Samastha is a comprehensive HIV/AIDS prevention, care and support project in 15 districts in Karnataka (KN) and 5 districts in coastal Andhra Pradesh (AP). KN and AP have the highest HIV burden in the country and the primary emphasis of the project is on adult care and support in selected districts of KN and AP, with a prevention program focus in rural KN. The Bill and Melinda Gates Foundation (BMGF) has a prevention program focused mainly in urban areas. The Clinton Foundation works in the areas of pediatric care, while the Global Fund supports the community care centers (CCC) through the national program. The prime implementing partner is the University of Manitoba/Karnataka Health Promotion Trust (KHPT), in partnership with several technical and implementing agencies working in close collaboration with National AIDS Control Organization (NACO), the State AIDS Control Societies (SACS) of both states and the District AIDS Prevention and Control Units (DAPCUs).

Key ongoing activities include:

Targeted interventions with rural female sex workers (FSW) and their regular partners, including peer outreach, condom promotion and linkage to sexually transmitted infection (STI), TB and HIV related services.

Focused interventions with rural men and women at risk of HIV, through behavior change programs that emphasize partner reduction, condom use, and access to HIV counseling, testing and care services.

People living with HIV/AIDS (PLHIV) driven facility and community-based care, treatment and support programs with a focus on positive prevention.

Technical assistance (TA) for scale-up and quality improvement in services through the NACO-supported counseling testing services (CT), antiretroviral therapy (ART), TB-HIV integration and community care centers (CCCs).

Health systems strengthening: building human resources for health through training in collaboration with the National Rural Health Mission (NRHM), regional supportive supervision and clinical mentorship; and utilization of program learning sites by state and national level players.

Capacity building of community-based organizations for organizational development, project and financial management.

Comprehensive strategic information (SI) activities including TA for monitoring and evaluation (M&E), with individualized tracking for FSWs and PLHIV.

Mainstreaming orphans and vulnerable children (OVC) interventions with the NRHM, the Department of Women and Child Development (DWCD) and the Panchayati Raj Institutions (PRI).

In FY10, the restructuring of the project's geographical focus will increase beneficiary coverage from 41% to 61% of rural sex workers clustered in eight districts of KN. Comprehensive prevention programs for the general population programs will continue in five northern districts, with a focus on reaching men and women with high-risk behavior. Integrated positive prevention and care interventions through drop-in centers (IPPC-DIC) driven by networks of PLHIV will continue in 12 districts.

In FY10, the last year of the Samastha project, direct implementation will be consolidated to move towards increased provision of TA. Samastha support to the national rural link workers scheme (LWS) within NACP-3 will continue. The LWS seeks to connect high-risk populations with HIV services at government health facilities. Learning sites including Bagalkote district for rural HIV programming, Pragathi-Bangalore targeted intervention (TI) for FSWs, Sangama-Bangalore for men having sex with men (MSM), and Snehadaan-Bangalore for care and support will serve as experiential learning sites for state and national level players. The Samastha TA to NACO for research and M&E activities will continue.

In KN, the sustained demand for TA in the areas of CT, ART, HIV-TB activities, capacity building, communication, gender integration, convergence across different health initiatives and strengthening of DAPCUs will be met. The support to the design and start-up of a university-recognized HIV fellowship course with the Rajiv Gandhi University of Health Sciences (RGUHS) will continue. Other TA to the government including scaling up of capacity building through the project's Regional Training Centers to train doctors, nurses and counselors with HIV team-training, clinical mentorship, and the Samastha HIV e-learning package (HELP) will continue.

In AP, increased priority will be given to TA for scaling up coverage and quality of state funded CCCs, while retaining the focus on community-based care programs for HIV-affected widows and orphans. Experiential learning sites and systems for clinical mentorship will be developed collaboratively with other state level partners.

Samastha has played a leadership role to operationalize convergence at the district level across health systems. It will continue to strengthen the integration of the PMTCT services with antenatal, delivery and postnatal services of the $8 billion NRHM program. It will continue to promote a synergistic use of materials; equipment, logistics and human resources within NRHM and NACP-III for joint trainings of service providers. It will collaborate with the State Institute of Health and Family Welfare (SIHFW) under the NRHM for various training initiatives. For example, the Integrated Management of Newborn and Childhood Illnesses (IMNCI) package includes a revised curriculum to integrate training on HIV, STI, and TB services to participating health care providers. Samastha will continue to build the capacity of the village health and sanitation committees (VHSC) under the NRHM to address gender inequity, and the community-based organizations of PLHIV, FSWs and MSM and the primary health care systems within the state as part of sustainable programming.

SUMMARY

The Samastha project focuses primarily on care support and treatment in Karnataka (KN) and selected districts of Andhra Pradesh (AP), the two states with the highest burden of HIV/AIDS. Activities are managed at the district level by University of Manitoba/Karnataka Health Promotion Trust (KHPT) regional staff in Karnataka and LEPRA society in Andhra Pradesh. Engender Health, St. John's National Academy of Health Sciences, NIMHANS, Swami Vivekananda Youth Movement (SVYM), Kempegowda Institute of Medical Sciences (KIMS), Karnataka Network of Positive People and Snehadaan are other implementing partners working in close collaboration with NGOs and the government at district and state levels. The Rajiv Gandhi University of Health Sciences is a proposed new partner.

In FY10, the activities under this program area will increasingly shift from a direct implementing mechanism to one of technical assistance (TA) as the national and state program expands its own care services across the state. Contributions to the national guidelines for the community care centers (CCC) for children and adults, leadership of the technical working group at state level, and partnerships for development of human resources for health will continue. The project's support to select CCC as learning sites to demonstrate delivery of comprehensive HIV services implementing National AIDS Control Organization (NACO) guidelines will continue.

The project supports people living with HIV/AIDS (PLHIV) led HIV care and support services in 12 districts in KN and five coastal districts of AP through 18 community-led drops in centers called Integrated Positive Prevention Care (IPPC) centers which serve as drop-in centers (DIC). Outreach activities with the family centric approach will continue with special efforts to reach out to children and women. Efforts to sustain the coordination between various HIV services in the districts and institutional capacity building of the State Institute of Health and Family Welfare (SIHFW) under the National Rural health mission (NRHM) will continue. Efforts at quality improvement will be sustained by supportive supervision and clinical mentoring visits. The Samastha project efforts to ensure that more CCCs provide one-stop services for HIV care will continue.

ACTIVITIES AND EXPECTED RESULTS

Activity 1: Providing TA models for Adult Care and Support

a) TA at the national level

TA for NACO in development of guidelines for adult and pediatric care and support will continue. TA for the CCC program in AP through its learning sites, clinical mentorship and quality monitoring and tracking of adult care services through computerized management information systems (CMIS) will continue.

b) TA for Global Fund-supported CCC under the national program

Samastha project will continue to provide TA to the Global Fund supported CCCs in KN through team-based trainings, clinical mentorship and supportive supervision through regional managers and DAPCU medical officers at a facility level. The team -based trainings target doctors, nurses and counselors and focus on the delivery of a comprehensive sequence of care involving task-shifting and task sharing. "Expert patient trainers" (EPT) who are PLHIV trained to simulate case studies are used. On-site clinical mentorship provided periodically by a team comprising an experienced doctor, nurse and counselor provide a model for a change in practice. Regional managers provide the supportive supervision and facilitate linkages required for comprehensive care. Based on simple semi-structured registration and clinic contact input forms, the individualized MIS tracks PLHIV and can generate reports required by the national program. Advocacy with NACO to adopt this computerized system will continue. Additionally, as part of the Technical Working Group at the State, the project will advocate for institutional capacity building of district AIDS control units (DAPCUs) to monitor the CCC for quality improvement.

c) Development of model CCC learning site for quality HIV care and support centers:

The project will support learning sites that will demonstrate delivery of combined CT, antiretroviral therapy (ART) and CCC services within a single institution and CCC as best-practice experiential learning sites for various thematic areas such as orphans and vulnerable children (OVC), integrated care, PMTCT, ART and palliative care. Key elements of the learning sites will be the provision of comprehensive medical, social and other interventions, integrating with community based outreach and monitoring of individuals using a computerized management information system (CMIS). These sites will be used both for training visits of SACS (State AIDS Control Society) officers/directors and technical support unit (TSU) staff, as well as for experiential learning for program implementers. Additionally participants of the HIV Fellowship course instituted at the Rajiv Gandhi University of Health Sciences (RGUHS) will also be trained at these sites in Karnataka.

d) TA to NRHM and SIHFW to mainstream HIV care:

The project will continue to provide TA to the NRHM and the Karnataka State Institute of Health and Family Welfare (SIHFW) to build the capacity of primary health care providers. The main areas of capacity building for health care providers will be on the integrated HIV-STI-PMTCT-adult care and treatment training package (ITP); infection prevention and reduction of stigma discrimination in health care settings, sexually transmitted infection (STI) and TB services. These trainings will be done in collaboration with District Training Centers under the SIHFW and the regional training centers.

e) Human resources for health

In FY09, the Samastha project advocacy efforts with the state government and the Rajiv Gandhi University of Health Sciences in Karnataka resulted in the approval of the first-ever university-recognized HIV fellowship course in India. The project will continue to provide TA and start-up support through two training sites to ensure that the course successfully gets off the ground. In 2010, efforts will continue to be made to leverage resources to sustain this fellowship on a long-term basis through partnerships with the national program and other international universities.

Activity 2: Provide community-led initiatives for HIV care and treatment services

a) Support to and transition of PLHIV-led IPPCC-DIC for sustainable programming

The project will continue to support 18 IPPC-DIC. Leveraged support from KSAPS and other donors will increase. These centers will shift to the government ART centre sites, yet offer safe spaces for PLHIV in addition to complementing outpatient medical care with psycho-social support, positive prevention, adherence support, home-based care, nutrition and linkages to legal, vocational services and other social entitlements. About 16,000 adults and children will receive at least one care service, while about 12,000 will receive at least one clinical care. Six thousand adults and children will receive cotrimoxazole prophylaxis, and 1,200 will receive TB treatment through effective referrals to government programs.

The management responsibilities of IPPC DICs will be transitioned from NGOs/KHPT to the community-based District Level Networks (DLNs). The project will focus efforts toward transitioning IPPC-DIC into funding by other partners and KSAPS in FY2010.

b) Strengthening the community home-based care

NGO link workers and IPPC-DIC outreach workers will continue to make home visits to provide home-based care to PLHIV and their family members. Coordination with other field level functionaries will be ensured to avoid duplication of efforts. The focus will be on identifying the social needs of PLHIV and their affected children and ensuring adherence of PLHIV to treatment. About 6,000 adults and children will receive supportive care services through this outreach.

c) Community- based strengthening of linkage and referrals

Linkages between ICTC, ART, IPPC-DIC, RNTCP and CCC will be strengthened through accompanied referrals, follow up and coordination meetings. At the community level, lead NGOs will provide outreach, home-based care and follow up on referrals. Village Health and Sanitation Committees (VHSC) will be strengthened to address stigma and discrimination and respond to care needs of women and children.

Activity 3: Ensure and sustain quality of services

a) Quality through capacity building, supportive supervision and mentoring.

The project will continue to build the capacity of care providers from both within the project and beyond. The five regional training centers' (RTC) capacity to leverage resources and independently conduct integrated STI-PMTCT-HIV care training will be strengthened. Engender Health will continue to provide technical support in quality improvement, HIV-TB and OVC. Clinical mentoring visits will continue by the training partners. St Johns e-learning, Snehadaan's best practice learning site for care, the university-approved HIV fellowship course will offer different forums for human capacity development.

b) Improving infection control in all CCC in KN and coastal AP

The project will continue to do follow up visits to practice and institutionalize protocols for infection control. It is envisioned that all CCC will have a system in place in regard to infection prevention practice and a policy for reduction of stigma discrimination in health care settings.

c) Facilitation of operational research assessments

Although the risk of HIV transmission in long-term married partners is well documented, initial assessments have demonstrated that the use of 'positive prevention' is very limited among HIV infected sero-discordant and concordant couples. In FY09, the project will focus on assessment of barriers to positive prevention and use its findings to advocate for better programming. Additionally, an end term assessment of the impact of the scale up in HIV care which will also include elements of cost-effectiveness of models for care will be completed.

SUMMARY: The University of Manitoba/Karnataka Health Promotion Trust (UM/KHPT) Samastha Orphans and Vulnerable Children (OVC) program -implemented with technical support partner Engender Health- is a community based approach. It addresses the six core service areas (nutrition, health, education, psychological support, shelter and protection) including the underlying theme of economic opportunity strengthening to ensure sustainability at the family unit. The program adopts a family-based approach to ensure sustainability in the child's unit/setting. The focus is on: building the capacity of the family, developing community safety nets and work with national, state and local government schemes to strengthen systems to address OVC needs. This ensures access to healthcare, nutrition, education services and builds community systems to safeguard OVC protection and legal issues. The target population will include all children (<18 years) orphaned and/or affected by HIV and AIDS, their families/ caregivers and communities in the 12 Samastha districts in Karnataka and in one district in coastal Andra Pradesh (AP). It aims to reach 3,000 OVC with PEPFAR funds. The OVC program is comprehensive and adopts increased data development for strategic planning, systems strengthening, policy development, community support and coordination, and quality assurance in service delivery.

Some of the successes of the program thus far include: the enrollment of a high number of OVC into the Samastha program; the development of different care models including community foster care, community short stay homes and community local body participation in care support; significant leveraging from donor, government and community support for basic needs of OVC; and the enhanced quality of clinical care through facilitation of HIV integrated management of newborn and childhood illness (IMNCI) package in Karnataka. Additionally, a mechanism has been developed for estimation of OVCs at the district level which is now used at the national level. It has also work to establish the participation of key government departments in m to the needs of OVCs.

However, challenges still exist. These include: Inadequate resources to provide the full-fledged support for the large numbers of OVC in the program. Inadequate human resources to ensure child specific planning and intervention as per the requirement of the child Working with aged caregivers to provide quality care for their children Attitudes of stigma and discrimination in the rural population

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Increasing access to quality services for orphans and vulnerable children (OVC)

A) Leverage funds from different government and private sources The OVC program leveraged services and support from various donors, government and philanthropists to cater to the nutrition, education and transport needs of OVC. This includes secondary and tertiary medical care. Project staff have generously contributed to continuous support for OVC interventions. The program will continue to source out funds from other entities and to scale up government services. Priority to actively ensure that all children eligible for ART access ART services in a timely manner will continue. Life Skills Education (LSE) will continue to be rolled out to build the resilience in OVC.

B) Strengthen family/household capacities The OVC program recognizes that the success of sustainable quality care of OVC is directly related to the development of the capacity of the family / household. The program will continue to train the caregivers to provide quality nutrition, education, shelter, access social entitlements in case of need and safeguard their rights. 300 caregivers will be trained in home based care, home care kits and ART adherence. They will also be trained to access ART services and to provide better care for their children. Vocational training will be leveraged to address their economic well-being.

C) Develop community support and coordination The implementing nongovernmental organizations (NGOs) and community-based organizations (CBOs) will actively engage the community -including Village Health and Sanitation Committee (VHSC) and community volunteers- to scale up support systems and define policy to protect and support the basic rights of OVC. The community will be involved in the reintegration of OVC within their community. Community support for nutrition, education and travel requirements will continue and innovative strategies like community farming will be explored.

ACTIVITY 2: TA for convergence of government departments including policy development for OVC

The Samastha program works with various levels of government to provide system strengthening at the state and the district level. Engender Health has been part of the peer group review of the National guidelines for Care and Support for Orphans and vulnerable children. Karnataka Health Promotion Trust (KHPT) will pilot the NACO OVC model initiative in the two districts of Bagalkot and Belgaum. This initiative will explore mechanisms of ensuring that basic needs of all OVC including nutrition, shelter, psychological needs, medical care and legal support are met through community based mapping and identification of children and the resources to meet their needs, linkages with the different government schemes and programs and monitoring and supportive supervision to ensure quality.

The Samastha team will continue the process of technical support and system strengthening with the Karnataka State Institute of Health and Family Welfare (SIHFW) in rolling out the HIV integrated management of newborn child infections (IMNCI) package through Engender Health.

The program has been responsible for leveraging a significant amount of funds ($ 0.25 million) for the Department of Women and Child Welfare Department and will continue to work with the department to provide technical support in program design and implementation to cater to the nutrition and shelter needs of OVC in Karnataka. An attempt to develop a convergence strategy between the departments of women and child development, education, food and civil supplies and housing is being sought to catalyze an appropriate response for OVC.

ACTIVITY 3: Address quality assurance in service delivery

Activities will be monitored with the help of the management information system (MIS) and qualitative reports, site visits and interaction with the caregivers and children under the program. Facilitative supervision and program supportive monitoring will enhance the technical support at the field level and bring about ongoing program quality improvement. The child health record that has been designed is now available in all the districts and this will serve as a tool for monitoring the child's status. A family assessment tool has also been developed to identify family units that are most in need. This tool will be used in all Samastha districts to identify and link family/child-headed units with government and nongovernment schemes for OVC and their mothers.

Summary

The focus of program activities under this budget code narrative was initially on supporting the scale up on ART services in the private and non-government sector in Karnataka (KN). This was done to complement the National AIDS Control Program phase III (NACP-3) scale up in the government sector. The current focus is on technical assistance (TA) for this scale up in coverage, comprehensiveness and quality of the antiretroviral therapy (ART) services. Samastha project will continue to support three sites which provide ART; St. John's Medical College and Hospital (SJMC), Kempegowda Institute of Medical Sciences (KIMS) -which are NACO designated ART centers- and at the Swami Vivekananda Youth Movement centre at Sargur -which is designated as a link-ART center at sub-district level. These sites will not only be service delivery points, but will also be involved in building the technical capacity of care providers for ART services across the state, as learning sites and for implementation of the HIV Fellowship course.

The technical consultant supported at the state level since the FY08 will continue to be supported under Samastha. The mentorship for counselors in ART centers initiated in FY08 will continue. Samastha will continue to input into the adult treatment initiatives, the linkages with TB-HIV, ICTC and TI and the leveraging of other supportive services through the technical working group created for this purpose. The Rajiv Gandhi University of Health Sciences (RGUHS) will continue to be supported with TA to implement the HIV Fellowship as well as to leverage funds from other sources to sustain the effort. A commitment has already been made by the government at the state level to absorb the successful candidates from this fellowship into the ART centers.

An internal analysis showed that lost to follow up (LFU) occurs at the following three levels:

From the CT site to registration at ART center,

Between pre-ART registration and initiation of ART and

After the patient has been put on ART

Samastha project had initiated district-level coordination meetings involving all prevention, treatment and care and support partners in FY08. These meetings are now being convened by District AIDS Control Unit (DAPCU) medical officers. At the meetings, lists of loss to follow up of those on ART are shared with the concerned CCC and Integrated Positive Prevention and Care Drop in Centers (IPPC-DIC) field staff. This has helped trace and retrieve a number of LFU cases. The challenge to reduce loss to follow up and death rates among those on ART will be addressed through coordination and collaboration of all HIV workers at the field level; health system strengthening efforts with a focus on strengthening the role of the DAPCU; and better monitoring and evaluation to explore the determinants of non-adherence and cause of death. Direct community level mobilization of PLHIV by Samastha field level workers will focus on improving access for women and children for treatment services, improved quality of care through training programs, clinical and counseling mentorship through St John's Medical College and Hospital and the implementation of the Client Oriented Provider Efficient (COPE) tool by Engender Health.

Activity 1: TA at the state level

A) Consultant Support

The consultant for ART services at the Karnataka State AIDS Prevention Society (KSAPS) will continue to be supported under the Samastha. Additionally, a technical working group appointed by KSAPS will continue to provide TA to determine locations, establish links, leveraging of resources for comprehensive care and for strategies to reduce the loss to follow-up at the ART centers. Training and capacity building plans for ART services will be drawn up by this group. The location of additional ART centers will be decided based on evidence gathered from triangulation of data available with KSAPS and other studies. The links with CCC, CT , HIV care sites implemented by positive group networks, NGOs working with targeted interventions and the rural link worker scheme will be strengthened through district level coordination meetings convened by the district AIDS control unit (DAPCU) and facilitated by Samastha. Operational guidelines development for IPPC-DIC, technical support and review meetings will continue to be the responsibility of the technical working group. ART services need to be complemented with adequate nutrition and other measures to increase accessibility. Location of link ART centers, leveraging nutrition from other sources and departments and advocating for free/concessional travel will also continue to be guided by the technical working group (TWG).

B) Improve the quality of service delivery at ART Centers

The project will continue to build the capacity ART center staff through continued e-learning opportunities. The HIV fellowship course will create the pool of trained doctors who could be offered positions within the ART centers. The ART sites will be provided ongoing technical support and supervision by Engender Health and KHPT. The site staff will be trained to use COPE© Quality Improvement tools to ensure high quality ART services at the site. Samastha will continue to support the mentorship of ART counselors to perform this function.

C) Human Resources for Health

Advocacy efforts made by Samastha project with the state government and the Rajiv Gandhi University of Health Sciences in Karnataka resulted in the approval of the first ever university-recognized HIV Fellowship course in India. Samastha will continue to provide TA and start-up support through its training sites to ensure that the course successfully gets off the ground. In FY 10, efforts will continue to be made to leverage resources to sustain this fellowship on a long-term basis through partnerships with the national program and other international universities.

Activity 2: Complement government ART services with ART services in non-government sector

In FY09 and FY10, the project will continue to provide significant site specific support in the form of personnel. A plan will be drawn up with the institution to absorb these personnel as regular staff of the institution in a phased manner. These sites function both as service delivery points for antiretroviral treatment and for hands-on experiential learning. 300 adults and children will be newly enrolled on ART, 1,000 will receive ART during the year and 700 will receive ART for more than 12 months.

Activity 3: Establish reduced rates of lost to follow-up (LFU) cases of uptake of HIV related care and treatment services

a) Field based outreach and community-based networks

Samastha project staff will continue to provide field-level tracking of PLHIV on ART and facilitate transportation to the ART center for timely follow up of both patients on ART and those registered as pre-ART. Additionally, peer outreach workers and link workers (LW, a cadre of workers tasked to link prevention sites with care and support and CT services) will be trained to support post-test counseling and follow up for ART registration for those testing positive. Attention will be paid to ensuring that pregnant women testing positive are followed up to get registered and access ART services. Those on government provided ART who have been lost to follow up will be traced and retrieved onto ART services by link workers covering rural areas, peer outreach workers of the PLHIV- led drop-in centers (DIC) in villages not covered by the LW scheme and by the community care centre (CCC) outreach workers in the urban areas.

b) Computerized individual tracking system (CMIS) for effective monitoring of LFU

In FY10, Samastha will support a NACO request to develop CMIS software that facilitates the individual tracking of uptake of services from the time of diagnosis at the ICTC level. Additionally, operational research to understand causes of high death rate among those on ART, that will be completed in FY09 will be documented and disseminated in this year.

SUMMARY

The Samastha project will continue to implement a modest CT program with increasing focus on provision of technical assistance (TA) for efficient delivery of quality CT services and linkage of CT with other prevention and care related interventions.

Under the National AIDS Control Program III (NACP-3), there was a significant scale up in the number of CT throughout the country. Karnataka (KN) now has 561 full-fledged CT sites in the government sector, 50 in non-government settings under the public private partnership initiative and 30 mobile CT sites. It is planned to launch integrated CT services under the National Rural Health Mission (NRHM) in at least 596 "24-hour" primary health care (PHC) centers by early 2010.

In FY08, district supervisors were appointed by the state to provide administrative support to the CT services as part of establishment of the decentralized district AIDS control Units (DAPCU). The Samastha project provides TA for the capacity development of the district supervisors through in-service training and supervision.

Since FY08, the Global Fund supports a resource pool of trainers and mentors for the CT counselors, with Bangalore University serving as the regional training centre. Hence, Samastha will transition out of service delivery and supportive supervision of CT sites. However, on request from the state government, the project will develop two of the existing CT sites as model learning centers for KN to showcase optimal use of Standard Operational Procedures (SOP) and adaptation of NACO guidelines. These sites will be linked to the existing counseling training institutes supported by the Global Fund initiative to serve as on-the-job training opportunities for integrated counseling and testing center (ICTC) personnel including laboratory technicians, counselors and doctors.

A TB-HIV intensive program was rolled out in FY08. Under this program, all newly diagnosed TB patients are also offered HIV testing and counseling. Samastha provided TA to the implementation and scale up of the TB-HIV initiative. Currently the coverage of CT services to an annual estimate of 55,000 newly diagnosed TB patients has increased from about 10% to more than 50% in the state. The project will continue to provide TA to support this initiative.

STI clinics under NACO have been approved to have a counselor. TA is provided for the capacity development of the counselors in the STI clinic to ensure effective provider initiated counseling and testing of all STI patients at the ICTC.

The project will continue to work in close collaboration with NIMHANS and KSAPS to strengthen the delivery of quality CT services.

Some of the challenges that persist include:

Poor quality of services and laboratory testing.

Poor forecasting and inventory management within procurement systems.

Inadequate access and coverage of female sex workers and transgender men who have sex with men with HIV counseling and testing services.

Inadequate links between the CT, TB and ART services.

ACTIVITIES AND EXPECTED RESULTS

Activity 1: TA for Institutional capacity building for quality CT service delivery

a) Development of model CT learning sites (LS)

This activity is a continuation of initiatives under PEPFAR funded Samastha project that commenced in FY09. Two LS will be initiated one each in north and south Karnataka. In collaboration with the Global Fund supported training institution developing cadres of counseling mentors, the USG supported LSs will provide hands-on training and skills to complement their knowledge. These sites will aim at achieving all the quality and quantity indicators of an effective ICTC program such as the use of standard operating protocols, external quality assurance for laboratory tests, links with sexually transmitted infection (STI), TB, antiretroviral therapy (ART), community care centers (CCCs) and targeted intervention (TI) programs and services and a computerized MIS system that links different services. The lab technician, counselor and medical officer at the LS will be trained to become efficient trainers and facilitators. A total of 300 clients, male and female will be reached with CT services using PEPFAR funds at these two sites.

b) Improving the quality of CT services

Tools for onsite supportive supervision and mentoring for doctors, counselors and laboratory technicians will be developed and pre-tested at the LS. The supportive supervision tools will measure client intake, stigma and discrimination and quality of counseling services and testing records. District supervisors will then be trained in the use of these tools through the Samastha project which provides TA to the induction, refresher and other trainings for district supervisors. Periodic client exit interviews will continue to be undertaken to identify training needs for development of refresher course curricula. One batch of 30 district supervisors will receive in-service training in the use of supportive supervision tools. TA will be provided for implementation of NACO recommended quality assurance mechanisms such as EQAS. A quarterly newsletter will continue to be published to highlight new guidelines, achievements, success stories and challenges faced through a case-based approach.

c) Logistic management information system (LMIS)

The LMIS in place at KSAPS will be sustained to support procurement, distribution and projection for the requirements of HIV test kits and supplies.

Activity 2: Expanding Access to quality CT Services for most at risk populations (MARPs)

As a national strategy CT sites are expected to undertake provider initiated testing for all patients with STI, TB and for pregnant women. However, MARPs will have to be reached beyond the walk-in (voluntary) clients. To reach out to MARPs it is essential to make CT sites more friendly and accessible. Samastha will conduct one 'Training of trainers (TOT) program for 30 participants and the roll-out will be done through leveraged funds from Karnataka state AIDS Control Society (KSAPS) and other sources and monitored through Samastha.

Mobilization of MARPS to test at CT centers will complement NACO's approach on provider initiated testing. Clients will be mobilized through NGO outreach teams including female sex workers (FSWs), peer educators, link workers and men who have sex with men (MSM) outreach activities and through outreach work by the counselors. Peer educators will be trained and encouraged to get to know their own HIV status. They will then be supported to accompany other peers to access CT services. At least 6,000 FSWs will be reached with CT services at least once during the year. Regular outreach to TI clinic sites from existing ICTC is already in place in a few districts. This will continue to be facilitated in all Samastha districts in close coordination with the DAPCU. Those newly diagnosed with TB and STI will also be offered HIV counseling and testing. Links with the nearest TB facility will be developed for cross referrals.

Activity 3: Facilitation of convergence and mainstreaming activities to increase uptake

To link the sites effectively with existing prevention and care services in both government and non government settings, outreach from the CT to targeted intervention sites for FSW and MSM-transgender sites will continue. This helps to increase the accessibility and coverage of counseling and testing services for those most at risk for HIV, but otherwise marginalized. Link workers (LW- a cadre of community based workers tasked to link CT and ART services at prevention sites) and peer outreach workers from the people living with HIV/AIDS (PLHIV) led drop in centers (DIC) placed at select CT sites will be trained to support post-test counseling.

SUMMARY:

The University of Manitoba/Karnataka Health Promotion Trust (UM/KHPT) Samastha program will continue the Pediatric Care and Support activities implemented with technical support partner Engender Health. The program caters to the needs of institutional based children, while addressing the core components of nutrition, shelter, protection, health care, psychosocial support and education. This initiative will continue to provide quality HIV care services at facility-based care units for children in the six core areas addressing access to health services including immunization, facilitate social entitlements including government schemes and community-mobilized support. The program caters to issues of protection and shelter services as well as capacity building of caregivers. The initiative is implemented with the principle of reintegrating these children into to their communities.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: Accessing quality care services for institution-based children

Through these activities, four facilities will be supported in Karnataka and one in coastal Andhra Pradesh. The facility-based children will be provided with quality care that addresses the six areas and these primary direct services will reach at least 200 orphans and vulnerable children (OVC) with overall care and 150 OVC (see narrative on OVC) with clinical care. Additionally, these centers will also serve as referral units for the transition stage of home and foster-based care models.

Nutrition assessment activities are implemented including regular monitoring and capacity building related to addressing malnutrition through medical services. Leveraging of nutritional support from the local to state and national level will be explored.

Healthcare, including regular monitoring for opportunistic infections (OI) and initiating assessment for ART are carried out and linked to government ART centers. Other government services including ICTC, TB DOTS and immunization are facilitated.

Various approaches are being facilitated to address educational needs of these children through regular school systems to open school curriculum. Strengthening of local government education systems and schemes catering to the needs of children will be prioritized. The program will build on the activities to facilitate vocational training opportunities for older children that results in a sustainable livelihood skill set. Additionally, a value-based educational system is being explored in the facility-based settings.

ACTIVITY 2: Quality Improvement of OVC Services:

The program enhances skills through capacity building of the three specific target groups which include the counselors, clinical team and the support staff at the centers. Capacity building addresses an array of themes like assessment of nutrition, psychological well being and child centered communication and child participation, education options, health including home-based care.

The pediatric HIV and ART skills of the clinical team that have been developed through the integrated HIV-STI-PMTCT package training for health care providers will be enhanced through mentorship and supportive supervision. Life skills education (LSE) activities will be sustained and new age specific groups will be formed as the adequate numbers are met to initiate the activity in these pediatric care and support centers. About 200 children will be reached with the LSE package.

Quality assurance at these units will be monitored and assessed through a management information system (MIS) and qualitative narrative reports as well as mentoring site visits and supportive supervision.

ACTIVITY 3: Technical assistance (TA) at national and state level:

The project will participate in the national pilot to operationalize the USG supported operational guidelines on implementing quality OVC programs. Two districts will be developed as learning sites in Karnataka and one in AP. These projects will demonstrate how pediatric care is mainstreamed and linked to existing institutions in government and non-government sector to address clinical care, nutrition, education, shelter and protection needs of OVC, reaching out to children in both urban and rural areas.

ACTIVITY 4: Leveraging from the other national health system programs implemented by Department of Women and Child Development (DWCD), NRHM and by the private sector for child care:

Samastha project has successfully leveraged Indian rupees 10 million (about $ 0.25 million) from the state government to the DWCD to meet the immediate nutrition and travel needs of children and women infected and affected by HIV. TA will continue to guide the DWCD to leverage support from the departments of education and food and civil supplies and from its own integrated child nutrition program.

Through leveraging support from the private sector such as the Deshpande Foundation and K2 solutions, children have been placed in foster care units that enable siblings to stay together irrespective of HIV status, under the care of an affected widow. About 300 children are covered under this initiative.

In an effort to mainstream pediatric care, the Village Health and Sanitation Committees (VHSC) are being galvanized to take responsibility and ownership for widows and children infected and affected by HIV. About 300 VHSC will be trained on OVC care and support.

SUMMARY

The main objectives of the program activities under this technical area in FY10 are (1) to sustain quality of program generated output data; and (2) to build capacity of the partner organizations and State AIDS Control Societies (SACS) of USG priority states to analyze data for evidence-based programming.

The Samastha project focused on developing and implementing a web-based computerized management information system (CMIS) for the USG supported link worker prevention program for rural female sex workers (FSW) and high risk individuals in Karnataka; and for the care and support program in Karnataka (KN) and Andhra Pradesh (AP). While the Global Fund supports the implementation of care services through community care centers (CCC) under the national program, the USG supported Samastha project has provided technical assistance (TA) in the USG priority states for developing a monitoring and evaluation (M&E) framework, implementing web-based CMIS and capacity building of the program staff. Additionally, the project has provided TA to the national program on data management and analysis and mentoring visits to the Global Fund supported CCC. As the national AIDS program has rapidly scaled up services in counseling and testing (CT), antiretroviral therapy (ART), community care, and prevention for MARPS, the quality of data continues to remain a challenge. While quality maintenance of source documents in settings with high client volumes and inadequate time for on-time recording is a well documented concern, staff competency and staff attrition are other factors impeding data management and optimal use of strategic information (SI).

The USG-supported CMIS developed under the Samastha program supports a unique tracking system for long-term target groups, including FSW and people living with HIV/AIDS (PLHIV) and orphans and vulnerable children (OVC). Based on the ease of generating periodic reports from the CMIS developed in Samastha that involved management and analysis of huge data-sets, National AIDS Control Organization (NACO) has requested TA for scaling of the CMIS at the national level.

In FY10 the SI component under Samastha project will focus primarily on provision of TA to the national program for optimal use of SI in program management and monitoring.

ACTIVITY AND EXPECTED RESULTS:

ACTIVITY 1: Improving quality of data through regular data quality audits and analysis of CMIS data for results based performance.

A) Conduct of regular data quality audits:

This is a quarterly activity and will be carried out at the district levels. Tools for regular audits are administered by a data quality audit team comprising the regional manager, deputy director (zonal) and zonal M & E officer who visit the district level entities. The audit team will randomly select records of CMIS and cross verify with source documents.

B) Decentralization of knowledge management at district level:

The zonal CMIS officer and the regional manager will be trained to share the district level CMIS data with the district-level implementing partner in monthly review meetings. A computerized dashboard indicator report with detailed district, sub-district and sub-partner level analysis of coverage, time-trend analysis will facilitate analysis.

C) Clinical mentorship and supportive supervision to ensure data capture:

The Samastha project uses only two input forms for adult care and treatment initiatives; a one time registration form and a clinic encounter form. The form has different elements based on a comprehensive sequence of care and includes assessments of clinical stage, nutrition, TB status, family planning, ART adherence, positive prevention and management of opportunistic infection (OI). Clinical mentorship and supportive supervision will use role-modeling, task shifting and task sharing as means to address this challenge.

ACTIVITY 2: Sustaining capacity of the partners to use evidence-based planning using program data

A) Monitoring program coverage and quality assurance

In addition to the PEPFAR targets, Samastha has devised internal milestone indicators to monitor the achievements of the program. The milestone indicators are denominator-based where the denominators are calculated on the basis of projected target group population in the operational area. The milestone indicators are sub-indicators of the PEPFAR indicators. In addition, some indicators are introduced to monitor most-needy sub-groups in the target population. Every quarter the M&E unit presents district- level analysis to the program directors and deputy directors and the major focus of the next quarter is decided. In FY10, 60 participants will be trained on data triangulation using data from multiple sources (Program data and data from public sector HIV/AIDS program).

B) Measuring the reach and effect of communications on target audiences

This activity constructs communication messages on the basis of results from the segmentation study for high-risk individuals, female sex workers (FSWs) and PLHIV. An output tracking survey will be carried out in every quarter to assess the effectiveness of the communication messages and the messages will be modified on the basis of results from output tracking survey.

C) Operational research to enhance knowledge about program implementation and to identify major opportunities and gaps in the program design

The operational studies include (1) effect of formation of income generating self-help groups (SHGs) on health status of PLHIV (2) determinants of nutrition among children infected and affected by HIV (3) factors leading to lost to follow-up cases on ART.

ACTIVITY 3: Conduct assessments to monitor outcome of the program in its last year of implementation

A) Evaluating program impact on risk behavior

The third round of Polling Booth Surveys (PBS) will be carried out to study change in sexual risk behavior in the general population as well as among FSWs. PBS is a simple evaluation mechanism to provide confidential self-administered assessments of behavior change. The sample population is guided through a set of structured questionnaires for behavior change, for which they 'poll' answers on the spot using a polling booth, assuring self-administration and confidentiality. In the general population, the PBS will be done among six demographic groups in about 900 villages. Among the FSWs, there will be a minimum of ten polling booth sessions per district, with ten participants in each group. In FY10, additional sample will be drawn from Stepping Stone participants groups from the program village to evaluate the effect of Stepping Stone session on the high risk individuals. The stepping stone is a behavior change communication-training module for rural high risk individuals.

B) Monitoring improvements in the quality of life of PLHIV

As part of studying the impact of the program on PLHIV's quality of life, in terms of components such as physical, social and psychological well being, access to and effectiveness of services provided, and experience of stigma and discrimination, this study will be conducted in FY09 for which 200 PLHIV subjects will be included in the year's assessment. Informed written consent will be obtained from the PLHIV, ethical approvals will be obtained through St John's Medical College and questionnaires are administered by trained interviewers. The study will have both a qualitative and qualitative element. There will be no collection of biological samples for the study. However, available results of relevant tests will be used in the analysis (e.g. CD4 count)

C) Measuring and documenting impact and cost efficiency of the program

As part of a final evaluation in the last year of Samastha project, this new activity will triangulate various data sets to identify both the impact of the Samastha project within different districts, and identify best operational models of program implementation. The proposed assessments will help to derive the operational cost of a district-wide model for comprehensive HIV programming.

ACTIVITY 4: TA for capacity building of the SACS establishing "One state-level M&E system"

A) TA to NACO and State:

The Samastha project has responded to multiple requests from NACO including a) to configure a CMIS to capture individualized data from the time of diagnosis at CT sites to ART centre, b) to triangulate data to understand the epidemic disease pattern and transmission dynamics within a district, c) to develop a CMIS and M&E framework for the LW scheme. Samastha project has already shared the CMIS package developed for HIV care, treatment and support interventions with NACO and other states. Advocacy for the "one state-level M&E system" will continue. At the state level, two workshops will be conducted to train persons on the triangulation and use of data for program planning.

B) Dissemination of lesson learned with program stakeholders

This is an ongoing activity wherein the experiences of planning and implementing a rural HIV/AIDS prevention, care and support program will be documented and disseminated to a wider audience including NACO, Karnataka State AIDS Prevention Society, Andra Pradesh state AIDS Control Society, other national and international agencies involved in HIV/AIDS prevention, care and support programs, academicians and community-based organization. The method of dissemination includes seminars, publication of manuals and reports, presentations in national and international conferences as well as publications in peer-reviewed scientific journals.

SUMMARY

A significant thrust of the Samastha project is the provision of technical assistance (TA) for HIV-related policy development for the state governments, primarily the Karnataka State AIDS Prevention Society (KSAPS), the Andhra Pradesh AIDS Control Society (APSACS) and the partner nongovernmental organizations (NGOs) and community-based organizations (CBOs (including people living with HIV/AIDS (PLHIVs) and sex worker networks). TA is aimed at improving the enabling environment for HIV programs, mainstreaming HIV programming into larger development initiatives, galvanizing political and popular support for HIV policies and programs at state and district level, and capacity-building of government and non-governmental organizations to participate in and lead policy development. Capacity building and strengthening of social structures includes training at various levels from field-based outreach to government personnel at KSAPS.

Samastha works with structures at state, district and village-level to help build the capacity of members for an enhanced and sustainable response to HIV/AIDS. In line with the planned decentralization of HIV programming to the district level as part of National AIDS Control Program III (NACP-III), District AIDS Prevention and Control Units (DAPCU) are now set up in all 29 districts in Karnataka. In coastal Andhra Pradesh, the process of recruiting is ongoing. Village Health and Sanitation Committees (VHSC) for mainstreaming under the National Rural Health Mission (NRHM) are established in most of the villages.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: TA for HIV-related policy development and mainstreaming of HIV

Samastha continues to provide TA to the state government departments including KSAPS, the NRHM, the Departments of Women and Child Development, Education, Social Welfare, Transport and Food and Civil supplies to develop a policy and response to PLHIV with a focus on extending social entitlements such as widow pension, housing, ration cards, voter identity cards, nutrition, education, vocational education and training to vulnerable women and orphans and vulnerable children (OVC).

ACTIVITY 2 TA for human resources for health

Samastha continues to conduct in-service training for a number of health care workers at different levels and for different roles.

About 30 district supervisors and supportive supervision teams (SST) will receive in-service training to provide ongoing TA and supportive supervision to counselors within counseling and testing (CT) sites. 30 doctors, nurses and counselors will receive training on mentorship to provide clinical mentorship to doctors, nurses and counselors in care settings on opportunistic infection (OI) management and antiretroviral therapy ART across all districts in Karnataka and coastal Andhra Pradesh.

TA for the in-service training of the DAPCU medical officers will continue from Samastha. One batch of 30 DAPCU medical officers will receive in-service training on data analysis for HIV program planning.

The National AIDS Control Organization (NACO) requested three Samastha project sites to serve as a Learning Site (LS) which will be accredited by NACO as a strategically positioned training site. They will demonstrate proven field success, cost-effectiveness, community participation, and tangible outcomes. Formal training followed by hands-on experiential learning and onsite mentorship in the field will focus on specific thematic technical areas listed below.

Sangama: prevention programming with most at risk populations (MARPs) men who have sex with men (MSM) and transgender people;

Swati Mahila Sangha and Swasti: rural prevention programming with FSW;

Bagalkot: an integrated rural HIV prevention and care programs, including link worker scheme; and

Snehadaan: care and support for PLHIV and OVC.

In coastal Andra Pradesh, four community care centers (CCC) will be strengthened in different thematic areas to function as LS for integrated HIV care, TB-HIV integration, and PMTCT programs and for orphans and vulnerable children (OVC). At least 200 program implementers and 100 clinical care providers will receive hands-on field level training and exposure at these LS.

ACTIVITY 3 TA for institutional capacity building

A) TA at NACO level

Samastha provides need based TA to NACO. NACO recognized Bagalkote as a LS of the country for its own nation-wide link worker (LW) scheme, cadre of community workers tasked to link CT and HIV services. Samastha will continue to provide TA for computerized management information systems (CMIS) to track clients from CT sites to ART centers.

B) TA at state level:

Samastha will continue to support the state level consultants for ART, TB-HIV and integrated counseling and testing center (ICTC) services at KSAPS. TA is provided for ongoing training needs of DAPCU. The logistic management information system (LMIS) system to ensure the flow of data to KSAPS, management of supplies and an inventory of kits and consumables will continue to be supported and maintained.

C) TA for civil society:

Capacity-building of Samastha NGO and CBO partners, as well as partners of KSAPS, began in FY07. About 60 NGOs/ CBOs leaders will receive in-service training and ongoing support on financial management, management of drugs and commodities, and linkages with supportive services for the community. The PLHIV-led drop-in centers will also receive ongoing support for financial and human resource management, for expanding their membership base, for leadership training, and management of drugs and commodities and program management. Training support for networking and advocacy with other stakeholders to promote access to supportive services and for 'positive speakers' to represent their communities in various forums continue.

The project will support a local FBO, Snehadaan to provide TA to the Global Fund supported CCC across Karnataka for quality improvement. Snehadaan will train 100 staff for experiential hand-holding in-service training for project managers, clinical and outreach staff, will conduct quarterly partner review meetings and provide technical assistance with project management, financial management and monitoring and evaluation issues.

The model of integrating ART and CCC services within the same institution in non-government medical colleges will continue to demonstrate a workable model for public private partnership with the NACO. This model is implemented at St John's Medical College and Hospital and Kempegowda Institute of Medical Sciences, in Bangalore. Again integrating HIV care within existing health care institutions will be the model for demonstration to the national program at SVYM, Sargur, and Mysore. These will be learning sites for the 10 HIV fellowship participants.

St John's Medical College partnered with the WHO to adapt the Integrated Management of Adult Illness (IMAI) module for India and will continue to strengthen the capacity of 5 regional training centers to conduct similar training. 150 clinical care staff will be trained using the team approach. Pending approval from the National Rural Health Mission (NRHM), this training will be rolled down to the primary healthcare center (PHC) level to expand HIV care to the village level. The Samastha HIV e-learning package (HELP) will continue to be expanded to reach out to 300 doctors in the state.

D) TA to institutions engaged in human resources for health:

Samastha will continue to provide technical assistance to the Rajiv Gandhi University of Health Sciences (RGUHS) to initiate special courses on HIV-TB care. Apart from support for the HIV Fellowship course that begins in 2009, TA will be provided to incorporate HIV into the regular curriculum of the medical and nursing undergraduate and post-graduate courses, to expand research pertaining to infectious diseases such as HIV and TB and to establish a 'chair' for infectious diseases within the RGUHS.

The support to the NRHM and the SIHFW, the department of Health and Family Welfare will continue to receive need based TA for integration of HIV into induction training of government PHC staff.

ACTIVITY 4: Reduction of stigma and discrimination

Samastha will continue to reduce stigma in health care and community settings to ensure affected and vulnerable populations are not discriminated against and are able to access services. About 100 health care providers will be trained on-site using the modules developed by Engender Health. This training will saturate teams in CCC, ART centers and ICTC settings to reduce stigma and discrimination processes in the healthcare setting.

Village Health and Sanitation Committees (VHSCs), the focal point for reduction of stigma and discrimination in community settings, comprised of local leaders, opinion makers, and village-level government functionaries will continue to be strengthened through funds leveraged from NRHM.

ACTIVITY 5: Training and systems strengthening for grass-roots link workers

The link workers who are tasked to provide referrals for MARPs to HIV services will continue to be trained to equip them to be effective frontline workers. Pre-service training will cover about 100 link workers and 100 peer educators. Capacity of the identified training institutions for field level workers will continue to be built.

Summary: The NACP-3 prevention strategy includes reaching vulnerable youth at risk through the link workers and through outreach by existing cadres of governmental health programs. A key challenge in the selected districts of Karnataka where Samastha works is the practice of child marriage, which translates into early sexual activity in the age group of 15-17 years. The Samastha project has worked intensively in 12 districts to generate awareness and skills on abstinence and partner reduction/fidelity messages in the past three years. However, in FY10, the project aims to gradually transition out and reduce the direct interventions and move to TA to build capacity of existing health workers to address fidelity and faithfulness messages. The project will adopt a differential approach across districts through capacity building of a) the link workers in districts where HIV risk is higher and b) of existing government field level functionaries where the HIV risk is lower and more dispersed.

In FY10, Samastha will focus only on five high prevalence districts through the link workers (LW) and volunteers to reach the target population directly. In the remaining seven southern and central districts of Karnataka, the project will explore ways to build capacity of existing health and other village functionaries to reach the target group. This will include training of other cadres of health workers under the NRHM such as anganwadi (nutrition) workers (AWW) and Accredited Social Health Activists (ASHA) to build their capacity to incorporate HIV/STI related messages when working with young people.

The target group for this program area is male and female youth (15-24 years) in the general population in rural Karnataka. Behavioral assessments in early 2009 indicate that 11% of unmarried boys and 2 % of unmarried girls engaged in pre-marital sex. The project will continue to provide information on abstinence and fidelity to young boys and girls and men and women in 835 villages across five districts. About 20,000 individuals will be directly covered under this program area during the period. The prevention strategy will specifically address delaying sexual debut and reduction of concurrent sexual partnerships with emphasis on being faithful to a single partner for the target audience of married individuals in this age group. The interventions will continue to include gender sensitive group communication tools like 'Stepping Stones' which stimulates discussions on delaying sexual debut, develops skills to tackle sexual coercion and builds peer pressure to support HIV prevention related behaviors.

TA currently provided to NACO for the development of guidelines and expansion of the LW scheme across the country will continue. Bagalkote district, a NACO recognized learning site for the LW scheme will continue to support other states and partners in conceptualizing and implementing the scheme. TA will also be provided to the NRHM and KSAPS to ensure that youth friendly services are integrated into the ICTC services.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1 Delaying sexual debut among young people Among the young boys and girls (15-24years) the focus will be to delay sexual debut. 20,000 individuals will be reached through group sessions using Stepping Stones. This will continue to be conducted with groups of boys and girls to ensure that they understand their risks and vulnerabilities. These sessions also help the participants to reflect on their life situations and choices that they make. However the challenge in the rural areas has been to find unmarried young girls. Child marriage practices are still prevalent in the villages and the most affected group is the young girls. Hence along with working directly with girls and boys, it will be important to work with the community and family to support them in this process. Another advantage of the group process is the peer support.

Activity 2 Increased focus on young and vulnerable girls and women at risk The project will prioritize working with young girls in the devadasi (traditional temple sex workers) families, families headed by single women, families in debt or poverty and families from the scheduled caste community. About 1,000 girl children in such families will be provided with information on sexual health and skills to be assertive against violence and coercion. These girls will be specially tracked and followed up by the link workers to ensure links and access to education and health services. Livelihood security and strengthening their economic standards through links with rural development and economic programs in the villages will also be undertaken as part of sustainable programming. Community support for such families will be built through effective outreach and media activities such as folk theatre and traditional art.

Activity 3 Enhancing sustainability through capacity building of existing functionaries in the village and volunteerism In the southern districts of the project, the target group will be reached through the existing functionaries of the government and the project will provide TA for building their capacity. About 1,000 AWW and the ASHA of the village will be trained to work with young boys and girls specially addressing their risks and vulnerability with the objective of delaying sexual debut or supporting them to be faithful if they have a partner. The trainings will be conducted in the village or in cluster of villages in consultation with the line departments. Additionally, the project will build a cadre of 1000 volunteers in the villages, who will undergo and complete Stepping Stones sessions before qualifying to become volunteers. The role of the village volunteers will include providing awareness and correct information and provide effective linkages for services to the young people.

Activity 4 - TA at the national and state level The LW scheme is now being expanded across the country under the Global Fund initiative of NACO in all high priority districts. The project site at Bagalkote will function as an experiential residential on-the-job learning site for the LW scheme. Participants from government, NGO and stakeholders supported by NACO will learn to implement the operational guidelines for the LS scheme through this participatory training. Samastha will provide TA for the curriculum development of the nationwide induction training and the implementation of the strategic information systems. At the state level, AWW workers under the DWCD and ASHA workers under the NRHM will be taught to address risks and vulnerabilities of young people through the NRHM initiative.

Summary

The focus will be on most at risk populations (MARPs): female sex workers (FSW), their regular partners / lovers and high risk men and women in the rural areas of 12 districts of Karnataka (KN). In FY10, Samastha aims to reach 18,000 rural MARPs (including 12,000 female sex workers and at-risk women and 6,000 high-risk men). The rural mapping exercise in FY08-09 showed that most MSM are urban based and covered through the Bill and Melinda Gates Foundation (BMGF). Additionally, the mapping did not show significant intravenous drug user (IDU) populations in the rural areas targeted by under Samastha.

The objective of the COP intervention is to help the target group perceive their risks and vulnerabilities, access treatment for STI and gain skills to negotiate and use condoms during sexual acts. The strategies include involving the MARPs in a process of reflection so that they understand various life situations that put them at risk and feel empowered to make safe choices during those situations. The underlying principle is to address issue of gender inequity which put men and women at risk of diseases and empowers the target group to make safe choices. Hence building strong and supportive community structures in a non-discriminatory and supportive environment will continue to be a key strategy.

Additionally, the project will address transition as it enters the final year of implementation using a two-pronged approach of evidence-based prioritized interventions and leveraging through other programs including the national program. The evidence from two years of program implementation has shown that sexual networks that include both commercial as well as non-commercial networks exist in five Samastha districts and that seven districts have mainly commercial sexual networks. The program strategy has been refined in accordance with this evidence and a differential strategy has been adopted for the five northern KN versus the seven central and south Karnataka districts. Based on the refined strategy, the project will focus directly on all MARPS listed above in two of the five northern districts where the HIV prevalence is high. In three of the five northern KN districts, the FSW and partners coverage will be leveraged through the BMGF funded program. The other MARPs including clients of FSWs and high risk men and women in these three districts will continue to be reached by the Samastha project. In the remaining seven districts the project will reach sex workers and their regular partners only, but will strengthen the capacity of the existing government functionaries and services to promote condoms and other prevention among those with risk behavior in the general population.

This strategy of reaching the rural MARPs fills a critical programmatic gap area in the state of KN. The strategies and implementation models developed under Samastha have helped shape the national program strategy for reaching rural MARPs using the link worker (LW) scheme which is now rolled out by the national program in 180 high prevalence districts across the country. Link workers are village level workers that link prevention interventions with CT and care and support services. The Samastha project has provided TA to the national program in developing the operational guidelines and developing the MIS and M&E framework for this program.

In the last two years, the comprehensive prevention program under the project has been broad-based to include structural interventions like addressing violence, gender, community mobilization along with condom promotion and STI services. Increased focus will be placed on mobilization of MARPs to access CT services as well as to provide care and treatment services to those MARPs who are people living with HIV/AIDS (PLHIV), given the increasing evidence that ART can reduce the risk of sexual transmission. This "combination prevention" strategy will empower the MARPS to access better health and education services. As part of sustainability, community-based organizations of sex workers are also strengthened in organizational development and project management, while leveraging with Village Health and Sanitation Committees (VHSC) under the NRHM to support and sustain the behavior change process by creating an enabling environment.

Activity 1: Improving focus in outreach for MARPs

A) Peer education and condom promotion for improved focus on MARPs and their partners as part of combination prevention programming

The Samastha project in the southern districts will focus only on female sex workers and their partners as a main target group for condoms and other prevention through outreach. Peer sex workers will be supported by field level supervisors. However, given the dispersion of sex workers in the villages, each peer educator will be responsible for 35- 50 sex workers. A total of 8,000 sex workers will be reached directly through the Samastha intervention. Using the experiences gained from the pilot project on rural social marketing of condoms in FY08, the project will leverage support from PSI's NACO supported project to ensure social marketing condom outlets in 600 Samastha villages in addition to the 1,600 free condom outlets.

The project will also address structural issues in sex work like that of gender, power disparity among facilitators (brothel madams, pimps) and sex workers and will address issues related to crisis and violence that they face due to the inequity. The project will also facilitate a sense of self esteem and dignity among the sex workers through the process of building group solidarity.

B) Addressing issues of gender inequity and communication

The training package called Stepping Stones will continue to be used with at-risk men and women especially in the five northern districts to support the men and women to understand their risk situation and find practical solutions to make safe choices. Group sessions give a sense of solidarity among the members and also maintain peer support to practice safe behaviors. These group members will be also referred to prevention and care services as per their need and followed up to ensure quality service was available. About 4,000 women and 6,000 men at high risk of HIV will be reached through the Stepping Stones intervention. LW and their supervisors will be responsible for strengthening a community response through VHSCs.

C) Community-friendly monitoring tools for improved quality assurance in peer education

The project has devised community-friendly tools for monitoring the project that can be easily used by the outreach staff for monitoring their contacts. These tools not only help them in monitoring but also create a sense of ownership for the community that they are in charge of. Peer cards, peer calendars, village summary report and maps of targeted prioritized segments of MARPs to be reached will continue to be used as tools for tracking individuals and for monitoring progress. The community based monitoring tool facilitates the tracking of each member of a MARP registered with the project and validated by selected 'senior' sex workers who serve as volunteers in the monthly review meetings of peer educators.

D) Sustaining changes through involvement of existing community structures and volunteerism

Building an enabling environment is a prerequisite for any prevention strategy to succeed. The larger general community needs to support the prevention strategies and people practicing prevention. The project will continue to involve and strengthen the VHSC to take up the prevention and care related activities leveraging the funds allocated to them under the NRHM. The LW is part of the local community and will serve as a trained resource pool in the village. Efforts will be made to advocate for compensation of the LW through the VHSC to continue their activities. In southern and central districts of KN, the capacity of 1,000 AWW and ASHA workers will be built integrating skills for risk assessment and interpersonal communication and also serve as a resource for free condoms.

Another strategy to build ownership is to expand on a volunteer base in the villages to ensure that people among MARPS and general population feel a sense of responsibility towards HIV prevention and care. The volunteers will support the LW in reaching out more widely.

Activity 2: Institutional capacity building of Community-Based Organizations (CBO)

It is expected that under the NRHM, the VHSC will eventually take responsibility for prevention and care of HIV among the general population. However, coverage of sex workers who are marginalized will continue to need additional support. The project will support FSW in rural KN to form support groups and link up with existing FSW CBO to strengthen their collective voice. Building group solidarity will not only provide them a space to share their pains and happiness but will also provide a space for advocacy for a life of dignity.

Activity 3: TA at the national and state level

The Samastha project will continue to guide and support the national LW scheme as an opportunity to halt rural HIV transmission. TA for development of operational guidelines, training of trainer programs, Bagalkote learning site and support for the implementation of the MIS and M&E framework of the LW scheme will continue.

At the state level, the project will continue to provide district level supportive supervision through its cadre of regional managers. Efforts will also be made to build capacity of the DAPCUs for the monitoring of combination prevention programs, links and also analysis of data. They will be trained to use triangulated data to determine district-level rural risk and transmission dynamics. Data from other studies will be documented and disseminated to increase understanding and estimation of the incidence and prevalence of HIV among rural sex workers on a regular basis.

SUMMARY

The Samastha project will continue to implement a modest PMTCT program with increasing focus on provision of TA for efficient delivery of quality PMTCT services.

Under the National AIDS Control Program III (NACP-III), there has been a significant scale up in the number of CT sites throughout the country. Karnataka has more than 561 full-fledged CT sites of which 50 centers are in non-government settings under the public-private partnership initiative and 30 centers are mobile testing centers. It is also planned to launch CT services under the NRHM in at least 596 "24-hour" primary health care (PHC) centers by early 2010.

In FY08, Samastha provided TA to link PMTCT activities with the NRHM initiatives in KN. In FY09 CT services were configured to reach most PHC within the districts. DAPCU medical officers were trained on the convergence between the HIV and Health program and District RCH officers made accountable for ensuring hospital delivery and administration of ARV prophylaxis. As a result of this convergence, the coverage of CT services for the statewide annual estimate of 1.2 million pregnancies has increased from about 17% to more than 60%. The target is to reach an antenatal coverage level of more than 80% with CT services and administration of prophylaxis and other services in the cascade. Increased access by positive pregnant women to the state funded 'Yeshaswini' insurance scheme that incentivizes institutional deliveries, has helped increase PMTCT uptake by more than 3000 in FY09. However this is still about 50% of the known HIV- infected pregnant women. USG-supported Samastha project will aim to increase this figure through TA to the NRHM.

Despite the massive gains made in coverage of antenatal CT services and hospital delivery with ARV prophylaxis, challenges still remain such as:

The scale up in ICTC and PMTCT has not been commensurate with quality in delivery of services.

Procurement systems to ensure no stock-out situations of HIV test kits and Nevirapine are lacking.

Expansion of PMTCT services beyond the CT and institutional delivery to also ensure counseling for safe infant feeding and follow-up of mother and baby is a need.

Inadequate involvement of men in the PMTCT program and integration of family planning services.

Diagnostic test for assessment of HIV infection in exposed infants is not available.

Samastha will continue to provide TA to the NRHM and KSAPS in this area. Included under this component are training programs for nurses and laboratory technicians in the 24-hour PHCs under NRHM to perform counseling and testing functions, TA for the roll-out of the integrated HIV-STI-PMTCT training package (ITP) for heath care providers in high HIV prevalence districts under the NRHM in collaboration with the SIHFW, ongoing capacity development of the DAPCU teams and TA to the IEC committee and technical cell for mobilizing pregnant women to access services. In response to SACS' expressed need for hands on training of counselors, two learning sites (LS) situated within the government recognized CT sites will continue to be supported. One will be in north Karnataka and the other in the south.

Engender Health will continue to work in close collaboration with the NRHM to integrate infection prevention and stigma and discrimination reduction in all health care settings and the roll out of the ITP module. St. John's Medical College and Kempegowda Institute of Medical Sciences (KIMS) and a site in north Karnataka demonstrate, through their learning sites, the linkage between PMTCT, adult and child care and treatment services and community initiatives.

The Logistic Management Information System (LMIS) to support procurement, distribution and projection of HIV test kit requirements, will continue to be implemented.

At the district level, district supervisors will receive periodic refresher training through the accredited training center at the National Institute of Mental Health and Neurosciences (NIMHANS). In FY10 issues related to family planning and sexual health for PLHIV will be addressed. The implementation of the HIV module within the training of the government supported Accredited Social Health Activists (ASHA) will be another area of focus.

In the five norther KN districts, Samastha link workers will directly mobilize pregnant women to access the full range of PMTCT services, including effective referrals to the ART and CCC services and follow-up of the child. In the remaining seven districts in south and central Karnataka, outreach workers will be placed at high-volume CT sites to provide post-test counseling follow up and linkage to care services for positive pregnant women. Additionally, government functionaries including the ASHA and community based outreach workers will be capacitated to make effective referrals for nutrition support.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: TA for improving efficiency and quality of PMTCT services

a) Development of model PMTCT LS

Two LS will be initiated in north and south KN. In collaboration with the Global Fund supported training institutions for nurses which provide pre-service training for developing cadres of nurses trained in HIV care and the training institutions developing cadres of counseling mentors, the USG-supported LSs will provide hands-on training and skills to complement their knowledge. These sites will aim at achieving all the quality and quantity indicators of an effective PMTCT program such as: follow-up of identified cases, monitoring administration of nevirapine for both mother and child, partner testing and linkages for early initiation of ARTs, ensuring adherence to drugs, safe infant feeding practices, immunizations, follow up of the mother and baby and HIV testing of the child at 18 months, and integration into RCH (reproductive and child health) services including FP services. Apart from the government provided personnel, the project will provide for a supervisor to ensure quality and mentoring.

b) Institutional capacity building for quality delivery of services

At the state level and regional level, District Supervisors are in place as part of the DAPCU in all 29 districts in KN. NIMHANS, a Samastha technical partner has leveraged NACO support for training and mentorship of the district supervisors across all states in south India. TA from the Samastha project will continue to be provided for the development of the training package of district supervisors. At the state level, Samastha will provide ongoing TA for supervision and monthly review meetings and quarterly regional reviews of the DAPCU teams. The Samastha project will continue to provide TA for the roll-out of the ITP module in high HIV prevalent districts while leveraging resources from the NRHM and SIHFW. This package will ensure that all health functionaries in these districts are trained to identify, manage, counsel and refer HIV positive pregnant women and her infant or child. The training of trainers (TOT) and the TA for monitoring the roll-out are supported by Samastha; the training itself is leveraged from the NRHM, through the State Institute of Health and Family Welfare (SIHFW). To make the CT sites friendly to beneficiaries, sensitization programs on stigma and discrimination will be conducted. The TOT programs will be conducted by Engender Health under the Samastha project and will be rolled out through the KSAPS appointed District Supervisors.

c) Quality assurance of lab services

Samastha will continue to work in close collaboration with NIMHANS; the nodal centre for the laboratory related quality assurance in HIV testing to adapt and disseminate the NACO recommended protocols and standard operating procedures (SOPs) and External Quality Assurance Scheme (EQAS).

d) Logistic Management Information System (LMIS)

Samastha project will continue to support the computerized LMIS that facilitates procurement management and distribution of pharmaceutical supplies across the state.

Activity 2: Demand Generation for increased uptake of PMTCT

Mobilization of pregnant women to government recognized ICTC sites will be facilitated though NGO outreach teams in the five districts that reach out through link workers under the Samastha project. In the remaining seven districts; FSW peer educators and local health functionaries such as the anganwadi worker (AWW) under the department of women and child development and the ASHA worker under the NRHM will be trained to make appropriate accompanied referrals to CT services. Samastha funds will be used to train newly recruited peer educators and link workers to identify and educate pregnant FSW to access CT and other HIV related services.

Activity 3: Facilitation of convergence activities to increase uptake

Link workers and peer outreach workers placed at CT sites to support post-test counseling will facilitate linkage to ART and delivery services. The integration between the PMTCT and NRHM program has ensured that all HIV positive pregnant women have access to a hospital delivery and nevirapine prophylaxis as per the national protocol. Many of the community care centers (CCC) started under Samastha and transitioned to the Global Fund project have integrated CT and PMTCT services. Samastha will facilitate the roll out of combined HIV-STI-PMTCT training package across high HIV prevalence districts. TA will continue to be provided to the laboratories at St. John's and KIMS hospitals in Bangalore to leverage resources to enable them to undertake HIV DNA testing for diagnosis of HIV in infants. Samastha will continue to publish the newsletter circulated state-wide on counseling issues as a joint collaborative effort between the technical partner NIMHANS, KHPT and the state SACS which will inform all government and non-government organizations of the key initiatives, success stories and challenges in CT.

SUMMARY:

This activity is a continuation of initiatives under PEPFAR-funded Samastha project that commenced in 2006. No fresh funds will be added to this technical area in FY10 when only technical assistance (TA) will be provided to support the state efforts for TB-HIV management. The project provides quality HIV palliative care services in fifteen districts in Karnataka (KN) and five coastal districts of Andhra Pradesh (AP) with the TA of Engender Health. Activities are managed at the district level by University of Manitoba/Karnataka Health Promotion Trust (UM/KHPT) regional staff in KN and LEPRA society in AP, both of whom work closely with the state TB division, Revised National TB Control Program (RNTCP) consultants and district TB officers.

The activities are targeted to reach people living with HIV/AIDS (PLHIV) to be actively screened and treated for TB disease by establishing linkages and referral mechanisms with the RNTCP. The activity previously targeted those newly diagnosed with TB to perform a behavioral and clinical assessment in order to determine the need for referral for counseling and testing for HIV. More recently, Karnataka is one of the states identified for implementation of the Intensified TB program, wherein all PLHIV are screened for TB symptoms at every visit and all newly diagnosed TB patients are referred for HIV counseling and testing.

Some of the challenges that this program area continues to face include:

The provider initiated counseling and testing of all newly diagnosed TB patients reported unexpectedly high levels of HIV-TB co-infection ranging from 13-56% among newly diagnosed TB patients.

A simulated patient survey among general practitioners across the state showed that few practitioners refer TB suspects or patients to the RNTCP program, despite having adequate knowledge about the same.

The number of newly diagnosed TB patients is about 55,000 per year. There are logistic and procurement challenges to ensure 100% coverage for counseling and testing for HIV.

The laboratory based monitoring for liver function is inadequate for patients concurrently on anti-TB and ART medicines.

Lack of nutrition interventions for co-infected patients poses another challenge.

The Samastha project does not have any PEPFAR allocated funds for this area, except as a component of Health System Strengthening.

The RNTCP is a centrally sponsored national program that places a high emphasis on diagnosis and treatment of TB. Recent attempts have been made to ensure that Community Care Centers (CCC) and Integrated Positive Prevention and Care Drop in Centers (IPPC-DIC) are integrated into the service network of the RNTCP and that counselors are placed at DMC to ensure effective HIV-TB linkages. The Global Fund funded CCCs are National AIDS Control Organization (NACO) supported inpatient facilities for minor opportunistic infection (OI) management and antiretroviral therapy (ART) adherence. The IPPC-DIC is centers run by networks of PLHIV providing both medical outpatient and social sector services for PLHIV and their families. Link workers have been trained to identify TB suspects and refer all suspects and PLHIV for TB screening. They have also been trained to refer all newly diagnosed TB patients for counseling and testing and to ensure compliance to TB treatment and adherence to ART.

Some of these initiatives and linkages have resulted in the significantly increased coverage of HIV counseling and testing (CT) among newly diagnosed TB patients from about 10% to more than 50% of the estimated 55,000 annual cases in the state.

ACTIVITIES:

Activity 1: TA at the state level

A) Consultant Support

The HIV-TB specialist under the Samastha project has been assigned fulltime to the Karnataka State AIDS Prevention Society (KSAPS) and will continue to provide ongoing TA. He has been instrumental in the roll-out of the intensified TB-HIV package across the state, in state level coordination planning and in the integration of TB-HIV services. He will continue to facilitate the SACS to implement Revised National Framework of TB-HIV collaborative activities and assist SACS and the district TB Officer (DTO) to develop District Action Plan on HIV-TB Coordination. Samastha will provide the TA for curriculum development of the TB/HIV Intensified Package and assist the DTO in conducting Training of trainers (ToT) workshops for improved screening and treatment.

B) TA for operational assessments

TB is the leading cause of the death among PLHIV, especially among those admitted to the CCC. Many of the patients who have died were on treatment for both diseases. It is important to evaluate the reasons for treatment failure in this group. The project has planned for an evaluation and is leveraging this assessment through other resources. TA will be provided for the development of the protocol and to establish institutional partnerships for this study.

Activity 2: Increasing demand generation for activities that increase referral and links

A) Strengthening access to TB services for improved treatment adherence

CCCs previously supported under Samastha, now supported under the Global Fund care and support project are functional as DOTS centers (Directly Observed Treatment Short-course).

To strengthen TB-HIV integration, Samastha, with the lead of Engender Health worked with the Cardinal Gracious CCC and received sanction to pilot the location of a DMC (designated microscopy center) as well as DOTS at one site. Only six months since its inception, the CCC at Cardinal Gracious Hospital has seen a marked increase in the number of patients referred for TB testing and an increase in the percentage of patients diagnosed as having active TB. It is planned to replicate this initiative in other neighboring districts.

Samastha participated in the joint district level reviews conducted by teams composed of a WHO consultant, District TB Officer, state TB-HIV consultant (Samastha/KSAPS) and local medical regional managers (Samastha). In Karnataka there is no NGO implementing the Global Fund for AIDS, TB, and Malaria round four (GFATM) HIV-TB coordination activities. The follow up actions will continue to be facilitated and monitored by the Samastha staff.

B) Increasing TB diagnosis and treatment among PLHIV

Outreach staff of CCC and Integrated Positive Prevention and Care Drop in Centers (IPPC-DIC) will continue to accompany PLHIV referrals for sputum testing and x-ray screening for those suspected to have TB. At least 12,000 adults and children living with HIV will be screened for TB and 1,200 will be followed up for complete treatment.

Outreach workers, link workers, PLHIV peer outreach workers, peer educators among sex workers and counselors will continue to promote utilization of TB diagnostic services among the communities where they work. They were trained to identify potential TB disease, to make referrals to diagnostic and treatment services, and to follow up with patients to ensure compliance to treatment and linking them to ART centers for evaluation for initiation of ART. Samastha project staff in all the project districts will also continue to follow up with DTO and the DOTS providers to ensure that TB diagnosed patients are routinely screened for HIV and referred to CT sites for HIV screening which is usually co-located where DMC-TB diagnosis is carried out.

Engender Health and KHPT staff will continue to provide hands-on TA support to outreach and link workers, PLHIV peer educators to enhance the utilization of TB diagnostic services and increase the referrals to diagnostic and treatment services.

C) Improving healthcare providers' capacity to diagnose and treat TB

The 205 staff at the service outlets underwent TB-HIV training of two or three day's duration. Engender Health's HIV/TB specialist led the training for medical officers, counselors, and health workers. Engender Health provided technical support in capacity building and quality improvement. This support and training will continue for newly recruited staff as part of in-service training, but will be leveraged from state TB-HIV program.

Karnataka was the first state to roll out the training program for the intensified TB/HIV initiative. Almost all health care staff has been trained at the district level. At both the state and individual Samastha clinic levels, capacity-building and systems strengthening have resulted in intensified case finding. For the State of Karnataka, the roll-out of training and supervision show improvements against 2008 targets set for cross-referrals between the Revised National TB Control Program (RNTCP) and HIV counseling and testing center (ICTC).