The International HIV/AIDS Alliance (the Alliance) Cooperative Agreement, "Scaling Up the National Response to HIV/AIDS through Information and Services", or SUNRISE, currently runs until 2011. The purpose of the SUNRISE project is to decrease HIV transmission by: a) reaching at least 60% of high-risk populations with effective, high quality information services; b) increasing the accessibility of high quality care and support services for people living with HIV/AIDS; c) strengthening the prevention-care continuum with a particular focus on VCT; and d) strengthening the ability of local NGOs and communities to deliver services.

SUNRISE directly contributes to the achievement of all three of Ukraine's forthcoming Partnership Framework goals and benchmarks. These are: the reduction of HIV transmission among most-at-risk populations (MARPs); improved quality and cost effectiveness of HIV prevention, care, and treatment services for MARPs; and strengthened national and local ability to achieve Ukraine's National AIDS Program objectives.

The Alliance supports activities designed to reduce the incidence and prevalence of HIV/AIDS. This entails reducing transmission among MARPs (SWs, IDUs, MARA, and MSM) as well as the sexual partners of these MARPs and other bridge populations. The project receives funding in the following technical areas: sexual prevention, biomedical prevention (injecting drug use), counseling and testing, and orphans and vulnerable children. Since the Alliance is also a Principal Recipient under a Global Fund Round Six grant, the Alliance gives focus to maximizing institutional efficiency through the leveraging of USAID and Global Fund resources where appropriate. The Alliance also plays a key role in advocacy, encouraging the GOU to increase state funding for MARP programming.

The SUNRISE monitoring and evaluation plan indicates that the project will achieve the following tangible outcomes by the end of the award:

60% of key populations covered through outreach and HIV prevention services

4,450 people trained in HIV prevention

26,000 HIV positive individuals provided with care and support services

43,000 people had HIV counseling and testing and received their test results

300 VCT centers supported by the project

900 providers trained in VCT service provision

300 IDUs on medication assisted treatment (MAT)

With limited USG PEPFAR resources in Ukraine and escalating rates of HIV among IDU, the primary focus of the program is on expanding prevention activities among MARPs, with attention to comprehensive prevention services for IDUs. Alliance's technical assistance efforts and program support for prevention activities among IDUs are closely coordinated with HIV/AIDS prevention, care, and treatment services supported by the GOU, Global Fund, and other donors.

The Alliance supports the USG strategy for health systems strengthening by building the capacity of local NGOs in HIV/AIDS project design, management, and service delivery. By introducing and strengthening NGO institutional skills and technical capacity, the Alliance's USG-supported efforts enhance the non-governmental response to the HIV/AIDS epidemic. This has tangibly increased the role and influence of civil society on national decision making as well as NGO participation in the National AIDS Program.

The Alliance's activities also contribute to the cross cutting issue of gender and in particular, in the areas of increasing gender equity in HIV/AIDS activities and services. MARPs face considerable barriers in accessing friendly, high quality, integrated HIV/AIDS services, but women especially so due to widespread stigma and discrimination. The Alliance mainstreams gender into its MARPs programming, including approaches to target female MARPs, and enhance service provider sensitivity. In addition, to ensure that 30% of IDUs receiving MAT are female, the Alliance is piloting innovative models to increase female IDUs access to services and MAT. The Alliance will support advocacy efforts to reduce coercion targeted to MARPs, both male and female, including coercive sex by authorities and oppressive raids by security forces.

During FY 2010, the Alliance will continue to implement activities targeting IDUs, SWs and MSM via small grants to local NGOs to provide prevention services for these MARPs.

Prevention services include peer counseling via outreach, medical and psychological counseling by project specialists, self-help groups, referrals to AIDS Centers and other medical facilities, VCT, care and support services for HIV infected individuals, and support for clients' relatives. Local NGOs also target the sexual partners of these MARPs; these bridge populations are critical to stemming the expansion of Ukraine's epidemic from concentrated to generalized. Due to the concentrated nature of the HIV/ADS epidemic and the difficulty of targeting and achieving multiple points of contact with individuals in these populations, the Alliance utilizes an outreach-based approach, using case management and referral systems, to implement prevention with MARPs.

The Alliance will update its peer mentoring program for MSM. During FY 2010, it will update and adapt the context of the training model and materials, train volunteer coordinators, and pilot the peer mentoring program among MSM in Odessa and Kyiv. Based on pilot results, the Alliance will produce and disseminate a final version of materials to its partner organizations.

The Alliance's activities help improve health care systems in the areas of decentralized service delivery and building the role of NGO providers in the substantive provision of HIV/AIDS services. In light of the high levels of stigma and discrimination directed at MARPs, and the reluctance of many MARPs to utilize public sector health facilities, local NGOs are critically positioned to provide and support service delivery to MARPs. Via the Alliance, the USG has contributed substantially toward decentralized non-public sector HIV/AIDS service delivery.

Via its "Onward Grant" Program, the Alliance has competitively issued subawards to 29 Ukrainian NGOs to conduct prevention activities targeted to MARPs. These services include prevention education outreach, case management, referrals, and medication assisted therapy (MAT) to IDUs. The organizations have received training and support in human resource management, financial management, technical updates, advocacy, and monitoring and evaluation. Additionally, as a larger inter-linked entity they have played an increasingly critical role in advocacy for health care reform in Ukraine.

During FY 2010, the Alliance will continue to provide technical support and mentoring to these local organizations. Supporting linkages include policy reform in decentralized health care; to this end, the USG will continue to work with the GOU to build a legislative framework for NGO service delivery (ref: Technical Area Narrative, OHSS).

Ukraine has the most severe HIV/AIDS epidemic in Europe and the Commonwealth of Independent States (CIS). With an estimated HIV prevalence rate of 1.6 percent among the adult population ages 15-49, the epidemic remains concentrated among most at risk populations (MARPs), primarily in injection drug users (IDUs). It is estimated that there are between 325,000 and 425,000 IDUs in Ukraine, and sentinel surveillances studies in multiple regions from the past few years estimate HIV prevalence in IDUs to range from 18 to 62.8 percent, with 95,000 of their non-IDU partners infected as well. With an average age of 20-29, the age of initiation of injecting drug use ranges from 13 to 30 years of age with initiation of drug use occurring earlier among males than females.

The Alliance will build on its work conducted during FY 2009 in piloting a medication assisted therapy (MAT) program to 150 IDUs in the three most affect oblasts in Ukraine (Kyiv, Odessa, and Donetsk). The pilot also tested linkages to ART and TB treatment for HIV infected IDUs. During FY 2010, the Alliance will expand MAT services, accompanying psychosocial support, and referrals to treatment and care to at least 300 HIV infected IDUs in the three pilot oblasts as well as in two additional oblasts. Of the IDUs targeted, at least 30% will be women. Comprehensive prevention services for IDUs will also target their sexual partners.

The Alliance will continue to manage subaward agreements with implementing local NGOs, conduct trainings among project staff, psychologists, social workers, and health care providers, and finalize clinical indicators for MAT projects. During FY 2010, the Alliance will award two new awards to local NGO to implement the expansion of MAT services to IDUs, and procure methadone for MAT clients. MAT work under SUNRISE will pilot comprehensive HIV/ TB/ STI referral systems for HIV infected IDUs, and advocate for the prescription and supervision of ARV treatment at the same health care institutions where IDUs receive MAT..

As part of a wider rollout of MAT services, the Alliance will work closely with WHO, CDC, USAID, MOH, and local organizations in testing new models for MAT provision in a variety of settings (mid to low resource, facility versus NGO service provision, etc.). This includes the adaptation of approaches, tools, referrals systems, and materials for each model and approach, and baseline assessments. This assessment will include a cost effectiveness analysis of MAT models (ref: CDC TBD SI, WHO IDUP).

Additionally, WHO will conduct a quality and cost assessment of the Alliance-supported delivery of integrated MAT packages (ref: implementing mechanism WHO). This technical assistance will provide critical direction in standardizing quality throughout MAT programs.

In early FY 2010, the Alliance will support two study tours to Lithuania and China for key stakeholders to investigate models and approaches to MAT delivery in a variety of settings. Participants will present their findings and recommendations at the local and national levels as a key information and advocacy tool to lead to revised MAT implementation models. The Alliance will facilitate the development of guidelines for MAT service delivery with a focus on implementing a continuum of services from prevention through care.

Throughout the expansion of MAT services, the Alliance will provide technical assistance to local NGOs in data collection, data quality, and results monitoring. This information will feed into national and regional reporting. The Alliance will assist with the analysis of key MAT program results and present results to the regional government, the MOH, and the wider community on an annual basis.

The Alliance will develop a module of gender-based interventions for female drug users, and reach at least 100 female IDUs with prevention services. The Alliance will support implementation of the pilot project using local NGOs in three sites, thus building the capacity of Ukrainian civil society to provide gender-sensitive IDU services. The Alliance will conduct a baseline assessment at pilot initiation and provide oversight and supportive supervision to each of the local NGOs implementing the intervention. The Alliance will then conduct a follow up assessment and evaluation in FY 2011, disseminate results, and produce program and communications materials.