The fundamental objectives of the SUM I project are to 1) Provide targeted assistance in key technical areas required to scale up effective, integrated HIV interventions that lead to substantial and measurable behavior change among MARPs and 2) Provide targeted assistance to government agencies and civil society organizations (CSOs) working on strategic information efforts related to the HIV response for MARPs. These goals are directly linked to the objectives of the Indonesia GHI Strategy, especially to improving the effectiveness of interventions and sustainability of activities by local government and non-governmental partners. SUM I strategically targets MARPs (FSWs, PWIDs, MSM and waria) in districts where HIV prevalence is highest: Jakarta, Surabaya, Malang, Papua and West Papua. In Papua and West Papua, where there is also a generalized epidemic, SUM I provides TA for a response to a generalized epidemic.In FY12, SUM I will target additional intervention sites with assessments and tailored package of support and will continue to deliver the package of support to the original sites. Planned activities will continue to build the capacity of CSOs to provide technically up to date and appropriate services and will increase the ability of CSOs to leverage funding other than USG funds. Finally, the CSOs will graduate into technical assistance providers for other community organizations. Technical assistance for district governments will also be provided. These activities will lead to efficiency gains and CSOs will be able to independently garner and manage outside funding to sustain their own activities. M&E plans include quarterly and annual progress reports.

Although there is some movement underway at the MOH to decentralize HIV treatment and care from hospitals to Puskesmas and from health facilities to community-based providers of services and support, HIV treatment and care services remain highly concentrated in hospitals, particularly those in large cities.SUM I will engage the MOH in dialogue concerning a longer-term strategy for HBHC. In targeted intervention sites, USG funding will support the demonstration of HBHC in the Indonesian context in collaboration with the NAC, MOH and other local implementing partners by including case management functions into the service packages of CSOs providing outreach services to MARPs.

At present, mechanisms in the national program to address client retention and referrals, including the use of outreach and bi-directional referral systems, are limited. Client retention and referral are emphasized for SUM-supported CSOs. As indicated above, SUM is advocating that a similar model be adopted as the national standard and will provide support should the national program move in this direction.

SUM I will provide technical assistance to CSOs and government counterparts to improve: Linkages between program sites with other HIV care, treatment and prevention sites within jurisdiction and linkages and/or referrals between program sites and non-HIV specific services (at a minimum food support, IGA, RH/FP and PLHIV support groups); and Program monitoring and evaluation of the quality of care and support services.

Indonesia ranks among the top 5 globally in TB disease burden, and TB co-infection is a major issue among HIV-infected persons in Indonesia, many of whom are members of one MARP or another. In FY11 SUM I assisted the MOH NTP (along with TBCARE and WHO) to develop the National TB-HIV Strategy and Guidelines, and SUM activities are fully aligned with host country national policies and strategic plans for TB and HIV. Revised recording and reporting forms for HIV-TB activities were finalized and socialized, and HIV-TB collaborations were established in priority provinces.

In FY12 USG will promote stronger integration of HIV and TB services in national service guidelines, accelerate the rate of training in clinician awareness, and improved management of HIV-TB co-infection among government health service providers and CSOs, improve linkages (including establishing appropriate sharing of medical records) between TB and HIV clinics and service providers to ensure follow-up on treatment for TB among PLWHA, and improve data collection for TB-HIV co-infection and treatment in priority provinces. SUM I will also work with hospital facilities to ensure that TB/HIV co-infected patients are not placed in HIV wards. TB/HIV activities supported under PEPFAR will also be closely coordinated with related activities supported by USAID/Indonesias TB program.

In addition to lab support for the control of STIs (included under HVOP) and HIV counseling and testing (included under HVCT), USG will provide general, national-level support for staff training and implementation of EQAS for labs located in targeted intervention sites.

Increasing the availability of quality data and improving skills to use data for policy and program decision-making are crucial to targeting resources for combating HIV. USG will provide technical support to strengthen strategic information systems at all levels through workshops, seminars, on-the-job training and mentoring, and joint data analysis and interpretation, through SUM I. At the national and district levels SUM I will focus on better-informed priority-setting and allocation of resource, and increase capacity to manage, analyze, and use data for decision making.

USG activities supporting M&E system reform will include: participation in ongoing the M&E health information system reform effort at the MOH; assisting provinces and districts to establish basic M&E databases and develop the capacity to produce routine reports of provincial- and district-level indicators; and building the capacity of CSOs to analyze and act based upon routine program data.

SUM I will focus on improving the quality and sustainability of epidemiologic and behavioral surveillance systems, and the use of surveillance data for program planning, monitoring and evaluation. Activities will include technical support for planning the 2013 IBBS among MARPs (GFATM Round 9 provinces); the 2012 IBBS of general population in Papua; and re-establishing regular, high-quality HIV sentinel surveillance.

SUM I and SUM II are jointly responsible for SI activities in targeted districts, while SUM I is responsible for SI support to national stakeholders. At the targeted intervention site level, SUM II is responsible for CSO recording and reporting, while SUM I is responsible for data base management and M&E support for provincial and district health offices and AIDS Commissions.

USG will work with the MOH to support a HSS process at the provincial/district level which brings all stakeholders together to identify priorities and develops plans to undertake HSS. The process entails (1) reaching consensus on a health outcome that would receive priority attention for at least the next 12 months; (2) analyzing the root causes of failure to adequately address the selected health issue; (3) identifying and prioritizing health system changes and/or service quality improvements that would address the problem; (4) choosing a set of priorities that each implementing partner would pursue over the next 12 months; and (5) agreeing to a provincial-level coordination structure to keep the joint efforts moving forward.

The systems/barriers that are addressed will be identified by local stakeholders and may vary from site to site, as may/will the activities supported in response. It is anticipated that linkages will cross functional areas, and the response may well entail leveraging funds from local government health budgets.

Unlike most of Indonesia, relatively few Papuan males are circumcised. Establishing male circumcision (MC) as a HIV prevention intervention is widely discussed in Papua, and some services are available. Recently, a Regent in Sentani District, Papua proposed that circumcision be made mandatory for all males in Papua to reduce HIV transmission, reflecting the limited understanding in Papua of the realities of MC as an HIV prevention intervention and how best to gain wider acceptance, as well as of basic human rights issues.

In response, SUM I will educate policy makers and community stakeholders about the role of MC for HIV prevention and the requirements for effective and safe intervention implementation. The initiative will entail the deployment of (1) a policy brief that places MC in the larger context of HIV prevention in Papua, (2) a technical brief that documents the requirements for MC to be an effective and safe prevention intervention, (3) a seminar for key stakeholders and (4) short fact sheets presenting the basic facts in about MC for use by CSOs and front line health staff to educate clients.

Despite the gains in coverage of HCT among MARPs reflected by the 2011 IBBS, HCT remains far from sufficient. USG funds will be used by SUM I to improve program performance for both supply and demand for HCT. At the national level, SUM I will promote formal integration of HCT into STI control services and expanded use of provider-initiated counseling and testing (PITC) for MARPs as means of increasing coverage. SUM I will also continue its support to the implementation of EQAS for HIV test kits and reagents. On the demand side, SUM I will provide TA to PKBI and NU, the GFATM civil society PRs, to strengthen referrals for HCT for all MARPs via community outreach, as well as prioritize knowing ones status in BCC messages.

To ensure successful referrals and linkages, SUM I will focus on increasing referral and follow-up for HTC among MARPs for CSOs. SUM I supports facility-based case management services to facilitate uptake of care and treatment services by persons testing positive for HIV, but as described above community services are not well linked to facility services. SUM I will also increase emphasis on partner testing in targeted intervention sites.

At present, activities for monitoring linkages from HTC to appropriate services, or systems to evaluate or otherwise measure successful linkages are implemented in the national program on an ad hoc basis. SUM I will test models to accomplishing the above in targeted districts following agreement with MOH. SUM I will also provide training and follow-on mentoring on QA/QI processes and systems to all CSOs, and will assess the extent to which QA/QI systems and processes have been internalized by the MOH.

Prevention efforts directed to MARPS are among the highest priorities in the Indonesian national AIDS response. Priority MARP populations targeted include FSW, MSM, PWID, high risk men and the sex partners of all MARPs. Support will be provided to national level counterparts (GFATM PRs and SRs), at the provincial level in up to five out of 8 priority provinces and up to 19 targeted districts.

Training and mentoring will be provided to all CSOs provided grants by SUM II. USG-supported CSOs provide MARPs with a standard package of services, including outreach, peer education/promotion, risk reduction counseling, access to prevention commodities (condoms and lubricant) targeted media/internet-based behavior change communications, and referral for clinic-based services (HC&T, STI management, MMT, CST for HIV-positives, management of opportunistic infections, including TB). SUM also provides limited lab support for EQAS for STI screening reagents and lab performance, as well as training of lab staff in STI diagnostics.

SUM interventions also include provincial and/or district level health system strengthening initiatives. Intervention packages were chosen and designed based upon global good practices.

Training for quality assurance/quality improvement (QA/QI) processes and systems are provided to all CSOs. SUM I will also support QA/QI at the MOH and Data Quality Management (DQM) at the NAC. Activities are implemented to supplement national program efforts in/for underserved areas and groups, and are thus fully linked with national program efforts.

Until recently, the HIV epidemic in Indonesia has been driven primarily by injection drug use although recent data seems to indicate that the types of drug used are shifting away from intravenous drugs. The epidemic appears to have shifted to one that is increasingly driven by sexual transmission, however, sizeable numbers of Indonesian males (and to a lesser extent females) in urban areas continue to inject drugs.

As the NAC has requested that the USG focus its support on the prevention of sexual transmission of HIV, SUM I will focus its TA/capacity building efforts on interventions to prevent sexual transmission of HIV+ PWID. SUM will also provide TA to seven CSOs working with PWIDs in four provinces: Jakarta, East Java, North Sumatra and Riau Islands. The TA package will consist of (1) introduction of an Implementation Manual based upon global and Indonesian good practices, (2) training workshops on activity design and implementation, (3) field mentoring, (4) TA for QA/QI and (5) support to district-level planning, monitoring and evaluation to facilitate integration.

CSOs will undertake quality improvement initiatives on a regular basis with support from the SUM project. Activities are implemented to supplement national program efforts for underserved areas and groups, and are fully linked with the national program.

At the request of the MOH, USG funds will also be used to support an update of national service guidelines for IDUs which will cover, among other things, (1) the integration of HIV sexual transmission prevention interventions into the national harm reduction model and (2) the role of CSOs in providing a comprehensive and accessible package of services.

Because HIV is largely concentrated among MARPs in Indonesia, only limited resources will be allocated to MTCT. USG funding will support: training of national- and provincial-level PMTCT Master Trainers and revision and finalization of service protocols and standard operating procedures (SOPs ) ( as necessary, following the transition of the program to the Sub-Directorate for AIDS and STIs from the Sub-Directorate for Maternal Health).

High-level discussion is currently underway concerning a major scale-up of PMTCT in Papua. In anticipation that the national program will prioritize scaling up PMTCT in Papua, additional funds were allocated to this program area to support training and mentoring. Details will be finalized in consultation with MOH and Papua provincial counterparts, as well as other development partners (UNICEF, WHO, CHAI) to identify the appropriate inputs by SUM I.

In support of the adult treatment area, USG will:

Support continued policy dialogue at the national level regarding on-going challenges to improved treatment, including: concentration of treatment services in hospitals, and the lack of access to treatment that results for PLWHA in remote areas (especially Papua); national service guidelines that restrict patient qualification for treatment. Priority areas for revision of policy and guidelines include: support for the decentralization of treatment to the Puskesmas level, which is necessary in order to more effectively and efficiently serve MARPs in the Indonesian context; and improving treatment adherence in both health facilities and communities.

USG will support in-service training on clinical management of HIV and Integrated Management of Adult Illnesses (IMAI), and mentoring of clinical staff in targeted intervention sites. SUM-supported CSOs will also be trained and mentored in community-based treatment adherence support strategies and practices.