A. Implementing Mechanism Narrative PSI's HIV prevention portfolio includes a range of interventions in counseling and testing (CT), and condoms and other prevention (HVOP) including condom social marketing, and behavior change communication. Specific programs include a network of fixed-site and mobile counseling and testing services; a post-test club program that provides life skills activities to community groups that have been through counseling and testing together; sales and free distribution of branded and generic male and female condoms; and multi-channel communication in support of testing, condom use, and partner reduction. In FY10, PSI hopes to expand this portfolio to include enhanced capacity building in public sector counseling and testing services; communication, training, and a communication campaign for male circumcision (MC); and strengthened distribution and demand creation for male and female branded condoms as well as generic male and female condoms. Partnership Framework linkages In FY10, PSI will support the USG/GoL Partnership Framework Agreement through interventions that feed directly into four partnership objectives - increased access to and availability of counseling and testing (obj. 1.4); increased supply and distribution of condoms (obj. 1.7); scale up of male circumcision services (obj 1.6); and increased coverage of behavior change interventions (obj. 1.1). Benchmarks for these interventions reflect both output-level PEPFAR indicators and outcome-level PSI objectives. The latter, which are measured through annual population-based surveys, include increased use of HIV counseling and testing services and increased correct and consistent condom use, with intermediate shifts in key determinants of these behaviors. Geographic coverage and target populations PSI's targeting is informed by the Demographic and Health Survey (DHS); condom coverage and distribution studies; and population-based surveys that measure exposure to and impact of ongoing behavioral interventions. The data offered by these studies supports PSI in segmenting potential audiences, separating "behavers" from "non-behavers," and allowing for identification of significant behavioral determinants within a given group. Regular programmatic monitoring and secondary data also contribute to program design decisions, including geographic areas of focus and target populations. PSI's counseling and testing and condom programs are nationwide in scope, providing services, products, and behavior change interventions to men and women throughout Lesotho. PSI's counseling and testing programming targets urban and peri-urban men 25-35 and their partners, while condom programming focuses primarily upon rural couples (men 25-35, women 18-35). In addition, PSI continues to support small-scale counseling and testing and condom interventions with other vulnerable populations, including men in uniform and factory workers. MC activities, including both the national pilot program and PSI's proposed pilot with the LDF, will likely target men 18 and older who are not already

medically circumcised. Key contributions to HSS

In FY10, PSI proposes strengthening public sector linkages at the district and community levels by employing New Start clinics as centers of excellence for training in primary prevention. At the district level, New Start will provide sustainable capacity building through attachments and mentorships for public sector health professionals. PSI New Start centers may expand beyond counseling and testing to include training and service provision for other primary preventative services such as screenings for diabetes, high blood pressure, TB and STIs. In addition to the focused capacity building provided through its counseling and testing program, PSI will also continue to provide tailored counseling and testing training and quality assurance services to partners in the public and NGO sectors, many of whom subsequently diffuse these skills through their work with the health system. Similar services will be offered to teams of public sector providers through the national MC pilot. Finally, PSI will adopt a larger role in the distribution of GoL condoms, and this program will also include a substantial capacity-building component (described in greater detail in the budget code narrative below). Cross-cutting programs In FY10, PSI will integrate HSS and gender across program areas. In addition to the HSS activities described above, PSI will focus on increasing women's access to health products and services by targeting couples for both counseling and testing and male and female condom programming. Additionally, male gender norms will be addressed through PSI's IPC activities for counseling and testing and condoms, which target men and couples and include content on concurrency and gender norms, and through the Post-Test Clubs pilot program, which uses a structured IPC curriculum focused on the development of life skills and healthy gender norms as a vehicle for HIV prevention. Plans to become more cost-efficient over time

The model of integrated counseling and testing services proposed in this narrative centers upon a gradual shift from direct service provision to support, training, and mentoring for public sector providers, which will result in cost-savings over time. In its condom programming, PSI will ensure cost-efficiency through improved stock management and streamlined distribution systems that rely heavily upon key partners to draw from lessons learned in our commercial distribution systems. Monitoring and evaluation PSI monitors its interventions through robust programmatic MIS, as well as periodic spot checks and mystery client visits. All MIS data is entered into web-based databases, which minimize data entry errors, facilitate analysis, and ensure program staff buy-in to and use of data. All communication activities include extensive formative research, pretesting, and monitoring to ensure their appeal, appropriateness, and effectiveness. In addition to routine monitoring and process evaluation, PSI performs annual product distribution studies and population-based surveys to inform program design and measure impact.

PSI proposes refining and strengthening its existing New Start counseling and testing model, with

increased emphasis upon mobile services; integration of counseling and testing with other services

(including MC, TB screening, STI diagnosis and treatment, or primary preventative care); and capacity

building of public sector counseling and testing services. Under this new model, PSI envisions that its

New Start sites will become centers of excellence, providing both direct services and pre- and in-service

training to public sector providers. Sites will expand their mobile services, through the addition of new

mobile units and partnerships with organizations active in areas in which PSI is not present. Over time,

New Start fixed sites will engage in less direct service provision, focusing more on training, mentoring,

and coordination of mobile units. Parallel to this, PSI will support the public sector in becoming the core

of fixed-site counseling and testing provision, through provider training and mentoring; quality assurance;

and procurement support. New Start sites and mobile units will continue to provide client-initiated

individual and couples' counseling and testing, while public sector sites will focus on provider-initiated

counseling and testing. This dual-track model, in which PSI provides mobile services and capacity

building and the public sector provides fixed services, will allow for more effective coverage of the

population as a whole, with women of reproductive age reached primarily through fixed sites and men,

vulnerable groups, and young people reached through mobile services. During FY10, PSI's counseling

and testing activities will continue to focus on the districts in which New Start sites are located (Maseru,

Mafeteng, Qacha's Nek, Leribe, and Butha-Buthe).

In order to effectively promote its counseling and testing services, PSI proposes expanding its cadre of

IPC agents. PSI will also increase its schedule of community mobilization activities promoting counseling

and testing. These activities target men and couples in particular, and focus heavily upon addressing key

determinants of testing behavior, including self-efficacy and social support.

In addition to counseling and testing service provision PSI will continue to partner with ALAFA, LDF, and

other partners providing counselor training, mobile CT and organizing special testing events as needed.

PSI also hopes to refine its post-test club pilot program, a structured IPC intervention through which

selected community groups who have elected to seek counseling and testing together go through an

eight-module sexual health curriculum. This curriculum promotes retesting and safer sexual behaviors

following testing and is appropriate for both positives and negatives.

With FY10 funds, PSI will build on the already established relationship with MOHSW to assist in

strengthening human resource capacity and information systems in order to improve Counseling and

Testing program data quality, and the data flow from health facility or community to district and national

level in a timely manner for use and decision making at all levels. Additionally, by leveraging other

Development Partners investments and working in close collaboration with MOHSW, NAC, Ministry of

Local Government and Chieftainship and other relevant key ministries and local organizations, PSI will

contribute to the monitoring and evaluation of the Partnership Framework's counseling and testing

objectives and to the transition from PEPFAR-specific reporting systems to strengthened, GOL-owned

systems.

In FY10, PSI proposes strengthening public sector linkages at the district and community levels by

employing New Start clinics as centers of excellence for training in primary prevention. At the district

level, New Start will provide sustainable capacity building through attachments and mentorships for

public sector health professionals. PSI New Start centers may also expand beyond CT to include training

and service provision for other primary preventative services such as screenings for diabetes, high blood

pressure, TB and STIs. In addition to the focused capacity building provided through its CT program, PSI

will also continue to provide tailored CT training and quality assurance services to partners in the public

and NGO sectors, many of whom subsequently diffuse these skills through their work with the health

system. Similar services will be offered to teams of public sector providers through the national MC pilot.

Finally, PSI will include a substantial capacity-building component in the distribution of GoL condoms.

PSI proposes two parallel activities in MC. The first is continued support to JHPIEGO in their

implementation of the national MC pilot program. PSI will provide training for counseling and testing to

providers in selected pilot sites, using the existing counseling and testing training curriculum. Trained

providers may be professional counselors, lay counselors, or nurses, depending upon the preferences of

the MoH and JHPEIGO; PSI routinely trains and employs members of all three cadres and has tailored

training materials targeted to each. In addition to this, PSI will provide technical oversight for MC

communication to support JHPIEGO's service provision activities with the MoH. These activities will

initially be limited to development of an MC communication strategy and design and production of

provider job aids (flipcharts) and client take-away materials, with an eye to expanded activities, including

demand creation, in later years when services have scaled up. Based on experience in MC

communication elsewhere in the region, PSI recommends a minimum package of communication

materials, to include: one provider job aid; one client take-away targeting men; and one client take-away

targeting female partners of male clients. If appropriate given existing levels of demand, PSI may also

begin to incorporate MC messages into its counseling and testing protocol.

Parallel to its support activities for the national MC pilot, PSI proposes to pilot MC services with the LDF,

establishing a mobile MC unit staffed with a trained doctor, as well as nurses and counselors. This unit

will rotate between an LDF hospital and two other public sector sites, providing CT, MC counseling, and

circumcision services. Site selection will be undertaken in consultation with the LDF, the MoH, and

JHPIEGO, and may be informed by JHPIEGO's upcoming site assessment. Post-operative follow-up will

be managed by the permanent staff at the clinics themselves following a prescribed schedule, with the

option of referral to PSI clinicians or counselors as necessary. Specific program activities will include:

training of project staff in MC service provision (including counseling); training of clinic staff in MC follow

up, including both post-surgical protocol and risk reduction counseling; procurement of MC supplies and

commodities; and implementation of the pilot, which will include substantial clinical quality assurance

efforts. JHPIEGO will provide support to the pilot in clinical training and clinical quality assurance. PSI will

provide quality assurance for counseling and testing and MC counseling using standardized tools piloted

in Lesotho and the region. It is estimated that, in the course of its first year, this pilot will provide MC

services to 1500 men (750 LDF).

PSI's sexual prevention activities include promotion and distribution of male and female condoms. In

addition to branded, commercially marketed condoms, PSI distributes GoL condoms to health centers,

and provides USG-donated condoms to local partners. PSI also distributes USG-donated female

condoms (FC) through its New Start sites.

PSI implements its condom programming nationwide, targeting men and women in union. Rural couples

are particularly high priority, as they are less likely to use condoms than their urban and peri-urban

counterparts. The mix of activities included in PSI's condom programming portfolio are influenced by our

target audiences; the need for balanced product supply and demand; and adherence to the Total Market

Approach, a principle which hypothesizes that the healthiest markets are those in which all market

segments - commercial, subsidized, and public sector - complement each other and grow in parallel.

PSI ensures the quality of its condom program through coverage and distribution studies and population-

based surveys, as well as robust MIS.

In FY10, PSI proposes expanding its condom programming. Male condom activities will include

continued sales of branded male condoms (funded by the Dutch government) as well as an expanded

role in the distribution of free -issue GoL condoms to health centers nationwide. Specifically, PSI will

formalize its partnership with the MoHSW, clearly outlining roles and responsibilities and engaging in

shared planning for greater distribution efficiency. Distribution of GoL condoms will be complemented by

increased efforts to valorize free condoms through targeted promotion using both mass media and an

expanded cadre of IPC agents, who provide interactive activities for individuals and small groups using a

toolkit of eight highly targeted activities.

In addition to expanding direct distribution activities, PSI will also seek to grow partnerships with groups

serving the general population and vulnerable groups in order to ensure better access to condoms. PSI

will distribute male and female condoms and conduct community mobilization events as appropriate

through existing networks of community-based partners. PSI will also continue to partner with the LDF,

providing customized condoms; peer education training and materials; and special events.

PSI proposes piloting a comprehensive female condom program in FY10. This intervention will employ a

model proven in the region, using non-traditional distribution channels (usually hair salons); intensive

interpersonal communication; and community promotional events. PSI will also work with churches and

FBOs to ensure that the female condom and dual protection are addressed in premarital family planning

counseling. Finally, PSI will train nurses in public sector clinics to promote the female condom in family

planning counseling, and will provide job aids and client take-away materials for this purpose. This pilot

program will increase prevention options for men and women in union, and may strengthen demand for

male condoms, as most female condom users tend to employ male and female condoms

interchangeably.