USAID has provided technical support for the HIV response in Papua New Guinea (PNG) since 2004, with a focus on Most-at-Risk Populations (MARPs) with regional funding. Beginning in October 2012, the USAID/Philippines Strengthening HIV/AIDS Services for MARPs in PNG Program, FHI 360 works to mitigate the impact of HIV/AIDS. MARPs targeted by the project include: women who engage in transactional sex, men who have sex with men, and people living with HIV and their sexual partners. The project will continue to support, strengthen, and expand the Continuum of Prevention to Care to Treatment (CoPCT) model developed by FHI 360 in the National Capital District and Madang Province. The CoPCT model enhances clinical services and referral linkages for HIV prevention, care and treatment among MARPs, their sexual partners, and their families. Components of the CoPCT model have been adopted by the GoPNG and adopted by other donors for scale up in other provinces. In addition to improving the demand and supply for comprehensive HIV/AIDS services by MARPs, the project will support facility and community-based gender based violence (GBV) interventions and work to provide support on monitoring and evaluation. To develop local capacity, FHI 360 has selected two faith-based, and one local NGOs/quasi-government body including Salvation Army, Four Square Church and Family & Sexual Violence Action Committee to have accountable systems to manage USG funding by the project end. Monitoring will continue throughout the project life, with illustrative five year results reaching 15,000 individuals from most-at-risk populations with prevention messages. A midterm process evaluation will be completed by FHI 360 and external final evaluation will be carried out by USAID.

The CoPCT model in NCD and Madang will utilize home-based care and clinical-based care in its care and support activities. Case Management Teams (CMTs) will be used to deliver comprehensive services to MARPs, including PLHIV. CMTs consist of five members including health care providers, counselors, and PLHIV case managers. The program team will further develop the scope and number of CMTs working together towards a holistic approach to care, treatment, and support of PLHIV in program implementation areas. Case managers, who will be individuals living with HIV, form a strategic client support system, particularly in urban settings, and are a key element of the National HIV/AIDS Strategy. The program team will ensure the appropriate gender representation among case managers. Regular meetings between outreach teams and CMTs will take place so all clients receive the highest quality care possible.

CMTs are highly successful, particularly in improving follow-up, overcoming stigma and discrimination, and maintaining confidentiality of client data. The engagement of PLHIV as mentors and advisors is central to successful care, treatment, and support of PLHIV in PNG. CMT members will receive training, supplies, and supportive supervision to provide service linkages and address the psycho-social and other needs of clients. The CMT approach will expand to manage GBV cases. The CMTs will capitalize on lessons learned and best practices regionally and in PNG to continue improving referral follow-up, retention in care, and treatment adherence. This will include exercises in mapping, tracking, and health systems support. The CMTs will conduct the following steps to strengthen referrals; (i) quality adherence counseling by CMTs; (ii) identification of treatment buddies and social support; (iii) mutual identification of case managers; and (iv) use of pill counts, visual analogue scores, reminder mechanisms (e.g., SMS, alarm clocks), and specialized tools. The CMTs will improve and expand the use of tracking logs, and will train outreach teams to use referral cards to improve referral mechanisms for services at community, district, and provincial levels. PEs and OVs will further serve as patient trackers, even accompanying clients to clinics if requested. The CMTs will develop a system to monitor the completion rate of different types of referrals to differentiate clients who are referred from hotspots versus those referred through community-based activities, or from other health, social, and legal sectors within the basket of interlinked CoPCT services. Special attention will be paid to the number of individuals enrolled and retained in care (pre-ART) services over time. Staff will also periodically apply a QA checklist to assure standards are being followed. These include data quality assessments to verify whether or not program forms are being completed correctly. Under its new revised strategy, AusAID/NACS has not prioritized community home-based care (CHBC). Most of the funding by AusAID/NACS has been diverted to focus on prevention for MARPs. Due to this, CHBC which is a much sought after intervention by communities, will not be a priority in FY 2013. This will pose some challenges in dealing with the community support for PLHIV after they receive CMT support.

National TB/HIV co-infection rates for PNG are very high at 9%, and TB/HIV co-infection even higher in Port Moresby at 23%.The program team will work with provincial counterparts to expand the coverage of CoPCT models in the current targeted sites, from the provincial facilities in Madang and the NCD, to lower level health facilities in select districts. Within USAID-supported facilities, all HIV cases will be screened for TB and referred for testing within government-supported facilities, and will be reported as part of the programs M&E. CMTs will be used to follow up referrals to assure any suspected case is followed up and tracked over time.

USAID will create and strengthen laboratories within clinical sites to assure STI diagnosis and HCT. USAID will assist these laboratories in the registration process and will provide on-going mentoring to laboratory technicians. As more services become integrated, these laboratories will be able to expand to address a wider range of health issues affecting the communities in their catchment areas.

USAID will provide strategic and intensive on-the-job TA and M&E to local partner staff and stakeholders on routine program monitoring, data management, analysis, and use. USAID will collaborate with local partners and GoPNG counterparts to improve overall data collection, including standardizing procedures and indicators. USAID will provide training and ongoing mentorship to local partner staff, case managers, and clinicians, on basic and descriptive data analysis, epidemiology, and biostatistics. At the national level, USAID will continue to provide TA to GoPNG through the National Oversight Committee and Strategic Information Technical Working Group to raise awareness about the importance of quality data collection and analysis. Additionally, USAID will support the GoPNG and local partners to interpret findings more accurately through rigorous analyses, and apply them to inform strategic planning, design, and implementation of CoPCT and GBV initiatives.

USAID will replicate the standardized Clinical Operating Guidelines in four clinics in NCD and Madang. Another core area is to strengthen the Provincial Monitoring, Evaluation, and Surveillance Team (ProMEST) in NCD and Madang, conducting quarterly analyses to generate real-time data from the ProMEST database. USAID will engage with the provincial health offices (PHOs) to help streamline data flow from clinics working with MARPs. USAID will work with NCD Health Services and the Madang PHO to develop consensus on an electronic data system. Priority areas include timely data reporting and data management standards, including regular backup of provincial level data, and secure storage. USAID will collaborate with government counterparts in the programs second year to establish a system that fully automates data entry at the partner level and sends reports to partners, outreach teams, and clinicians. This will facilitate timely use of data to inform service delivery. Clinical databases will link with the programmatic databases and allow for local analyses and improved case management. USAID will ensure linkages with family and sexual violence units and police stations to improve data reporting on violence. USAID will continue to conduct QI/QA assessments in Madang province, introduce these systems to new partners in NCD, and integrate global QI/QA organizational standards for care, support, and treatment for MARPs. To ensure the program achieves targets, USAID will institutionalize and link mechanisms to routine facility M&E, using client records, program data, and checklists. USAID will conduct QA/QI assessments twice yearly with each local partner and build their capacity to lead this process over time. Data Quality Audits (DQAs) will be conducted twice annually at all supported facilities. In accordance with monitoring guidelines, partner staff, the NDoH, and the PHO will jointly conduct DQAs, thereby increasing country capacity. This activity aims to improve data use and feedback, data accuracy, systems integrity, data integrity, data validity and reliability, and the overall M&E system.

In order to expand more clinics and health care providers to deliver quality services for MARPs, the program will support new clinics in NCD and Madang, improving the capacity of clinicians and institutions. These efforts will increase the network of MARP-friendly services and further link community-based prevention and care services within settlements and urban centers. Relationships with all of the new clinical sites are already established and USAID will work with the GoPNG on their accreditation. USAID will engage NCD's Health Department as a focal point in coordinating services.

Given the fragile health care system in PNG, and the lack of coordination among service providers, there are many missed opportunities to improve comprehensive care. To address this gap, USAID will work with key stakeholders to ensure linkages and positive relationships are strengthened between clients and providers of clinical (e.g., HCT, STI management, PPTCT, OI), social (e.g., GBV, legal), community (e.g., positive prevention, case management, psychosocial support, shelter homes), and non-clinical services (e.g., livelihoods, education). A significant amount of training and mentoring will be required to assure human resources are equipped to deliver quality services. The CoPCT process evaluation noted cases of stigma and discrimination at health facilities, which has great potential to deter clients from accessing much-needed services. To further develop competent, long-term providers of quality HIV services, USAID will train and build capacity of providers within supported sites with the goal of delivering quality, MARP-friendly services. Since there is a limited number of service delivery sites currently providing a full spectrum of HIV services, USAID will expand service provider options, including for HCT, ART and STI services. Critical to successful expansion of CoPCT in NCD will be strong engagement and coordination with the GoPNG and civil society partners. The CoPCT process evaluation noted cases of stigma and discrimination at health facilities, which has great potential to deter clients from accessing much-needed services. USAID will train both community members and government clinicians to assist in building confidence among MARP members to access services.

Specialized trainings for service providers and clinicians will aim to improve: i) acceptance of clients through sensitization activities and meaningful involvement of PLHIV; ii) treatment for STIs (symptomatic and asymptomatic); iii) HIV testing uptake and ART adherence through improved counseling skills, clinical service quality, and logistics for supply chain management; and iv)testing and treatment of OIs, including TB. USAID will train staff members to conduct concurrent TB and HIV testing, and refer to public-sector services as necessary. USAID will engage MARP representatives to participate in clinic response committees, building their capacity in peer counseling, advocacy, and leadership. USAID will also seek community leader participation on stakeholder committees to promote and secure community support and buy-in and improve the response to GBV through improved trauma counseling skills and appropriate referrals. TA will enable: i) proper PEP provision in clinics; ii) ensure appropriate legal and psychosocial support; iii) contribute to effective advocacy, and raise community awareness of GBV and related issues; and iv) expand access to a comprehensive package of he

According to the 2012 Global AIDS report, just over half of the population has tested for HIV in the past year; among WTS this is 46.4% and among MSM this is close to 56%. HCT is the entry point into the CoPCT model and will be a cornerstone of the programs activities. Referrals from community and hot spot-based outreach will be tracked to assure that those at highest risk - MARPs and higher risk men and women - are routinely tested and know their results. It is critical to assure these populations know their status, so they are linked to care and treatment services if they are found to be HIV-positive, or prevention messaging is reinforced if they are HIV negative. HCT uptake will be heavily promoted through outreach activities, the use of media, and special events such as World AIDS Day. Clinic providers will be trained on identifying and referring clients to HCT services.

In FY 2013, the new program will aim to provide HCT services to 800 people: 200 WTS, 50 MSM, and 550 higher risk men and women. In FY12, the previous program reached 1,773 people, but new partners and the need to create testing services and train counselors makes this target unfeasible for FY 13. Approximately 40 clinical staff will be trained in HCT and quality assurance (QA). Within the programs M&E activities, routine QA will be carried out to assure counselors carry out HCT in accordance with established standards. Client satisfaction surveys will act as spot checks to assure counselors are addressing key messages with clients during their interactions (i.e., understanding what results mean, the importance of encouraging partners to be tested). Within the care and treatment cascade, tracking of MARPs and higher risk men and women within communities will allow the program to identify if referrals are being taken up, and to initiate further studies to understand why these higher risk groups may not be accessing testing services. Referrals to care and treatment services will also be provided and tracked to identify the proportion of PLHIV lost between testing and pre-ART or ART services. USAID will engage a strategy using CMTs to play an essential role in following up with individuals referred to these services in order to promote service uptake and reduce the likelihood of spreading infection. The approach to testing will be focused per GoPNG guidelines, particularly to Providers Initiated Counseling and Testing (PICT) in addition to voluntary counseling and testing (VCT). The PICT will encourage pregnant mothers to undergo HCT as included in the recently developed National PPTCT Curriculum and VCT guidelines. USAID will ensure PICT is integrated with the PPTCT component of the clinics once ART is initiated. In case of any gap in PPTCT services within these clinics, local partners will work to build a strong referral and linkages system with other clinics to support these clients a strength of the CoPCT model as observed in the last phase of the previous program. During FY 13, USAID will include interventions on partner management to improve the completeness of treatment besides testing of clients partners. To ensure quality counseling and testing, USAID will use quality improvement/quality assurance (QI/QA) checklists and a performance standards tool to improve and substantiate the quality of GBV and HIV services in all the clinics.

USAIDs focus in prevention is to reach adult (over 18 years of age) MARPs (including MSM, transgenders and WTS), higher risk men and women who have multiple concurrent sexual partners, and people living with HIV (PLHIV) through Social and Behavior Change Communication (SBCC). USAID will provide these groups with quality HIV prevention services and linkages to care and treatment in NCD and Madang. In the first year, the program will continue providing technical assistance to provincial counterparts in strengthening the delivery of the comprehensive prevention package (CPP) with referrals to care and treatment services in current sites. The CPP comprises two interrelated sets of interventions: 1) prevention services (SBCC, referrals to, and provision of HCT and STI management, and condom and lubricant distribution) and activities that address livelihood development, policy advocacy and strategic information; and 2) activities to reduce stigma and discrimination. The CPP serves as an entry point for the CoPCT model, a well-coordinated network that links and consolidates prevention, care (OI treatment), ART treatment, and support services for people vulnerable to, living with and affected by HIV/AIDS. An important new element to the model is the integration of GBV reduction interventions. These include building civil society capacity for the prevention of GBV; GBV mitigation and case management, including shelter, legal, and psycho-social services, trauma counseling, referral, and Post-Exposure Prophylaxis (PEP) treatment; referrals to and between essential and related health facilities, labs, and pharmacies; and linkages to and between essential community social services.

The program team will recruit 30 outreach team members across 30 sites (20 sites in NCD and 10 sites in Madang), including peer educators (PEs) recruited from MARPs to cover hotspots and outreach volunteers (OVs) to cover general community sites where higher risk men and women can be reached. These higher risk men and women differ from our MARPs populations in that they: 1) do not identify as being at high risk for HIV transmission; and 2) engage in higher risk sexual behaviors such as having multiple, concurrent sexual partners and/or engage in high levels of unprotected anal or vaginal intercourse. The outreach team will focus on raising awareness of HIV, convey prevention messages, conduct service promotion activities and provide referrals to HIV testing and STI management services. The outreach team will also distribute and promote male and female condoms and lubricants, address negative social norms regarding condom use, strengthen condom negotiation skills, and increase self-efficacy for requesting condom use, particularly within relationships that may be non-monogamous. The outreach team will also focus its efforts on reducing stigma and discrimination within communities and in clinical settings, by adapting and enhancing the training and advocacy package. This includes sensitization activities to improve policies and practices, heighten access to information, and link MARPs to other services and opportunities. In order to better understand the effect of these prevention efforts, a care and treatment cascade will be integrated into the program to track progression from prevention through to treatment.

As part of its start-up activities, USAID will hire and train 35 clinicians (including staff from local partners and government clinics) to provide high quality HCT, STI management and OI care. These trainings will be carried out over a period of a few days and periodically followed up using QA and supportive mentoring to assess the degree to which skills are being utilized and identify areas where strengthening is required. Clinician job aids will be provided so they can reference specific steps in case management to assure a comprehensive response. USAID will provide on-site supportive supervision by providing hands-on mentoring for clinical and non-clinical staff. The Senior Technical Officer for Care, Support and Treatment will visit clinics managed by partners in the NCD twice in a week while visiting Id Inad clinic and Modilon Hospital in Madang once every quarter. The Senior Technical Officer and M&E Officer will provide support for partners weekly in NCD, and support Madang partners quarterly. Program officers both in Madang and NCD will provide on-site supportive supervision daily. Performance data is collected using case sheets and summary sheets at the clinical level. PEPFAR and other indicators will be used to measure progress in achieving outcomes and outputs.

CMTs will be based within ART clinic sites to assure continuity and monitor loss to follow up and to track down clients who have not returned for treatment. Under the previous program, the introduction of this approach contributed to a decrease in loss to follow up for patients on OI medication and/or ART. Rates decreased from 38% in 2008 to 5% in 2011 at the two NCD clinics and from 14% to 1% at the Id Inad Clinic (Modilon Hospital) over the same period. Adherence will be supported by counseling. Under the previous program, CHBC activities helped increase adherence to ART from 58.8% to 75.1% among 184 PLHIV in the NCD-funded sites.

Under the care to treatment cascade, the clinical data available in USAID-supported clinics and hospitals will be critical to assess overall outcomes of the CoPCT. At this level of the cascade, close attention will be paid to enrollment into treatment and survival at 12 months. At the site level, clinical data can be used to carry out mortality assessments and identify cases of premature mortality, which could indicate areas where further provider capacity building may be needed.

Transition will occur over time, and facilities will be integrated into existing government facilities where applicable form the beginning of the program. This will maximize exposure to government officials and reinforce the concept of a one-stop shop" for clients.