Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 5812
Country/Region: Thailand
Year: 2009
Main Partner: U.S. Centers for Disease Control and Prevention
Main Partner Program: NA
Organizational Type: Own Agency
Funding Agency: HHS/CDC
Total Funding: $2,597,880

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $68,538

n/a

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $28,101

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 02 - HVAB Sexual Prevention: AB

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Thailand is well recognized for its success in slowing the spread of HIV in the 1990s. As a result of an organized national

prevention campaign, HIV transmission fell rapidly, from a high of 141,000 new infections in 1991 to approximately 14,000 in

2007. HIV prevalence among the overall adult population (ages 15-49 years) is estimated at 1.4%. Despite these successes, in

recent years there are signs that the country is vulnerable to a resurgence of the HIV epidemic. HIV prevalence among most at

risk populations (MARPs) continues to be high or is increasing (see Five-Year Strategy). Recent MOPH and MOPH/CDC surveys

reveal an alarming increase in HIV prevalence among men who have sex with men (MSM) in Bangkok from 17% in 2003 to 28%

in 2005 and 31% in 2007. In Chiang Mai, HIV prevalence remains high (15% in 2005 and 17% in 2007).

HIV prevalence among direct female sex workers (FSW) and indirect FSW in Thailand declined steadily from the mid-1990s

reaching 4.6% among direct FSW and 2.3% among indirect FSW in 2006, and then increased to 5.6% among direct FSW and

3.4% among indirect FSW in 2007. FSW increasingly meet clients in indirect settings (over 90% of contacts), which places sex

workers at a disadvantage in negotiating condom use. Sexually transmitted infection (STI) clinics have been relocated from

community locations to hospitals, where sex workers are reluctant to go; and the volume of outreach activities and condom

supplies have decreased, due in part to budget cuts. Street-based FSW may be at particularly high risk as a recent USG-

supported survey of primarily street-based FSW in three areas of Bangkok found that 20% were HIV-positive.

Current epidemiologic models based on the shifting transmission dynamics of HIV in Thailand are from the Analysis and

Advocacy (A2) Project supported by USG. In 2010, it is estimated that over 30% of new HIV infections will occur among MSM,

while 25% of new cases will be from husband to wife and another 10% from wife to husband who are sero-discordant couples.

Prisoners are also an important priority population for HIV sexual prevention interventions. In 2008, prison-based voluntary

counseling and testing (VCT) service delivery data indicated that 6.5% and 11.5% tested HIV-positive in Phuket and Pathumthani

prisons, respectively. A 2001-2002 study conducted among prisoners in a Bangkok central prison found an HIV prevalence of

25%.

In contrast to MARPs, the HIV prevalence rates among pregnant women in antenatal care and young male military conscripts are

less than 1%. HIV risk remains low among Thailand's youth—approximately 0.5% of reported AIDS cases and an estimated

<1.0% of PLHA are 15-19 years of age. However, evidence is increasing that young people are at risk of STIs, potentially

including HIV. Increasingly early sexual initiation, high rates of chlamydia infection, and low rates of condom use among

vocational and high school students have prompted the Thai government to strengthen HIV prevention programs and promote

condom use among sexually active teens. MOPH has endorsed a comprehensive ABC—Abstinence, Be Faithful, and correct and

consistent Condom use—approach and collaborates with the Ministry of Education to implement HIV prevention programs for

youth. For HIV-positive youth, there are currently no targeted Prevention with Positives (PwP) programs.

While the HIV epidemic is concentrated among MARPs in Thailand, prevention efforts among these populations have been

inadequate. In the 2008 UNAIDS Global AIDS Epidemic Report, no national estimates are reported for prevention program

coverage among FSW, injection drug user (IDU), and MSM populations. In the same UNAIDS report, it is estimated that only 54%

of FSW and 35% of MSM were tested and learned their HIV status in the past year.

Male sex worker (MSW) exposure to HIV prevention outreach in the last year was low, but increased in USG-supported areas

(Bangkok - 35% in 2005, 50% in 2007; Chiang Mai - 57% in 2007). MSW are more visible and accessible, but other MSM are

more difficult to reach. Among MSM who are not sex workers, outreach exposure is significantly lower (Bangkok - 21% in 2005,

28% in 2007; Chiang Mai - 38% in 2007). Few prevention programs for MSM exist beyond USG support in Thailand. Barring the

success of the Global Fund Round 8 proposal, which targets MARPs, a serious prevention gap for MARPs will continue. This gap

comes at a time when MARPs are driving Thailand's concentrated epidemic and sexually bridging the epidemic to lower risk

populations, such as wives and partners of HIV-infected MSM, IDU, and sex workers.

USG-Supported Activities

* HIV Prevention for MARPs:

USG supports the development, evaluation, dissemination, and replication of prevention models aimed at MARPs.These models

will be implemented by both NGOs and government (MOPH, BMA, and local governments). The models are developed using

proven MARP approaches, with Thai government input and support for potential future replication using funds from the

government, GFATM, or other resources. Models are based on the USG-developed concept of a comprehensive prevention

package which includes a "minimum package of services" (MPS), or the minimum combination of services needed to have a

significant impact on the spread of HIV. Strategies used in these models are:

• Outreach for education, risk reduction, and condom promotion in communities where MARPs congregate. Risk reduction for

MARPs includes comprehensive prevention messages, emphasizing reduction in partner numbers, condom promotion, and

referral to STI and VCT services. USG is building the capacity of government and local partners to conduct peer outreach

education.

• Drop-in centers which serve as "safe spaces" for MARPs to meet and for project implementers, including peer educators, to

reach their target audiences with behavior change communication (BCC) and prevention education as well as providing access or

referral to clinical services such as STI and VCT. USG is building the capacity of local partner agencies to implement the drop-in

center model.

• Linked prevention services, especially VCT, with care and treatment services to facilitate access for marginalized populations.

• STI and VCT services that are "MARP-friendly," accessible to the populations, and include risk reduction counseling with

comprehensive messages.

• PwP programs for MSM, including risk reduction counseling, disclosure counseling, and condom and lubricant distribution.

• Targeted media to increase awareness of HIV and risk behaviors. USG works with local partners to conduct audience research

and develop and evaluate media messages.

MSM (MSW and transgenders [TG]): USG supports a comprehensive prevention package model for MSM (Bangkok, Chiang Mai,

and Phuket), MSW (Bangkok, Chiang Mai, Pattaya, and Phuket), and TG (Pattaya). Additionally, USG has begun to build the

model in Udon Thani and Khon Kaen, in the northeast of Thailand. In FY 2008, three new MSM-friendly clinics were established,

and community-based groups were trained on organizational development. USG provided training on sensitivity and STI

management for MSM and integrated STI services and VCT promotion for MSM into existing clinics. Complementary activities

strengthening community-based organizations (CBOs) will be linked to government-run clinical services. A BCC training

curriculum for MSM was developed and used to train outreach workers. The Popular Opinion Leader (POL) intervention activities

ended this year with 64 POL trained and 934 MSM reached by them. All trained POL are now part of the Rainbow Sky

Association, a CBO working with MSM in Thailand.

In FY 2009, priorities for these sites will include strengthening the capacity of MSM organizations and local health care providers

in conducting outreach, VCT, and STI services, and advocating for provincial governments to include MSM-targeted STI services

in their STI service plans. For HIV-positive MSM, PwP counseling and referrals to care and treatment will be key elements of the

model. An MSM community group has already been formed in most sites to conduct outreach, and promote condom use and VCT

and STI screening. USG will support capacity building and sustainability of these groups through Pact, working on organizational

development.

FSW: USG will provide technical support to the MOPH and BMA to use the results from the respondent driven sampling survey

completed in 2007 to adapt and implement surveillance and interventions for non-venue-based sex workers, who currently are not

targeted by the mainstream HIV/AIDS prevention program. In STI clinics, USG will continue to provide TA to the government to

improve STI services for high risk populations, including FSW and MSM. TA will be focused on VCT, STI screening, STI case

management, and M&E.

Prisoners: USG support for HIV prevention with prisoners focuses on peer education, VCT and STI services, and linkages to care.

Support includes development and implementation of an HIV training curriculum for both inmates and guards. For peer education,

USG supports adaptation and evaluation of peer education for HIV prevention among prisoners at provincial prisons in Phuket

and Pathum Thani in collaboration with the prison, the provincial health offices, local hospitals, and a local NGO. The peer

education program aims to increase HIV knowledge and promote use of HIV VCT; linkages have been established with local

hospitals to provide HIV VCT and HIV treatment to infected inmates. As of July 2008, the program in Pathum Thani successfully

trained 120 peer educators who reached 1,009 inmates and provided HIV VCT to 200 inmates. The program in Phuket trained 50

peer educators who reached 1,360 inmates and provided HIV VCT to 340 inmates. In 2008, meetings were convened between

USG partners and local stakeholders including the national-level Department of Corrections (DoC), and it was agreed that the

integrated peer education, VCT/STI services, and referral model in Phuket will be transferred to the Wachira Phuket hospital in

2009. USG support for the integrated model programs will be continued in Phatum Thani and expanded to four additional sites

(Chiang Rai Prison, Khon Kaen Prison, Khon Kaen Correctional Institution for Drug and Addicts, and Udon Thani Prison). USG

will continue to provide technical support and coordination to local stakeholders and policy-level support to staff at DoC and the

Bureau of AIDS, TB, and STIs to implement these models. This will include training support, supervision, and monitoring to help

ensure the quality of services, and to support M&E for program effectiveness and potential scale-up.

* Prevention with Positives:

USG supports development of appropriate prevention service models for adult and pediatric PLHA, including specific models for

MARPs (see Adult and Pediatric Care and Treatment narratives).

* Youth:

Due to the overall low HIV prevalence rates in general youth populations in Thailand and the significantly higher rates in MARPs,

USG will not focus on primary HIV prevention in general youth populations. Rather, USG Thailand will address the need for

secondary HIV prevention among HIV-infected youth, and will develop a youth PwP model. An aging cohort of perinatally-infected

youth in Thailand is now reaching adolescence. These young people are facing the challenges of going through adolescence

while being HIV-positive, and some are engaging in risky sexual behaviors. No tools or guidelines currently exist on how to

provide counseling or address risky sexual behaviors in HIV-infected adolescents. Health care providers rarely address these

issues with adolescents.

USG has developed a clinic-based intervention, including sessions on the following topics:

• Health promotion (adherence, sexual and reproductive health, and self-care counseling).

• Self-empowerment and life skills (communication/negotiation, decision making, problem solving, and stress management).

• Sexual and behavioral risk prevention (including counseling, substance abuse issues, disclosure/partner testing, and STI

screening).

Outcomes and effectiveness of this model will be assessed in 2009 through pre- and post-intervention assessments at three sites,

including two pediatric ART clinics and an orphanage.

USG Thailand will work with the Prevention for Positives Task Force to adapt the youth PwP model for African settings where HIV

-infected youth are a mixture of vertically and sexually infected persons, and provide tools, materials, and technical support for

adaptation and implementation of the model in other PEPFAR countries.

Policy

Condoms are not procured directly by USG. Condoms are readily available for purchase in Thailand, but free condoms are only

available in limited quantity and are not targeted for distribution to MARPs. Since the successful Thai government response to HIV

in the early and mid-1990s, Thai government policy has become more restrictive and sometimes acts as a barrier to effective

prevention efforts. For instance, under current law, the provision of condoms in entertainment venues is used as evidence by the

Ministry of Public Security that the venue is an illegal establishment for commercial sex. This law discourages entertainment

venue owners from participating in HIV prevention efforts. Additionally, BMA's policy of using only primarily health staff for

outreach is counter to international recommendations that indicate that peer outreach workers are a crucial behavior change

intervention tool.

Program Budget Code: 03 - HVOP Sexual Prevention: Other sexual prevention

Total Planned Funding for Program Budget Code: $1,516,986

Total Planned Funding for Program Budget Code: $0

Table 3.3.03:

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $371,615

n/a

New/Continuing Activity: Continuing Activity

Continuing Activity: 17984

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17984 11584.08 HHS/Centers for US Centers for 7908 5812.08 Management / $622,543

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

11584 11584.07 HHS/Centers for US Centers for 5812 5812.07 Management / $500,328

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $152,362

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 04 - HMBL Biomedical Prevention: Blood Safety

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

HIV transmission among IDU in Thailand remains a critical problem. In 2007, HIV prevalence in this population was as high as

29%, and the estimated number of IDU in the country range from 40,000 to 100,000. In 2004, the number of IDU in Bangkok was

estimated at around 3,600. Although the population size of IDU in Thailand appears to be declining, projections derived from the

Asian Epidemic Model estimate that in 2010 almost 10% of all HIV transmission nationally will occur through drug injection. HIV-

related risk behaviors among this population also continue. During January 2005 - August 2008, reports from IDU contacted by

outreach workers in Bangkok (n=990, BMA outreach program) indicated that 6% were sharing needles and 43% were sharing

other injection equipment. Among sexually active IDU, condom use during last sex with steady and casual partners was 42%

(n=577) and 79% (n=504), respectively.

USG-Supported Activities

USG support for IDU prevention interventions includes a peer outreach program and referral linkages to methadone treatment and

HIV care services in Bangkok. USG works closely with the Bangkok Metropolitan Administration (BMA) in developing the peer

outreach model, which includes IDU and health care staff capacity building, M&E activities, and referral to existing drug treatment

and HIV care services.

Incorporation of health care staff into community-based HIV prevention outreach activities was started in 2004, and by 2007 BMA

had successfully integrated the staff-based outreach model into their routine services for IDU at all 18 public methadone clinics in

Bangkok. Currently, USG supports the staff outreach model by supplying hand-held computers to collect and download field data,

and by providing information technology support and training to BMA outreach staff. In FY 2009, USG will support a strategic

information workshop among the 18 BMA methadone clinics on how to use resulting data to monitor program implementation and

to share lessons learned and best practices.

Following the success of the staff-based outreach model, USG supported the development of a peer outreach model and the

training of 50 peer educators on conducting community-based outreach. Between 2005 and 2008, 990 IDU have been reached

through peer education outreach activities. As part of networking and capacity building for IDU peer outreach workers, USG

supports an annual forum for outreach workers to share information, experiences, techniques, and best practices for outreach

activities. This event is hosted by BMA, and several organizations participate in the forum including the PSI Ozone, Raks Thai

Foundation, Thai Treatment Action Group, and the Asian Harm Reduction Network. In FY 2009, USG will continue to support IDU

peer outreach by helping to coordinate efforts between partner organizations and by technically supporting the incorporation of a

PwP program into this model. It is estimated that roughly one-quarter of IDU in Bangkok are HIV-positive, and the high-levels of

risk behavior among IDU require customized behavior change interventions. Program data indicate that care and treatment

service delivery uptake among HIV-positive IDU is poor, so linkages to care and treatment services will be strengthened as well.

During 2009, an evaluation of the effectiveness the peer-based model for outreach education will be conducted to assess the

potential for integrated scale-up.

In 2009, USG together with the MOPH and BMA will conduct a RDS survey among IDU to estimate the prevalence of HIV and key

behavioral outcomes in Bangkok and Chiang Mai. The resulting survey data will be used to estimate the population size of IDU

and service utilization as well. Collectively, these data will increase knowledge of the dynamics of the HIV epidemic among IDU

and will inform program planning.

Services, Referrals, and Linkages

USG, together with BMA, uses IDU peers to provide HIV outreach interventions and to link IDU to care and treatment services,

particularly among those who are not in methadone treatment or have never accessed HIV services. Linkages to VCT and

methadone treatment are implemented through BMA's 18 methadone clinics throughout Bangkok, which provide methadone to

heroin users at no cost.

Other services at these clinics include HIV counseling and testing and the four-month outpatient Matrix rehabilitation program for

methamphetamine users. USG helps strengthen access to VCT for IDU by working together with BMA methadone clinic staff to

provide mobile VCT twice a month at the PSI Ozone IDU drop-in center. IDU who need STI care are referred to BMA public health

centers that provide STI services. USG will continue collaborating with NGOs working with IDU (PSI Ozone drop-in center and

Raks Thai outreach program) under the direction of BMA and will assist in the coordination and linking of these activities. USG will

also provide technical support to training curriculum development and for forums to share lessons learned, best practices, and

opportunities for networking.

For FY 2009, USG will continue to support and strengthen activities implemented by BMA in Bangkok using the peer outreach

model. Positive prevention messages will be added to the outreach component, and the linking of HIV-positive IDU into care (CD4

testing, ARV treatment, TB testing) will be strengthened by taking advantage of recent improvements in the HIV care referral

system where ARV will be provided in 12 participating BMA public health centers. These public health centers are usually

adjacent to BMA methadone clinics and can be easily accessed by IDU.

Policy

In 2008, USG provided TA to BMA on proposal development to help leverage GFATM financial support to subsidize costs

associated with the expansion of IDU prevention activities to more sites in Bangkok. In 2009, USG will support BMA proposal

development to obtain financial support from Thai government resources. In addition, USG will provide technical leadership for the

development of an outreach manual by the MOPH with WHO financial support. The results of the planned 2009 RDS survey

among IDU in Bangkok and Chiang Mai will be used to inform policy decision making for IDU programs and services.

Program Budget Code: 05 - HMIN Biomedical Prevention: Injection Safety

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 06 - IDUP Biomedical Prevention: Injecting and non-Injecting Drug Use

Total Planned Funding for Program Budget Code: $85,268

Total Planned Funding for Program Budget Code: $0

Table 3.3.06:

Funding for Prevention: Injecting and Non-Injecting Drug Use (IDUP): $40,715

n/a

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $16,693

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 07 - CIRC Biomedical Prevention: Male Circumcision

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $840,370

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

At the end of 2007, there were an estimated 610,000 PLHA (600,000 adults and 10,000 children) in Thailand, and it is projected

that about 45,000 PLHA will develop AIDS each year in the next several years. Since 2004, Thailand has made ART available

nationwide, and an estimated 115,000 patients receive ART through the universal health care scheme run by NHSO as of August

2008. By the end of 2007, the number of persons on ARV treatment was estimated by WHO to be 61% of the estimated eligible

population. The national ART program, including all government health coverage schemes, accounted for all but 10,000 private

sector patients on treatment. An estimated 31,000 persons died of AIDS in Thailand during 2007, half of the estimate for 2001 but

still a very substantial number.

The government provides HIV care and treatment to Thai citizens through the universal health care scheme managed by NHSO;

835 hospitals participate in the program. These services include not only ART but also basic medical care, HIV counseling and

testing, CD4 monitoring, and prophylaxis for opportunistic infections. In Thailand, 78% of patients receive health care services

through NHSO; other health insurance schemes include government schemes for employees of private companies and civil

servants, and private coverage. Thai national ART guidelines provide the technical basis for NHSO's benefit package for HIV

care.

The quality of HIV care and treatment, including associated laboratory services, is variable; human resources to deliver care are

insufficient in many places, and HIV counseling and testing services and linkages to treatment for MARPs are weak. Stigma and

discrimination related to HIV are substantial barriers to HIV testing as well as care and treatment, especially for MARPs. As

expansion of HIV care and treatment services occurs in Thailand, there is an ongoing need to monitor and support service quality,

and the MOPH and NHSO are working to expand quality systems for these services.

Other services such as home- and community-based care are provided through a combination of local and national budgets.

However, since the decentralization of the Thai health system, funding allocations are now made at the local level, which has

resulted in a wide range of activities and not always providing a full continuum of care, depending on local resource levels and the

recognition and awareness of communities and prioritization of public health problems in each locality. Guidelines for

Comprehensive Continuum of Care for PLHA were developed by MOPH in 2004, but they are not in systematic use.

To address these needs, USG provides technical support for the following: 1) national scale-up of performance measurement and

quality improvement for HIV care and treatment services (HIVQUAL-T), 2) scale-up of national PwP training for facility-based

services for general population patients, and 3) integration of comprehensive HIV/AIDS care for MARPs through development of a

PwP program and community-based services and referrals for MSM. USG support for models in these areas will include

evaluation and dissemination of findings for replication within Thailand, and where appropriate, to other PEPFAR countries.

USG-Supported Activities

• Performance measurement and quality improvement of HIV/AIDS care in facilities HIVQUAL-T: HIVQUAL-T model development

was supported by the Health Resources and Services Administration and the New York State Department of Health AIDS

Institute, based on HIVQUAL used in the U.S. (for Ryan White services). The HIVQUAL-T model was piloted and underwent initial

expansion in Thailand from 2004 - 2007. Nationwide implementation started in 2008 with collaboration between the MOPH,

Thailand's Institute of Hospital Quality Improvement and Accreditation, and NHSO. As of the end of FY 2008, 734 hospitals from

all regions have received training on HIVQUAL-T, and several hospitals and MOPH have received additional training on quality

improvement methods. Also, 555 hospitals have done at least one performance measurement of HIV care, and their coverage of

key indicators are: CD4 testing 91%, PCP prophylaxis 82%, cryptococcal prophylaxis 74%, ART for eligible patients 91%, TB

screening 81%, and cervical cancer screening 25%.

In FY 2009, USG will continue to provide technical support to MOPH, in cooperation with NHSO on HIVQUAL-T model

implementation with a goal of expanding to all 835 hospitals providing HIV care under NHSO. USG will provide technical support

to the national QI committee and to hospitals for continued expansion of performance measurement and QI. An additional

emphasis will be on integration of NHSO's facility-based HIV service data with HIVQUAL-T to facilitate and increase the capacity

of hospitals to report HIVQUAL-T indicators.

• Prevention with positives (PwP) and increased linkages to care and treatment: A facility-based PwP model was developed by

USG and MOPH in 2007, and covers six prevention strategies:

1) Sexual and behavioral risk reduction.

2) STI screening and treatment for PLHA and their partners.

3) Promotion of HIV disclosure to partners.

4) Promotion of partner HIV testing.

5) ARV treatment and adherence.

6) Family planning and PMTCT.

The PwP intervention tools, including a PwP service manual, risk screening form, flip chart to provide prevention messages,

posters, reminder card with short PwP messages, prevention pamphlet, condom demonstration model, and a PwP training video,

were developed in 2008. The PwP model has been piloted with more than 1,000 PLHA in seven hospitals in 2008 and will target

1,700 PLHA in 2009. Of these, one hospital has piloted a combined facility- and community-based PwP model with 100 patients.

Evaluation of the community- and facility-based models is ongoing and will be completed by 2009-2010. USG is providing TA to

Global Fund and MOPH for scale-up of community and facility-based PwP programs. MOPH and USG have expanded the facility-

based PwP model by providing two-day PwP trainings in five regions in Thailand, with funding support from NHSO. In 2008,

approximately 1,200 care providers from 400 hospitals in all provinces in Thailand were trained on PwP. 6,000 copies of PwP

tools and materials will be distributed to all public hospitals (>800 hospitals) in all provinces by December 2008. In FY 2009, USG

will continue to support the evaluation of the PwP implementation in seven hospitals. Risk reduction counseling and HIV

disclosure and partner testing flip charts will also be developed in 2009. Facility-based PwP training of trainers (ToT) for health

personnel in 12 regions is planned in 2009. The trainers will conduct training to cover another 400-500 hospitals in 2009-2010.

In FY 2009, USG will develop a PwP program for HIV-infected MSM and will pilot the model in four sites. The model includes both

community- and clinical care-based interventions or counseling. Proposed strategies include:

1) Ensuring HIV-infected individuals learn their status.

2) Supporting HIV status disclosure by infected individuals.

3) Providing psychosocial care through community-based support groups.

4) Providing clinical care including STI treatment and ART.

5) Counseling on behavior change for individuals with HIV.

6) Developing leadership by MSM who are PLHA in positive prevention efforts.

The three main approaches will be: 1) capacity building of health care staff, MSM peers, and community groups, especially in

knowledge of sexual risk behavior and in counseling skills; 2) development of tools/materials needed for interventions, training,

and services; and 3) development of a referral system between communities and clinical settings. M&E plans will also be

developed (see Sexual Prevention narrative).

• ARV resistance monitoring and development of early warning indicators (EWI) for ARV resistance.

With the establishment of the national ART program in Thailand, there is a need to monitor for the development of resistance to

ARV drugs as well as the transmission of resistant virus. USG continues to provide technical support to the MOPH for their

national ARV resistance monitoring (see Strategic Information narrative). Goals are the following:

1) Expand ARV resistance surveillance, according to WHO-CDC guidelines, to 43 provinces.

2) Adapt WHO-CDC recommended models for monitoring treatment outcomes and early warning indicators for ARV resistance

and ART program failure and implement these models in pilot provinces.

Referrals and Linkages

National program needs continue to include early referral for CD4 testing and HIV care services for HIV-positive persons, and

strengthening referral systems among hospitals, health centers, and communities. USG supports these linkages through

prevention programs, including VCT services for TB patients and MARPs. USG also supports linkages to PwP services, including

education, counseling, STI screening, and VCT for MARPs (see Sexual Prevention and Counseling and Testing narratives).

Policy

Effective HIV care and ART programs and HIVQUAL-T scale-up are challenged by the low priority given to HIV services in many

hospitals and the high work burden on health care providers since the initiation of the universal health care scheme. The

practicality and effectiveness of these models and the support from the MOPH and NHSO are key to the sustainability of these

programs in Thailand.

Community involvement in HIV/AIDS prevention and care is included in the National AIDS Committee strategic plan. Integration of

PWP programs with community- and facility-based services is consistent with this strategy, but needs a concrete action plan.

Engagement with the MOPH and NHSO and careful M&E of PwP models that link community- and facility-based services with

prevention is critical to successful program replication and scale-up.

Table 3.3.08:

Funding for Care: Adult Care and Support (HBHC): $401,995

n/a

New/Continuing Activity: Continuing Activity

Continuing Activity: 17985

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17985 11585.08 HHS/Centers for US Centers for 7908 5812.08 Management / $474,799

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

11585 11585.07 HHS/Centers for US Centers for 5812 5812.07 Management / $493,929

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $164,818

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.08:

Funding for Treatment: Adult Treatment (HTXS): $106,319

n/a

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $43,591

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 10 - PDCS Care: Pediatric Care and Support

Total Planned Funding for Program Budget Code: $423,378

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Most children living with HIV in Thailand become infected through mother-to-child transmission. An estimated 6,300 infants are

born to HIV-positive mothers each year in government and private sector facilities. The Thailand PMTCT program has a high

uptake of PMTCT interventions, including HIV testing, ARV prophylaxis for mothers and infants, and infant formula for 18 months

(see PMTCT narrative). As a result, the mother-to-child transmission rate was 2-4% in 2007 (based on the results of a PMTCT

evaluation in 14 provinces in 2008).

HIV-exposed infants in Thailand can be diagnosed using in-house DNA polymerase chain reaction (PCR) tests supported by the

NHSO at 1-2 months and 2-4 months of age. HIV-DNA PCR testing for infants is available using either dried-blood spot (DBS)

samples (tested by Chiang Mai University) or whole blood samples (tested by the Department of Medical Sciences, MOPH); the

use of which testing method is determined by NHSO reimbursement to the laboratories. An HIV antibody test is recommended as

a confirmatory test for all HIV-exposed infants at 18 months of age and for all children with HIV signs and symptoms. However, a

USG-supported national evaluation of the PMTCT program in 2008 found that 56% of the HIV-exposed infants were diagnosed by

15-18 months of age (see PMTCT narrative). Delayed infant diagnosis leads to late ARV treatment initiation in these infants.

Cotrimoxazole prophylaxis is recommended for all HIV-exposed infants. However, individual physicians use their own judgment

about whether to give prophylaxis to infants born to HIV-positive mothers. Most physicians routinely offer cotrimoxazole

prophylaxis for HIV-exposed infants who have HIV signs and symptoms or receive incomplete PMTCT regimens. In the 2008

PMTCT evaluation, the prophylaxis coverage rate among HIV-exposed infants was 36%.

According to UNAIDS, an estimated 14,000 children were living with HIV in Thailand in 2007. Of these, about 26%, 35%, and 39%

were 0-4, 5-9, and 10-14 years old, respectively (based on data from the BOE, MOPH). In 2007, WHO, UNAIDS, and UNICEF

reported that 6,687 HIV-infected children were receiving HIV treatment. In the 2007 report, >95% of HIV-infected ART eligible

children were receiving ART. The 2008 United Nations General Assembly Special Session on HIV/AIDS reported 84.9% of

children remained on treatment 12 months after initiation.

Most HIV-infected children receive HIV care and ARVs at public hospitals. More than half of HIV-infected children receive care at

tertiary care or provincial hospitals. Some tertiary care centers are overburdened by the number of patients, and many patients

come from remote areas of the provinces, making visits to the provincial hospitals difficult. In recent years, an increasing number

of HIV-infected children have been referred to community hospitals for pediatric HIV care and treatment. Yet most Thai community

hospitals lack both pediatricians and pediatric HIV treatment experience (only about 100 hospitals have pediatricians available,

and all are tertiary or secondary care hospitals). Taking care of children on ART is complex. Therefore, it is important to ensure

the quality of pediatric HIV care in Thailand, when care is being provided by pediatricians, general practitioners, and in some

areas, nurses.

OI prophylaxis and treatment is part of the benefit package from NHSO. Cotrimoxazole is recommended for Pneumocystis carinii

pneumonia (PCP) prevention in all HIV-infected infants and HIV-infected children who have CD4 less than 15% or 200 cells/mm3

(for children aged >6 years old). From pediatric HIVQUAL-T data in 2006 in five hospitals, 82% of HIV-infected children received

cotrimoxazole for PCP prevention. Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens are first-line regimen

for HIV-infected children; however, for HIV-infected infants with exposure to single dose nevirapine (NVP) or NNRTI-containing

maternal ART, a protease inhibitor-based triple ARV regimen is recommended.

In FY 2009, the overall USG strategies for pediatric HIV care, support, and treatment and care will be to 1) continue technical

support for expanding pediatric HIV care and treatment network sites by providing monitoring and supervision; 2) improve the

quality of pediatric HIV care services by implementing the pediatric HIVQUAL-T model and QI program in these settings; 3)

conduct program evaluation to determine outcomes of expanding pediatric HIV care and treatment to community hospitals; 4)

support development of a PwP youth program; and 5) improve coverage of early infant diagnosis by DBS PCR and early referral

of HIV-infected infants to care.

USG-Supported Activities

• Pediatric HIVQUAL-T model: The pediatric HIVQUAL-T model was developed in 2005 in collaboration with MOPH, Thailand's

Institute of Hospital Quality Improvement and Accreditation (IHQIA), Health Resources and Services Administration, and the New

York Department of Health AIDS Institute. The model was implemented at five hospitals beginning in 2006 and was expanded to

28 hospitals in 2008, with USG and GFATM support. USG Thailand, along with NHSO, IHQIA, and MOPH, plans to scale-up the

adult HIVQUAL-T model to all public hospitals in 2009 (see Adult Care and Treatment narrative). In 2009, USG will work with

NHSO and MOPH to integrate pediatric HIVQUAL-T into the adult HIVQUAL-T model. USG will continue to provide technical

support to MOPH on implementation and use of facility-based pediatric HIV-related data for program monitoring and planning.

USG will support the use of pediatric HIVQUAL-T performance measurement data and hospital quality infrastructure assessment

data for improvement of HIV service quality and hospital infrastructure. USG will also support training of trainers for both the adult

and pediatric HIVQUAL and QI tools (see Adult Care and Treatment narrative).

• Pediatric HIV care network expansion: USG supported three provinces to develop and implement a comprehensive community-

based HIV care network. Care networks allow routine follow-up and adherence monitoring of HIV-infected children to occur in

community hospitals near their homes, in coordination with HIV-trained physicians at the community, district, or provincial

hospitals. The pediatric HIV care network was developed in three provinces and 52 community hospitals with direct USG support,

and was expanded to 12 additional provinces with USG technical support and GFATM funding in 2008. USG provides TA to

MOPH to expand and integrate the pediatric community-based HIV care network model into the existing health system. USG will

continue to provide TA to MOPH and participating hospitals, pediatric HIV treatment and care training, and tools, including the

pediatric HIVQUAL-T manual, software, QI tools, and pediatric HIV care site supervision checklists. In 2009, an evaluation of this

model with direct USG support will be completed. The feasibility of expanding the model to other provinces and hospitals will be

assessed. MOPH is seeking Thai government funds for national scale-up of the pediatric network model, and has requested USG

technical support.

• HIV disclosure model: USG developed an HIV disclosure model for HIV-infected children to address the growing number of

perinatally HIV-infected adolescents and pre-adolescents. From 2005 through August 2008, 164 HIV-infected children at two

Bangkok hospitals had their HIV status disclosed to them. A pediatric HIV disclosure manual was developed in 2008, and was

distributed to many hospitals across Thailand. An evaluation of this model was initiated in 2008 and will be finalized in 2009.

Preliminary expansion of the model has begun as, from May 2007 - August 2008, approximately 700 health care providers from

hospitals in 16 provinces in Thailand were trained on HIV disclosure to children. In FY 2009, the feasibility for model expansion to

additional provinces and hospitals will be assessed. USG will provide technical support for the model evaluation and expansion.

• Prevention for HIV-positive youth: Approximately 40% of HIV-infected children in care at two Bangkok hospitals are older than 10

years. A prevention program is needed for these HIV-positive youth. In 2008, a youth PwP model was developed, and will be

piloted and evaluated at these two sites in Bangkok in 2009. If the model works well, it will be shared with other HIV care and

treatment centers in Thailand. The model will be pilot tested for feasibility, acceptability, and impact on knowledge and practice

among HIV-positive adolescents and pre-adolescents (see Sexual Prevention narrative).

• Early infant HIV diagnosis and early referral of HIV-infected infants: USG will provide technical support to MOPH to provide

training for health care personnel and local HIV/ AIDS program managers at the provincial level on the importance of early infant

diagnosis and early referral of HIV-infected infants to care, DBS PCR techniques, and specimen collection and transportation to

laboratories in four pilot sites. An evaluation will be conducted to compare the uptake of early infant diagnosis in the same

provinces in the previous year and/or with other provinces participating in the routine system.

Referrals and Linkages

All HIV-exposed infants delivering in hospitals (>95% of infants in Thailand are born in health settings) are referred to pediatric

clinics for routine immunizations, PCP prophylaxis, growth and developmental monitoring, and follow-up of HIV infection status.

HIV-infected children are given CD4 count tests and screened for clinical TB. Caregivers are given basic information on HIV and

ARVs, and are trained on how to take care of HIV-infected children. HIV-infected children who are eligible for ART initiate

treatment, mainly at tertiary care centers. Clinical status, CD4 count, and viral load are monitored according to national guidelines.

In provinces with pediatric care networks, HIV-infected children who are clinically and immunologically stable are referred for ART

and adherence support at community hospitals near their residence. HIV-infected children aged greater than 15 years old are

referred to adult HIV clinics.

Policy

Many departments within MOPH are involved in the pediatric HIV care and treatment and program. The Department of Medical

Sciences and Chiang Mai University provide laboratory support for PCR testing with budget support from NHSO. NHSO supports

HIV care and treatment services. The Department of Disease Control in MOPH and provincial health offices provide technical

support and site supervision to public hospitals providing pediatric HIV care and treatment. Coordination of their various

responsibilities is challenging. The pediatric HIV care and treatment data are monitored using the NHSO database. Further staff

training and management support are needed to develop a long-term plan for coordination, data management, data

dissemination, and use of data for improving or sustaining high program coverage. Current policy or guideline issues in Thailand

include the use of DBS for early infant diagnosis, when to start ART in children <1 year old, and what regimen to provide for NVP-

exposed infants. These long-term planning, policy, and guideline issues are being addressed in part with USG support.

Table 3.3.10:

Funding for Care: Pediatric Care and Support (PDCS): $311,996

n/a

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $127,918

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.10:

Funding for Treatment: Pediatric Treatment (PDTX): $122,658

n/a

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $50,290

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 12 - HVTB Care: TB/HIV

Total Planned Funding for Program Budget Code: $159,319

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

In 2008, Thailand ranked 17th on WHO's list of 22 "high-burden" TB countries; an estimated 90,000 persons develop TB annually

for an annual incidence of 142 cases per 100,000 persons. HIV-associated TB accounts for an estimated 11% of all new TB

cases in Thailand. TB is the most common opportunistic infection in HIV-infected persons, accounting for over 20% of all initial

AIDS diagnoses. Nationally, approximately 42% of TB patients are HIV tested. National estimates for TB screening of HIV patients

are not available, but data from HIVQUAL-T sites (see below) suggests that screening coverage has increased over the past few

years. TB case notifications have not decreased, though, despite a declining HIV incidence. A 2007 WHO review of Thailand's TB

program commended Thailand for its accomplishments in integration of TB and HIV services, but noted that improvements were

still needed in recording and reporting, implementing HIV testing in TB clinics, promoting TB screening in HIV clinics, expanding

laboratory services, and partnering with private sector TB care providers. A second drug-resistance survey initiated in 2006 found

that the rate of multidrug-resistant (MDR) TB in Thailand was 1.7% in 1,150 new TB patients and 34.5% in 194 previously treated

patients.

USG-Supported Activities

USG supports a partnership with the MOPH to demonstrate best practices for TB/HIV in selected provinces. This partnership,

known as the Thailand TB Active Surveillance Network (TB Net), develops evidence-based models for sustainable TB

interventions that can be scaled-up throughout Thailand and Asia with a particular focus on TB/HIV. In FY 2009, this activity will

involve five provinces, the national infectious diseases hospital, and the national TB program. An important principle of this

program has been leveraging other USG resources (USAID/Child Survival Health, CDC/Global Disease Detection) to support TB

activities unrelated to HIV to strengthen the overall TB control infrastructure within TB Net sites. Moreover, the MOPH recognizes

that USG will not be able to support full national scale-up of the model being developed in selected provinces. Rather, the goal is

to identify best practices, support evidence-based national policy changes and, when necessary, provide seed funding for national

initiatives to scale-up successful models.

The core TB/HIV activities in TB Net include:

• Conduct surveillance and program monitoring using an electronic information management system to measure the burden of

TB/HIV and HIV-related services being provided to ~8,500 TB patients across a population of 5 million persons in the public and

private sector.

• Provide provider-initiated HIV testing and counseling (PITC) as a routine part of TB services. With this approach, 80% of TB

patients in TB Net sites receive HIV testing or have a pre-existing HIV diagnosis.

• Link HIV-infected TB patients to HIV care and treatment.

• Screen for TB disease in HIV-infected persons and for TB and HIV in contacts of HIV-infected TB patients in selected districts.

• Train ~300 health care staff at the district, provincial, and national level and in the private sector on increasing ART use among

HIV-infected TB patients.

• Train PLHA leaders in 15 sites about TB screening in HIV-infected persons.

• Expand capacity to perform mycobacterial culture and drug-susceptibility testing on HIV-infected persons in five provinces and at

the national level.

In addition, USG supports the HIVQUAL-T model for quality improvement (QI) and HIV care performance measurement (see

Adult Care and Treatment narrative), which includes TB screening among HIV patients as one indicator and area for QI. Among

the 550 hospitals implementing HIVQUAL-T to date, the percentage of HIV patients receiving TB screening according to national

guidelines has increased from virtually 0 in 2002 to 81.5 % in 2008.

Key TB/HIV successes from USG support include:

• Development by MOPH of a national policy and health care worker training curriculum for PITC of TB patients.

• Increases in HIV testing among TB patients and TB screening among HIV patients, as described above.

• Engagement of national policy makers to support early access to ARV treatment for HIV-infected TB patients by demonstrating

that 90% of these patients meet CD4 eligibility for ART.

• Demonstration of the feasibility and effectiveness of liquid media culture for the diagnosis of TB in HIV-infected persons.

• Development of an electronic M&E system for TB/HIV and integration of HIV-related variables into the national paper-based

recording and reporting system.

In 2008, TB/HIV accomplishments include:

• Development by the MOPH national TB Program of a curriculum and manual for PLHA leaders on TB screening in HIV-infected

persons with 73 PLHA leaders trained in 15 sites.

• Development of a curriculum and manual on increasing ART referrals for HIV-infected TB patients with 323 physicians and

nurses trained.

Referrals and Linkages

MOPH, with financial support from GFATM, has recognized these successes, demonstrated its willingness, and "bought" products

from TB-Net, funding the scale-up of HIV PITC in 20 additional provinces in Thailand, national scale-up of mycobacterial culture,

and implementation of the electronic M&E system in over 20 private hospitals based on the success of TB-Net. Further, WHO has

demonstrated its willingness to incorporate TB-Net's successes into regional and global TB/HIV policy and practice. In 2005 and

2006, WHO partnered with USG and MOPH to train country HIV and TB program managers from nine Asian countries on TB/HIV

best practices. In 2007, data from TB-Net's mycobacteriology network was presented to policy makers from WHO, and the USG-

supported national PITC initiative was used to support the revision of the WHO Western Pacific Regional Office's TB/HIV strategy.

Policy

Despite the successes of the USG program, major challenges remain to be addressed in FY 2009; these include:

• Scale up use of ART in HIV-infected TB patients.

• Document the cost-effectiveness of culture-based diagnosis of TB in HIV-infected patients.

• Strengthen TB infection control in hospitals.

• Address the large differences in the standard of care offered for persons with TB and HIV-associated TB in the public and private

sectors.

• Strengthen program monitoring of TB, TB/HIV, and MDR-TB at the national level.

• Remove barriers to HIV testing, care, and treatment in selected provinces and scale up HIV testing of TB patients nationally.

• Develop successful public health models for TB screening of persons with HIV, and for incorporating HIV testing into contact

investigations of HIV-infected TB patients.

Table 3.3.12:

Funding for Care: TB/HIV (HVTB): $124,948

n/a

New/Continuing Activity: Continuing Activity

Continuing Activity: 17986

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17986 11586.08 HHS/Centers for US Centers for 7908 5812.08 Management / $163,168

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

11586 11586.07 HHS/Centers for US Centers for 5812 5812.07 Management / $183,235

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $51,229

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 13 - HKID Care: OVC

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

N/A in Thailand

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $284,720

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

The National Health Security Office (NHSO) provides free (two times per year with a Thai ID card), client-initiated voluntary

counseling and testing (VCT) at all 835 government hospitals registered under NHSO. However, these services are not well

utilized. Nor are key high-risk populations being targeted. VCT services are primarily hospital-based, names-based, and directed

at the general population. Thailand's highest HIV prevalence rates are among MARPs—31% in MSM (Bangkok) in 2007 and 29%

in IDU in 2006. Data are limited on the uptake of VCT services among MARPs, but in 2007 at selected sites it ranged from 52%

among MSM in Bangkok to 44% among MSM in Chiang Mai. Among other populations, 42% of TB patients and 30-40% of STI

patients receive VCT. Beyond these data, there are limited data on the uptake of VCT nationally in Thailand. Overall, 170,000

people received VCT through the NHSO last year, representing 0.36% of the adult Thai population (approximately 76% of the

general population receive health care through NHSO).

MARPs in need of testing often do not have access to it, or are deterred from routine hospital testing sites by lack of anonymity

and fears of stigma and discrimination. Additionally, there is a perception among MARPs that there is little benefit to learning

one's status. Low uptake of testing represents a critical missed opportunity to provide one-on-one prevention counseling to

MARPs, and to provide PLHA with care, support, and education that can reduce HIV transmission to others. Currently, rapid

testing is not widely available through NHSO; approximately 30% of clients do not return for their results or post-test counseling

after testing. There is a lack of standardized procedures for testing MARPs to ensure that those who test HIV-positive receive

appropriate follow-up care with counseling.

Few targeted prevention services exist for MSM in general, and VCT for IDU has been contingent upon joining a methadone

treatment program. Similarly, STI centers are not providing universal testing for high-risk clients and uptake is quite limited. There

has been a shift from direct to indirect or street-based sex workers, who may not have access to VCT services and tend to opt for

limited STI services from private clinics. Only limited counseling is available for couples or HIV-positive clients. HIV-positive clients

in routine hospital-based VCT centers are generally referred to the care and treatment program at that hospital, but referrals from

mobile or outreach services for MARPs are limited. Finally, VCT services in Thailand are constrained by the fact that most

counselors are part-time, have other primary work, and have limited support for counseling training.

Implementation of the HIV testing algorithm in Thailand is variable and includes enzyme immunoassay in most hospital-based

VCT sites with results typically provided within 3-14 days. Rapid testing is sometimes available at selected sites at increased cost

(approximately $6 USD). But outside of research settings, confirmatory same-day results are rarely provided, even with rapid

testing. Recognizing the need to improve this situation, four areas have been identified that fit into the comparative advantage of

the USG and the strategic approach of the USG in Thailand in HIV/AIDS:

1. Assistance with development of national VCT guidelines, including testing algorithms, client- and provider-initiated counseling

and testing messages, approaches for MARPs, and M&E.

2. Evaluation and expansion of quality improvement (QI) and performance measurement tools for VCT services (HIVQUAL-T

VCT).

3. Development of VCT services for MARPs, including improved promotion and access to VCT services, improved outreach and

links to community-based organizations, and follow-up care and counseling.

4. Development and implementation of specific HIV counseling models including risk reduction counseling, couples counseling,

and disclosure counseling for both HIV-infected children (disclosure to them) and HIV-infected adults (disclosure to others).

USG-Supported Activities

HIVQUAL-T VCT: HIVQUAL-T was developed and implemented with support from the New York Department of Health AIDS

Institute, Health Resources and Services Administration, Institute of Hospital Quality Improvement and Accreditation, MOPH, and

USG as a performance measurement and QI tool in Thailand. HIVQUAL-T (adult care and treatment) was expanded to 550 sites

in FY 2008, and all 835 public hospitals will be reached in FY 2009. A VCT component of HIVQUAL-T was developed in FY 2007;

in FY 2008, the model was tested in nine BMA hospitals, and in 2009 support will be provided to evaluate and improve this model.

Performance data from HIVQUAL-T VCT have shown high (>90%) rates of pre- and post-test counseling at most hospitals.

Weaker performance areas, such as informed consent and post-test counseling in some hospitals, are being addressed through

QI initiatives. Increased implementation of HIVQUAL-T VCT should facilitate improvement in the proportion of clients receiving pre

-test counseling, HIV testing, and post-test counseling according to national standards. In FY 2009, this model will be evaluated

for validity and potential for scale-up to other hospitals in Thailand.

MARPs and VCT: Counseling and testing services are a critical component of the minimum package of services, which is part of

the comprehensive prevention package the USG supports for MARPs, both as an entry point for care and treatment services and

as the basis for primary prevention and PwP. Over the past year, USG supported model development programs for MSM,

prisoners, IDU, and FSW. As noted above, VCT services have been promoted as part of routine services in hospitals nationally

although there is urgent need for sensitivity training on MARPs issues within these hospitals. USG continues to support

developing comprehensive prevention package models for MSM in six urban centers (Bangkok, Chiang Mai, Khon Kaen, Pattaya,

Phuket, and Ubon Ratchatani). USG supports VCT for MSM through outreach and promotion, by integrating VCT services into

community-based MSM drop-in centers and through provision of TA and training to MSM clinics and MSM-friendly government

STI sites. USG plans to address key barriers, such as stigma and discrimination, while promoting benefits of early testing for

treatment and control of HIV and better health as well as protection of partners.

In FY 2009, USG will provide TA to NHSO to develop provider-initiated counseling and testing (PICT) guidelines and training

materials, specifically addressing MSM and FSW, for use in STI and TB clinics and. Among IDU, VCT has been promoted through

peer outreach workers who refer other IDU to methadone clinics for VCT in Bangkok. Unfortunately, the uptake of VCT through

referrals has been low and, although this may be partially explained by high HIV testing rates as part of screening and enrollment

for the Bangkok Tenofovir Study, a new model to bring health center staff to IDU drop-in centers will be evaluated at one site.

Among prison populations, USG worked with a provincial health office and a local NGO to support promotion of VCT through peer

educators in two prisons. To date, this program has provided VCT to 540 prisoners (approximately 10% of the prison population in

the two provinces). Of these, 8% were HIV-positive and have been referred for care. One of the barriers to VCT in prisons has

been the lack of services on-site and this will be addressed in the future. In 2009, USG will work with the Department of

Corrections at the national level to integrate the successes of the two model prison sites into additional prisons.

In all model development sites, VCT will continue to be offered through clinic settings that address MARPs' specific needs, or

through referrals to selected hospitals or clinics that have been sensitized to vulnerable populations. USG will work with partners

and policy makers to advocate for integration of rapid testing into national guidelines and for increased use of rapid testing with

same-day results. USG supported validation of a rapid testing algorithm, and this will be incorporated into the national guidelines

and used for policy advocacy.

PLHA and VCT: A PwP model will be developed and assessed for MSM, including curricula and training materials for counseling

HIV-positive MSM, provision of psychosocial support, and linkages to care and treatment services. USG is supporting the

development and evaluation of a PwP program for general population PLHA in seven hospitals in FY 2008 - FY 2009. This

program provides disclosure, family, risk reduction, and couples counseling to PLHA. The model also promotes partner HIV

testing. Tools and materials from this program include a short prevention messages flipchart and a PwP manual. In FY 2008,

training on the PwP model was conducted in all 12 regions in Thailand for 1,200 providers in 400 hospitals. The evaluation of this

model is ongoing and is expected to be completed by the end of FY 2009. For HIV-infected children, a disclosure counseling

curriculum was developed for use in clinic settings, and 700 providers in 16 provinces were trained (see Pediatric Care and

Treatment narrative). Couples counseling for women in ANC and their partners has been offered since mid-2008. A manual and

materials are being developed; training will be conducted in early 2009; and implementation and evaluation are planned for later in

2009.

TB/HIV: USG-supported TB clinics developed a model for PICT for TB patients, which supports implementation of a national

policy on PICT developed during 2006 (see TB/HIV narrative). As a result of implementing this model, 82% of TB patients in these

sites have been HIV tested, and HIV-infected TB patients are linked to HIV care and treatment. In addition, there is screening for

TB disease in HIV-infected persons, and for TB and HIV in contacts of HIV-infected TB patients in selected districts. For TB/HIV-

infected patients, USG will work with the Bureau of TB to increase PICT for all TB patients nationally. Currently, national HIV

testing rates for TB patients is approximately 40%, as compared to >70% in USG-supported sites. Additionally, USG will support

implementation of guidelines to increase referrals and access of TB patients to ART.

Policy

USG support in Thailand for VCT includes support for MARPs, rapid HIV testing, increased utilization rates in STI and TB clinics,

M&E, performance measurement and QI, and disclosure and couples counseling for HIV-infected clients. Ongoing challenges

include policies and service delivery which are not focused on MARPs, lack of non-clinic-based VCT services, lack of routine rapid

testing with same-day results, and limited M&E systems for VCT.

Table 3.3.14:

Funding for Prevention: HIV Testing and Counseling (HVCT): $114,305

n/a

New/Continuing Activity: Continuing Activity

Continuing Activity: 17987

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17987 11587.08 HHS/Centers for US Centers for 7908 5812.08 Management / $98,210

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

11587 11587.07 HHS/Centers for US Centers for 5812 5812.07 Management / $107,596

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $46,865

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 15 - HTXD ARV Drugs

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

N/A in Thailand

Program Budget Code: 16 - HLAB Laboratory Infrastructure

Total Planned Funding for Program Budget Code: $445,221

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Thailand has a well-established public health laboratory system. The Thai NIH serves as a national reference laboratory, and a

network of regional, provincial, and community laboratories provide routine laboratory services. HIV serology testing is conducted

at a wide range of laboratories at all levels, using an algorithm of two or three enzyme immunoassay tests based on WHO

guidelines. Because there is no formal policy or established algorithm regarding rapid testing in Thailand, use of these tests is

limited. Thai national guidelines for HIV care recommend CD4 testing for initial staging and for monitoring of persons on ARVs.

Under the country's universal health care scheme, CD4 testing, viral load monitoring and, in some cases, ARV resistance testing

are covered services. HIV IgG BED capture immunoassay (BED-CEIA) testing to estimate HIV incidence is performed as part of

the MOPH's annual sentinel surveillance among pregnant women and FSW. Acid-fast bacilli (AFB) smear is performed routinely

for patients with suspected TB; conventional TB culture is performed routinely for patients with positive AFB smears. However,

quality systems are lacking in many laboratories.

A national External Quality Assessment (EQA) program for HIV serology testing was established in 1994 for public health

laboratories located at the community, provincial, and regional levels. This program was later expanded to include private hospital

laboratories and the Thai Red Cross blood screening center, reaching around 1,000 laboratories. Supported in part for several

years by USG to increase the number of laboratories served, this EQA scheme is now supported by the MOPH and NHSO.

However, human resource capacity to provide needed training and TA in response to poor performance in the EQA scheme is

limited. A national CD4 EQA program was developed by Mahidol University with USG support and in collaboration with the

MOPH; this program was adopted and funded by NHSO beginning in 2007 for expansion to all laboratories conducting flow

cytometry. During the past two years, with USG support, 44 laboratories began participating in a new EQA program for TB and

opportunistic infection (OI) diagnostic tests managed by Bamrasnaradura National Infectious Diseases Institute. This program

provides EQA panels for AFB smear and for microscopic identification of bacteria, fungi, and parasites causing OI. Chiang Mai

University, which is now providing infant diagnostic testing for the universal health care scheme using an in-house DNA

polymerase chain reaction (PCR) on dried-blood spots (DBS), participates in CDC's DBS EQA panel for DNA PCR. The Thai NIH

participates in CDC's BED EQA scheme.

Public health laboratory certification and accreditation play an important role in promoting implementation of quality systems in

laboratories. National policy endorses laboratory accreditation, and promotes networking of laboratories for quality assurance.

However, fewer than 70 of the country's 1,300 laboratories are accredited to the WHO-endorsed international standard. A few

additional laboratories have met the standards set by the Association of Medical Technologists of Thailand (AMTT) for national

laboratory accreditation, a set of minimum requirements that contain elements of International Organization for Standardization

(ISO) 15189 and 17025 standards. New accreditations occur at the rate of approximately seven per year.

USG-Supported Activities

Despite the progress in laboratory services and programs in Thailand, a number of gaps exist. To address these needs, USG will

continue to provide TA and other support for development and scale-up of EQA schemes for HIV-related clinical testing,

implementation of specialized testing for surveillance and TB/HIV, and establishment of the quality systems necessary for

laboratory accreditation.

* EQA Programs

USG support will address the following gaps: some laboratories still do not participate in HIV serology EQA; turnover of hospital

laboratory staff creates training needs that exceed the capacity of the current training system; EQA schemes for viral load, AFB

smear, and microscopic diagnosis of OI are not fully developed.

Specifically, USG will support MOPH to:

• Strengthen the quality of the HIV serology EQA program by providing additional training to participants on proper testing

methods, and increasing membership and full participation by all members in the program.

• Support ongoing development of HIV viral load and HIV genotyping (ARV resistance) EQA programs.

• Expand the AFB smear and microscopic diagnosis of OI EQA program through Bamrasnaradura to regional laboratories within

Thailand.

The USG role in supporting MOPH to develop and monitor these EQA programs focuses on TA and training for underperforming

laboratories. For long-term sustainability, the EQA programs will require additional support by MOPH or another organization such

as NHSO. The current EQA for HIV serology is supported directly by MOPH and NHSO, whereas the new EQA for CD4 testing is

supported by NHSO alone. USG will facilitate further negotiations to identify appropriate mechanisms for long-term support of the

expanded and new EQA programs.

The HIV serology and CD4 EQA schemes described above are now being provided to a number of other PEPFAR countries in the

region. Cambodia and Vietnam participate in the schemes with USG Thailand support. The CD4 EQA scheme developed with

USG support will expand to Laos and Papua New Guinea in 2009, and is also provided to Indonesia and Nepal with WHO

funding. Vietnam has participated, with USG support, in the microscopic diagnosis of OI EQA scheme since 2007. In addition,

USG supports Thai NIH to provide TA and training to Vietnam Ministry of Health (MOH) to develop their own EQA schemes.

* Specialized Testing for HIV Surveillance and other HIV-Related Testing

USG support will address two main gaps. First, use of HIV rapid testing is limited because there are no established guidelines or

algorithm for it. Second, mycobacterial culture capacity has been developed in five provinces and drug susceptibility testing (DST)

capacity strengthened at the national level, but performance of culture and DST need monitoring and optimization.

USG will provide technical support to MOPH to:

• Develop an HIV rapid test algorithm (with FY 2008 funds).

• Train trainers to roll-out implementation of the HIV rapid test algorithm, and monitor the implementation process.

• Build capacity to optimize performance of mycobacterial culture and DST for specimens from HIV-infected persons at the

provincial and national level (see TB/HIV narrative).

USG will continue supporting an NGO to use rapid HIV tests within the MPS model for MSM in one site. USG will also support

Thai NIH to provide training on fungal culture and identification to Vietnam MOH laboratory staff.

* Quality Systems for Laboratory Accreditation

Leadership, technical support, and funding aimed at implementing quality systems in hospital laboratories are limited. The USG

team will provide TA and funding to regional offices of the MOPH's Department of Medical Sciences to support the initial

implementation of quality systems and accreditation processes in hospital laboratories within that region. USG funding will be

used to leverage government funds that are available for quality systems and accreditation processes for particular provinces.

USG will support the processes for hospital laboratories to meet ISO 15189 or AMTT standards in selected provinces with a high

burden of HIV. USG has already initiated implementation of laboratory quality systems at 54 public health laboratories in three

provinces. In FY 2008, one of these laboratories achieved AMTT certification, bringing the total to 14.

To facilitate sustainability of the laboratory accreditation process, USG brought together the stakeholders for hospital laboratory

quality (NHSO, MOPH Departments of Medical Sciences and Medical Services, and the Medical Technologist Council, which is

the certifying body for AMTT certification) to discuss the critical role that quality systems play in the laboratory and future options

for funding the process. As a result, the Department of Medical Sciences and the council will develop a curriculum for training on

laboratory accreditation; the Department of Medical Sciences will include national laboratory accreditation, along with ISO

accreditation, in the indicators it requires hospitals to report; and NHSO has agreed to pay the audit fee necessary for the national

laboratory accreditation process.

Policy

MOPH has policies for laboratory quality systems and use of EQA schemes to ensure quality of testing at laboratories around the

country. USG will continue to support training, laboratory accreditation processes, and development of model systems consistent

with these policies.

Table 3.3.16:

Funding for Laboratory Infrastructure (HLAB): $186,207

n/a

New/Continuing Activity: Continuing Activity

Continuing Activity: 17989

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17989 11589.08 HHS/Centers for US Centers for 7908 5812.08 Management / $170,231

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

11589 11589.07 HHS/Centers for US Centers for 5812 5812.07 Management / $101,080

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $76,345

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 17 - HVSI Strategic Information

Total Planned Funding for Program Budget Code: $807,510

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

In Thailand, the USG SI strategy focuses on providing SI technical assistance and support for HIV/AIDS prevention, care, and

treatment activities conducted by the government, GFATM, and other donors while strengthening linkages between the national

and sub-national levels. For FY 2009, the major SI priorities will focus on the following areas:

• Technical transfer and capacity building for counterparts at national levels for development of high quality, second generation

surveillance models targeting MARPs, including MSM, non-venue-based FSW, and IDU.

• Integration of the "Third One" by strengthening government HIV/AIDS surveillance and M&E management information systems

and data use to inform program planning and policy advocacy.

• Development of standardized program monitoring guidelines to monitor implementation of MSM programs.

• TA for scale-up of performance measurement and quality improvement (QI) systems in care settings.

• Promotion of data use for developing policy and strategic plans at the sub-national level.

Functioning of the SI Team within the Country Team

The USG SI Team includes four staff members—two Senior Technical Advisors who closely work with and supervise the

CDC/GAP prevention, care, and treatment teams; a Medical Epidemiologist who leads the CDC/GAP surveillance, monitoring,

and evaluation team; and a SI Specialist who works with the USAID RDM/A HIV team and serves as the SI Liaison.

During the FY 2009 mini-COP development process, the USG program and SI teams set targets, which were then reviewed by

the SI Advisor for Thailand from CDC/GAP Atlanta. Technical staff and USG partners held discussions to set downstream (direct)

and upstream (indirect) targets for FY 2009 and FY 2010 based on FY 2008 program results and projected program growth. The

USG SI team obtained information from the MOPH and the GFATM on their future program plans and targets, which were used to

estimate the USG upstream targets.

Overarching SI System

National surveillance systems in Thailand are well established, including passive case-based AIDS surveillance, HIV sero-

surveillance, and sentinel behavioral surveillance. However, with evolving risk behaviors, the changing nature of the HIV

epidemic, and widespread availability of ARV therapy, new approaches are needed to appropriately monitor the HIV epidemic and

provide data for planning national responses. Systems are limited in their ability to track the early warning signs of a rising HIV

epidemic with new HIV infections and risk behaviors among high-risk populations, as well as the early warning signs of ARV

resistance. Although Thailand has high quality data, these data are underutilized. Capacity to undertake integrated analysis and

synthesis and use data for policy and program planning needs to be strengthened at both the national and provincial levels.

USG is committed to building the long-term SI infrastructure and capacity of the Thai government's national HIV/AIDS

surveillance, monitoring, and information systems. The USG strategy includes 1) developing and evaluating replicable

surveillance models, 2) integrating and expanding these models by the Thai government, and 3) assuring the quality of these

models once they are integrated into routine surveillance systems. Each surveillance system typically requires a 3-5 year period

for program development, piloting, and transitional integration with routine governmental systems. In FY 2008, the HIVQUAL-T

program to monitor the quality of HIV/AIDS care and treatment services at governmental facilities and HIV incidence surveillance

using IgG BED capture immunoassay (BED-CEIA) were successfully integrated with routine governmental systems. In FY 2009,

these programs will be fully funded by the MOPH, and the USG will provide technical support for program supervision and

mentoring.

A national integrated M&E framework and system (the UNAIDS "Third One") has recently been developed. However, many

individual programs, such as PMTCT, still have M&E systems that were specifically designed for their programs and funding

agencies. Transition to a decentralized health care policy and concomitant strengthening of local health authorities have created

new challenges for planning, implementing, and evaluating national SI tools. To make the "Third One" work in Thailand, strong

leadership from government, technical support, and close collaboration from all stakeholders will be needed.

In FY 2008, the M&E subcommittee appointed by the National AIDS Committee helped plan, prepare, and harmonize the

UNGASS report. A process was established to compile and analyze relevant data through full participation of various stakeholders

from government, NGOs, civil society, academic institutions, international organizations, and donors. Key results from the

UNGASS report will guide the work plan for the NAP.

Surveillance and Surveys

Between FY 2006 - FY 2008, the USG and MOPH successfully undertook HIV incidence sentinel surveillance among FSW,

second generation surveillance among FSW and MSM in pilot provinces, and ARV drug resistance monitoring. USG provided TA

to adapt surveillance approaches to Thailand, conducted training and pilot tests of these approaches, supported initial

implementation, assessed implementation and results, and transitioned the surveillance systems to Thai government support. In

FY 2009, USG activities will focus on supporting MOPH to:

• Pilot an integrated biomarker and behavioral risk surveillance system using RDS among non-venue-based FSW in three tourist

provinces and among IDU in two provinces.

• Provide TA to expand a biennial survey using venue-day-time sampling to monitor risk behaviors and HIV infection among MSM

in five provinces.

• Continue TA on HIV incidence surveillance, using BED-CEIA testing, to monitor the impact of the National HIV Prevention

Strategy among venue-based FSW, women attending antenatal care, and male military conscripts.

• Expand ARV resistance surveillance, according to WHO-CDC guidelines, to 43 provinces.

• Adapt WHO-CDC recommended models for monitoring treatment outcomes and early warning indicators for ARV resistance and

ART program failure and implement these models in pilot provinces.

• Undertake population size estimation of IDU in two provinces.

• Share surveillance training curricula and practical surveillance guidelines with other PEPFAR countries, and provide TA in HIV-

related surveillance and use of epidemiologic data to Laos and Papua New Guinea.

USG will continue to support capacity building on the analysis and reporting of biological and behavioral surveillance data to

monitor the response to the epidemic, and will work closely with MOPH to modify the national surveillance framework for MSM

and non-venue-based FSW.

Health Management Information Systems

NHSO developed a comprehensive national health information system that includes HIV/AIDS. In FY 2008, significant progress

was made on implementing a facility-based reporting system, which includes clinical care, ARV treatment, and HIV counseling

and testing, from government health facilities to the NHSO. In FY 2009, USG Thailand will compliment these efforts by

strengthening community-based information systems for monitoring prevention activities for MARPs. USG will continue to provide

TA to MOPH and NHSO in formulating the NAP database and integrating key indicators related to performance measurement for

QI in care and treatment (HIVQUAL), PMTCT, HIV counseling and testing, PwP, and early warning indicators for ARV resistance.

Monitoring and Evaluation

USG Thailand TA and support for M&E includes:

1) Develop standardized monitoring guidelines and build M&E capacity for MARPs prevention programs particularly MSM.

An effective and efficient monitoring and quality assurance and quality improvement (QA/QI) system is key for successful MSM

interventions. USG aims to develop a simplified tool to produce consistent and reliable information to track project progress and

improvement. In FY 2009, USG will develop standardized M&E indicators and intervention definitions for MSM and provide

training to USG partners and the MOPH on how to use the monitoring system.

USG will continue to strengthen the capacity of MSM implementing agencies and the MOPH in QA/QI assessments by providing

the following TA:

• Monitor and ensure standardized M&E guidelines are followed to correctly and completely monitor and report on MSM

interventions in accordance with the MPS for MSM.

• Assist MSM implementing agencies in developing and implementing QI plans for MSM interventions in accordance with standard

operating procedures developed for the MPS.

• Conduct a training workshop to strengthen M&E and QA/QI systems.

USG will work to institutionalize and sustain M&E systems within the government, NGOs, and CBOs providing services to

MARPs. USG will support customization of the system to suit local needs while ensuring consistency across organizations in

understanding and complying with standard definitions, procedures for data collection, and reporting. USG will support

development of standardized definitions, clear data collection protocols, and enhanced use of data to improve quality of services

for MARPs in seven provinces.

USG will ensure routine data quality assessments will be implemented as an integral part of USG-supported activities. A simplified

tool and method will be developed and institutionalized within USG and USG partners. TA and forums to share lessons learned

from the assessments will be provided by the USG SI team.

2) Implement data use for development of policy and strategic plans at sub-national level.

To build on this national level success and address the challenges created by health system decentralization, USG, in

collaboration with MOPH, has developed a model to strengthen local leadership to develop an integrated policy on HIV prevention

and alleviation and provide institutional capacity building for local agencies to develop integrated work plans and resource

mobilization. A major technical strategy of this model includes strengthening local capacity to undertake in-depth analysis of

strategic information, develop and implement local M&E plans, and increase use of data for resource mobilization and action

through health and non-health government organizations, NGOs, CBOs, and the private sector (see Health Systems

Strengthening narrative). The model was piloted in three provinces (Chiang Rai, Phuket, and Ubon Ratchathani) in 2007, and was

expanded to another two provinces (Lampang and Nakhon Phanom) via the Programme Acceleration Funds (PAF) in 2008.

In FY 2009, USG will provide technical support to the MOPH for the integrated analysis and triangulation of available data as a

broad strategy to better understand the success of the national response to the evolving HIV epidemic in Thailand among MSM,

FSW, and IDU. Key findings of this effort will inform the next national HIV/AIDS strategy and program planning.

Table 3.3.17:

Funding for Strategic Information (HVSI): $432,393

n/a

New/Continuing Activity: Continuing Activity

Continuing Activity: 17990

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17990 11590.08 HHS/Centers for US Centers for 7908 5812.08 Management / $446,529

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

11590 11590.07 HHS/Centers for US Centers for 5812 5812.07 Management / $632,204

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $177,281

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.17:

Funding for Health Systems Strengthening (OHSS): $35,759

n/a

New/Continuing Activity: Continuing Activity

Continuing Activity: 17991

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17991 11591.08 HHS/Centers for US Centers for 7908 5812.08 Management / $132,417

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

11591 11591.07 HHS/Centers for US Centers for 5812 5812.07 Management / $160,817

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $14,661

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 19 - HVMS Management and Staffing

Total Planned Funding for Program Budget Code: $305,432

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

The institutionalization of the team structure to reach the PEPFAR goals in Thailand is well underway. The U.S. Ambassador

leads the PEPFAR team with agency representation from the State Department, USAID, HHS, and DoD. The embassy's

Environment, Science, Technology, and Health Officer facilitates interaction with the embassy. Agency roles are clearly defined

based on core strengths. Cross-agency planning and management began in FY 2007. Joint PEPFAR team meetings are held

periodically, with representation from each agency, along with regular e-mail and telephone communications.

The PEPFAR management staffing in Thailand is based on the TA focus of the program, and the broad range of program areas in

which the USG team provides TA. Specifically, the skills necessary to implement PEPFAR in Thailand and provide TA to other

PEPFAR countries, include:

1. Technical skills in the supported program areas - prevention, care, treatment, laboratory, and strategic information.

2. Public health program skills to facilitate translation of science into programs, and adaptation of proven approaches to the local

context.

3. Skills in working with NGOs to provide oversight to NGO capacity building, and development of program models in the NGO

setting.

4. Administrative support for program logistics and coordination.

For overall technical leadership and management of PEPFAR in Thailand, and for coordination of TA provided to other countries,

1.90 full time equivalent (FTE) U.S. direct hire (USDH) staff are currently in place. These staff also provide management of TA in

specific priority areas (prevention services for MSM and IDU, quality of care, SI, and evaluation of model programs), and oversight

of NGO capacity building and model development. An additional 2.0 FTE USDH staff serve as senior technical advisors to the

locally-employed staff (LES), providing capacity building and mentoring in state-of-the-art technical skills, TA provision, and

diplomacy and communications skills, especially for global TA work. A total of 38.12 FTE LES and 0.3 FTE contractors with skills

in the four categories listed above provide TA in all supported program areas, as well as some administrative and operational

support. The TA focus of PEPFAR Thailand creates sustainable public health program improvements, while capacity building for

LES develops a group of technical experts who can provide TA to government and NGOs for the long term. No new staff is

requested for FY 2009.

In FY 2009, USG in Thailand will take on a more substantial role in transferring technical expertise and experience in the four

categories listed above to the Thai government and other PEPFAR countries, with a focus on developing local capacity for

implementing and managing PEPFAR activities. This expanded role recognizes the important contributions that PEPFAR Thailand

can make to other PEPFAR countries by sharing intervention models that have been successfully developed, implemented,

evaluated, and adapted for local use.

The USG team will examine several of its current practices. Among these practices are communication, coordination, and

management within the USG team and with host governments, partners, and other stakeholders; adoption of technical working

groups; and annual priority and budget setting processes. In FY 2008, the USG Thailand team established regular coordination

meetings to discuss and coordinate joint MSM HIV/AIDS programming and issues related to VCT. The team will also examine the

impact of the movement by OGAC away from a Thailand-specific HIV program to a more global focus. One challenge the team

faces, as a result of the greater focus on global aspects of the program, is the current balance of staff with experience and skills

appropriate to providing global TA, as opposed to staff with experience and skills more appropriate to developing and evaluating

model programs in Thailand.

The USG Team works closely with non-program offices at the Mission, particularly HR, the Executive Office, and the Regional

Office of Procurement to carry out relevant PEPFAR activities. USAID/RDMA is currently in the process of possible expansion to

launch a training center under Henrietta Fore's Development Leadership Initiative for new USAID Foreign Service Officers.

Details of this potential expansion are still being determined. Given that USAID/RDMA manages six country programs, all staff

have a large management burden.

While not physically housed together, all of the USG PEPFAR team for Thailand is located in Bangkok. The USAID HIV staff are

located at the USAID Regional Development Mission/Asia (RDM/A), adjacent to the U.S. embassy complex in Bangkok. All

USAID staff working on PEPFAR Thailand are also responsible for PEPFAR programs in other USAID non-presence countries.

The HHS/CDC offices are co-located with the MOPH, facilitating close collaboration with MOPH policy makers and program

directors. HHS/CDC technical staff are frequently asked to serve on various planning and evaluation committees for MOPH HIV-

related programs, offering important opportunities to contribute to policies and strategic direction.

As requested in the Department of State cable 112759, best practices for interagency collaboration in Thailand include:

• USAID and/or CDC representation at appropriate planning sessions for joint USG HIV/AIDS programming.

• Collaboration on activities where both agencies are working in a specific PEPFAR program area; specifically, this includes

representatives from both agencies participating in program design and ongoing coordination meetings.

• Establishing interagency coordination groups on thematic areas (i.e., programming for MSM, VCT, and strategic information and

surveillance efforts).

• Sharing technical expertise (and mechanisms) of USG-supported partners across USG agencies (i.e., USAID supported

international NGO Pact will assist in capacity building efforts for CDC-supported MSM NGOs in Thailand).

• Ensuring joint programming in shared provinces through partner meetings.

Additional health-related government agencies, such as the Institute of Hospital Quality Improvement and Accreditation and the

National Health Security Office (NHSO), are located in the same compound or nearby, facilitating critical collaboration with these

agencies for scale-up of care and treatment quality programs. The Country Coordination Mechanism (CCM) secretariat is located

within the MOPH compound and CCM meetings are held at MOPH, facilitating active USG participation in the CCM. WHO is also

located within the MOPH compound, facilitating a WHO-MOPH-USG collaboration to address ARV resistance. The Armed Forces

Research Institute of Medical Sciences (AFRIMS) is co-located with the main medical campus of the Royal Thai Army, facilitating

close collaboration on HIV surveillance and other scientific issues.

As mentioned above, USG agencies focus on areas that use their comparative advantages: HHS/ CDC focuses on TA and

working with host governments, USAID focuses on NGO programs and NGO capacity building, and DoD/AFRIMS collaborates

with the Royal Thai Army.

Currently, the PEPFAR team builds on existing CDC-MOPH structures (Executive Committee and HIV/STI Steering Committee)

for formal communication with the MOPH about PEPFAR. More frequent working-level communication with MOPH occurs through

specific project meetings and USG participation in several MOPH or Thai government technical working groups. PEPFAR staff

serve as active members of several working groups and committees, such as:

• Thai Working Group on HIV Estimates and Projections

• MOPH committees to write national adult and pediatric HIV management guidelines

• Monitoring and evaluation team for "2010 Universal Access, Thailand"

• Working group for development of national guidelines for ARV resistance monitoring

• Working group for development of national monitoring system for PMTCT

• Working group for revision of national surveillance guidelines for youth and sex workers

• MOPH-BMA working group on Prevention with Positives

• MOPH HIVQUAL-T advisory committee

• BMA HIV Care Quality Improvement Advisory Committee

• MOPH Advisory Committee for HIV Prevention in Female Sex Workers

• MOPH Working Group for FSW HIV Prevention Projects

• Ethical Review Committee of the Department of Disease Control, MOPH

• NHSO committee on HIV laboratory standards

• Technical Committee for GFATM Round 8 Proposal Development

The USG is represented on the Thailand CCM for the GFATM, and on the CCM HIV Technical Team. The USG PEPFAR staff

participates in the National TB/HIV Committee and CCM TB Technical Team in a non-membership role. In addition, PEPFAR staff

are frequently invited to participate in ad hoc committees for curriculum development, training of trainers, and program evaluation

related to non-USG-supported MOPH programs.

Table 3.3.19:

Funding for Management and Operations (HVMS): $189,121

The management and staffing budget for CDC is used to provide technical oversight and technical

assistance for the conduct of PEPFAR-related activities by the Thai Ministry of Public Health (MOPH), its

provincial health offices, the Bangkok Metropolitan Administration (BMA), and partner NGOs. A team of 41

personnel engaged full-time at CDC/Thailand carries out this support. The 41 positions include 4 direct-hire

U.S. staff, 36 locally hired staff, and one locally hired expatriate contractor. Of the direct hires, one is in a

technical leadership/management position, two are in a technical advisor/non-M&S staff position, and one is

in a technical advisor/program manager position. Of the locally hired staff, six are in technical

leadership/management positions, 23 are in technical advisor/non-M&S staff positions, two are in technical

advisor/program manager positions, and five are administrative/support staff. The contractor is in technical

advisor/non-M&S staff position. Additionally, seven non-PEPFAR funded personnel from the CDC TB

Program provide 30% to 50% of their time supporting GAP activities.

Activities carried out by these staff are:

•Technical oversight and technical assistance for project design, implementation, and evaluation, working

collaboratively with partners primarily in the Thai government and to a lesser extent in collaborating NGOs,

in the areas of PMTCT, Other Prevention, Palliative Care (basic health care and TB), VCT, ARV Services,

Laboratory Infrastructure, Policy and Systems Strengthening, and Strategic Information

•Capacity building for government and NGO staff, within the context of specific projects or to meet specific

objectives of the National AIDS Plan

•Project management, including reporting and financial oversight, for all collaborative projects with the Thai

government

•Coordinating PEPFAR Thailand strategy and planning with the MOPH and BMA to ensure that PEPFAR

Thailand contributions address priority areas and gaps within existing programs, and to ensure that

PEPFAR Thailand support will lead to strengthened, sustainable programs within the government systems

•Liaising and coordinating with other USG agencies (USAID and DoD/AFRIMS) on the PEPFAR Thailand

team

•Preparing strategic and operational plans and reporting results for OGAC

•Representing CDC and USG at coordination meetings with other donors, on the CCM, and on multiple

technical working groups of the MOPH.

•Global technical assistance role: technical assistance and training for PEPFAR programs in other

countries, especially Vietnam and Cambodia, in the areas of PMTCT, TB/HIV, Pediatric Care and

Treatment, Biomedical Prevention (IDU), and Laboratory Infrastructure.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17992

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17992 11558.08 HHS/Centers for US Centers for 7908 5812.08 Management / $325,051

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

11558 11558.07 HHS/Centers for US Centers for 5812 5812.07 Management / $274,453

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

Table 3.3.19:

Funding for Management and Operations (HVMS): $91,311

ICASS charges support the administrative costs associated with supporting 40 FTEs by the Embassy. This

includes the ICASS basic package for four U.S. direct hire FTEs, human resources services for 36 locally

employed staff (LES), procurement actions, and vouchering.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17993

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17993 11559.08 HHS/Centers for US Centers for 7908 5812.08 Management / $4,589

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

11559 11559.07 HHS/Centers for US Centers for 5812 5812.07 Management / $154,699

Disease Control & Disease Control Technical

Prevention and Prevention Staffing

Table 3.3.19:

Cross Cutting Budget Categories and Known Amounts Total: $950,154
Human Resources for Health $28,101
Human Resources for Health $152,362
Human Resources for Health $16,693
Human Resources for Health $164,818
Human Resources for Health $43,591
Human Resources for Health $127,918
Human Resources for Health $50,290
Human Resources for Health $51,229
Human Resources for Health $46,865
Human Resources for Health $76,345
Human Resources for Health $177,281
Human Resources for Health $14,661