Although NSEP, substitution therapy, condoms and drugs are not supported through USG funds, mechanisms for leveraging these resources have been set- up in line with the national mandate by NACO.
NGO partners will include ex-users as part of the outreach team. This will greatly help, since these ex-users know how to address challenges faced in the area of service utilization and will be have greater acceptance by IDUs. Female members who are part of the outreach team will deliver services among partners/spouses of IDU. This will facilitate uptake of services from spouses/partners of IDU.
Special emphasis will be placed on reaching out to IDU who are HIV-positive and their family members. Services to positive IDU and family members will include distribution of condoms; counseling of safe injecting practices, safer sexual practices and on home care and follow-up for adherence; HIV testing of spouses/regular sex partners; referral to opioid substitution programs and de-addiction services; and linkages to care, support and treatment centers.
APAC will provide training to NGO staff implementing programs among IDU on specific components addressing prevention and care and treatment strategies. Nearly, 25 NGO staff, 5 community health educators and 30 peer educators will be capacitated to provide comprehensive prevention and care services to IDU and their sex partners. Monitoring of services will be done through experience sharing meetings and visits by technical officers and consultants who have experience in implementing programs among IDU.
The composite intervention experiences in IDU intervention will be documented by APAC and shared with SACS, NACO and other organizations engaged in IDU programs.
ACTIVITY 2: Technical assistance to State AIDS Control Societies (SACS) for effective implementation of IDU interventions. Budget: (* included under OHSS)
APAC through the Technical Support Units (TSU) will provide assistance to SACS in TN, Puducherry and Kerala to ensure saturation of coverage of IDUs at the state level. The TSU will also coordinate with SACS to enhance the quality of programs and to accelerate roll-out of medication-assisted treatment for IDU. The TSU will develop a comprehensive prevention-to-care continuum package of services for IDU interventions and will build the capacity of the State Training and Resource Centre to train NGOs engaged in IDU programs. APAC will also identify a panel of national/international consultants and identify learning sites that can be used by the State AIDS Control Officials and NGO staff from these three states. A dedicated website will be established and will function as a repository for communication materials, training modules and research studies on IDU. The possibility of providing telephone counseling to IDU through Hello + (Hello + is a toll free helpline which has been established by APAC in partnership with TATA Business Support Solutions for providing counseling and health education to people living with HIV/AIDS) will also be explored. APAC will also support needs assessments for evidence collection and impact assessment.
