The goal of the SMART TA project is to: 1) deliver quality HIV services within the continuum of response (COR); 2) transition financial, administrative and technical ownership of services to the government of Vietnam (GVN) and other stakeholders; and 3) strengthen the technical capacity and country ownership to sustain quality HIV services. Geographic coverage is in 9 PEPFAR-focus provinces (Hanoi, Hai Phong, Quang Ninh, Dien Bien, Nghe An, Ho Chi Minh City, Can Tho, Lao Cai and An Giang). Technical assistance (TA) also will be provided at the national level. Target populations for the project are IDUs and their sexual partners, sex workers (SWs) and their clients, MSM and PLHIV. SMART TA will work with GVN and other stakeholers to develop a reponsible plan to transition HIV prevention and care services. To achieve this, SMART TA will 1) assess the capacity of GVN and CSOs to implement individualized interventions and develop a national 5-year capacity-building plan; 2) develop cost-effective models and service packages that can be replicated using local resources; 3) strengthen national, provincal and district referral networks; 4) strengthen data use for program planning and revision; and 5) ensure quality across implementing sites and implementing agencies. The transition of financial, administrative and technical responsibilities for the implementation of HIV programs supported by SMART TA will require national and provincial consensus-building, standardization of models and service packages, development of provincial transition plans, technical support, and ongoing monitoring and QA/QI. Site visits and assessments will ensure accountability and inform decision making. No vehicles will be purchased for this project.

In preparation for financial, administrative and technical transition of sites to government of Vietnam (GVN), SMART TA will begin working with the Vietnam Administration for HIV/AIDS Control and provincial Departments of Health (DOHs) to make both facility and community HIV-service provision more efficient and less costly. This will include a review of community and home-based care (CHBC) models to focus transitioning CHBC interventions to be led by PLHIV peers and CSOs, with supervision support from outpatient clinic health staff. SMART TA will develop and employ screening tools to assess whether individuals and families have high, medium or low/no CHBC needs. CHBC activities will prioritize peer outreach and counseling to ensure that newly diagnosed PLHIV and those who have been lost to followup are enrolled into care. For facility-based services SMART TA will integrate HIV clinical services into GVN hospitals, examine ways to make client flow more efficient and reduce staffing ratios. In COP 11, to facilitate early enrollment in care and treatment (C&T) services, SMART TA collaborated with VAAC and DOH to pilot an intervention facilitating early enrollment in the HIV outpatient clinic immediately following a positive diagnosis. SMART TA also worked with WHO, VAAC and other partners to develop a standardized pre-ART care package for facility- and community-based services. Pre-ART health clubs run by PLHIV peers promoted PLHIV self-acceptance, self-confidence and self-care. In COP 12, SMART TA will commence transitioning service delivery sites across provinces while continuing work initiated in COP 11 with GVN and other partners to institutionalize standardized, cost effective core packages of facility- and community-based care. Core clinical services are likely to include pre-ART care; OI prophylaxis and management; ART; adherence counseling and education; assessment of positive health needs; and referral to GVN services. Auxiliary services may be provided in different locations according to resources, capacity and commitment, and include palliative care, mental health and nutrition, services. While the number of service-delivery sites may reduce in COP 12 due to site transition, the number of clients enrolled in care and support will increase due to improved efficiencies and interventions to improve early enrolment and increased retention due to positive health programs. SMART TA will work with GVN to pilot a referral tracking system across several sites and scale it up over the projects life. This will involve mapping district and provincial HIV-related services, in preparation for transition, and supporting the development of a local level referral system for the continuum of response. To further improve clinic flow, SMART TA will develop simple, systematic assessment checklists and SOPs for all appointments at the HIV OPC to triage clients and ensure access to needed services. To build upon existing food support programs and avoid duplication, the program will provide nutrition counseling and assessment, while linking and referring clients to services providing therapeutic food under FANTA III and local nutrition initiatives. To support the transition of CHBC services to PLHIV peers and CSOs, SMART TA will work with the USAID Pathways for Participation project to utilize and adapt CHBC training curricula, job aids, and monitoring and QI tools to ensure they are consistent across programs. Funding includes $222,000 for OIs.

SMART TA will continue to provide discrete and focused technical assistance (TA) to the Ministry of Labor, Invalids and Social Affairs (MOLISA) to implement the National Plan of Action (NPA) prioritizing TA in case management approaches and family centered care. SMART TA will work with the government of Vietnam (GVN) and other stakeholders to re-focus Vietnams OVC program and will develop a more efficient, less costly and sustainable OVC program model while phasing out nonessential OVC programming in SMART TA-supported sites. The new OVC program model will focus on the priority needs of HIV-infected children and their families, and will include further developing family centered approaches and using peer and PLHIV networks, MOLISA social workers and CSOs supported under the USAID Pathways for Participation (Pathways) project to assess the needs of HIV-affected children, and respond accordingly. In COP 12, SMART TA will work with GVN, PEPFAR-implementing partners and other stakeholders to provide TA to refocus and scale-up less costly and sustainable OVC interventions in Vietnam. This will include development of rapid screening assessment tools to identify most-at-risk HIV-infected and affected children and families, and leveraging GVN support, particularly from MOLISA, to assist these families. SMART TA will review and adapt previously developed SOPs, job aids and training curricula so that they are consistent with the new OVC programming approach. SMART TA will provide TA to MOLISA, VAAC and PEPFAR partners, including Pathways-supported CSOs, to train OVC trainers and mentors in the new model, using the new curriculum. The Global Fund (GF) has expressed an interest in providing integrated family centered care at its HIV clinics. SMART TA will standardize family centered care models and packages, developing simple tools to assist GVN and GF-supported healthcare providers implement family centered HIV care throughout Vietnam.

While SMART TA-supported sites provide among the highest levels of patient care quality available in Vietnam, much remains to be done to improve outcomes for patients with TB, as they are referred into the TB healthcare system. During COP 11, SMART TA supported provincial and district TB/HIV committees to strengthen TB/HIV case detection, management and control. The program provided training for community and home-based care (CHBC) teams and outpatient clinic (OPC) staff on screening and managing TB/HIV co-infection using standardized algorithms, SOPs and job aids. SMART TA supported the Vietnam Administration on HIV/AIDS Control (VAAC) to operationalize Isoniazid Prevention Therapy (IPT) across all sites, and also supported Vietnams pilot of GeneXpert, to improve diagnosis of smear-negative TB. In COP 12, SMART TA will increasingly focus on improving the efficiency and effectiveness of TB/HIV programs including integrating provider-initiated testing and counseling (PITC) in TB services and improving TB/HIV clinical management through implementation of TB/HIV guidelines. SMART TA will work with VAAC and the National TB Program (NTP) to improve patient referral tracking systems to ensure that people affected by TB and HIV can access well-coordinated care. Optimizing, operating, standardizing and monitoring the linkages between HIV and TB services is a critical component of HIV programming. As SMART TA begins to transition services to GVN, the program will support the Ministry of Health (MOH) to improve TB outcomes through the development and implementation of models that leverage existing resources and other donor programs, in particular those supported with Global Fund funding. SMART TA will develop strategic behavioral communications focusing on the prevention of TB in the community and support KNCV and the National TB Program (NTP) to develop a systematic TB QI/clinical supervision package.

While supporting implementation for pediatric care and support, SMART TA will increaingly focus on PEPFARs strategic goals to transition to country ownership and provision of technical assistance (TA). During COP 11, SMART TA developed, implemented, operated and standardized a core package of services for HIV-infected children and affected families, including early identification and referral into treatment; provision of TA to national and provincial authorities to manage and provide quality services in the continuum of patient care; and monitor and improve quality of services before, during and after transition to full government ownership and management while ensuring ongoing growth of the pediatric ARV program. In COP 12, the focus will be on sustainability, improving cost-efficiency and improving program access for HIV-infected children and families. While the number of service-delivery sites may decline in COP 12 due to transitioning of sites, the number of pediatric clients enrolled in care and support will increase due to improved efficiencies and interventions to improve early enrolment in the HIV outpatient clinic (OPC). In COP 12, clinical facility-based care will be provided for 415 pediatric HIV-infected clients. The Global Fund (GF) has expressed an interest in providing integrated family centered care at its HIV clinics. SMART TA will standardize family centered care models and packages, developing simple tools to assist the government of Vietnam (GVN) and GF-supported healthcare providers to implement family centered HIV care throughout Vietnam. While supporting GVN and GF to scale-up family centered care approaches, SMART TA will prepare for transition of pediatric care and treatment programs, which may occur simultaneously or separately from the adult care and treatment, depending on the site and the existing resources. SMART TA will be active in the provision of services and TA in these key areas, in addition to the standardization and institutionalization of national training curricula and clinical care capacity-building and QI.

In collaboration with the government of Vietnam (GVN) at the national and provincial levels, and with other stakeholders, SMART TA will implement the following activities in COP 12. 1) Data use: Together with the PEPFAR SI team and other partners (HPI, Vietnam Administration for HIV/AIDS Control (VAAC), NIHE, Pasteur Institutes) in the third year of the Data for Decision Making project (DDM), FHI will continue to work with the Vietnam Authority on HIV/AIDS Control (VAAC), the Ministry of Health (MOH) and PEPFAR Provincial AIDS Committees (PACS) in (HCMC, Hanoi, Quang Ninh, Hai Phong, Nghe An, Can Tho, An Giang, Dien Bien and Lao Cai) to build capacity for GVN agencies with focus on HIV epidemiological topics such as: -HIV research methodologies, study design and basic analysis; -Target population size estimates; -Data sets presentation and communication to appropriate audiences; and-Data triangulation in program evaluations and review at provincial and the PEPFAR TWGs level. SMART TA also will continue to focus on GVN-centered capacity development for strategic information by supporting HIV epidemiological and program data gathering, managing, and participating in analysis and dissemination workshops. 2) HIV/AIDS Modeling: FHI will continue carrying out the Advocacy and Analysis (A-squared) and Estimation and Projection (EPP) activities in high-HIV burden provinces to: -provide outcome indicators and coverage information for PEPFAR-supported prevention programming among MARPs in Vietnam; -strengthen government staff capacity for data utilization; -provide information to explain changes in HIV prevalence, including the impact of PEPFAR-funded prevention programming; -provide epidemiologic and behavioral data in specialized formats tailored for advocacy to policymakers; and -develop a clear understanding of the HIV epidemic in different regions of Vietnam so that that effective national policies and appropriately targeted programs can be developed. 3) Operational research and evaluation: FHI will work with VAAC and PEPFAR TWGs to implement program coverage evaluation (CARS) of intervention for both prevention, VCT and care and treatment (C&T) programs to provide insightful data for programmers, as well as to strengthen data use capacity at the program level. FHI also will work closely with PEPFAR SI and other TWGs on designing operation research targeting MARPs and bridge populations to better understand these populations to guide programming. 4) Program monitoring and data quality assurance: -C&T Monitoring Data management: FHI will work with other PEPFAR partners on C&T to upgrade the program database. This system will help maximize work efficiency at the field level and enable data analysis to assist project partners in continuous QI. -Data QA and QA/QI quality of routine monitoring data will continue to be strengthened through the integration of data quality audits as part of regular QA/QI visits to project sites. FHI will work with VAAC M&E to develop national standardized guidance for conducting data quality audit activities for all HIV-related programs. In addition, FHI will continue its QA/QI activity as routine monitoring and provide TA to other PEPFAR partners on applying QA/QI tools. -Methadone M&E system development: FHI will continue to conduct and provide TA to PEPFAR and GVN on routine M&E activities for the national methadone maintenance treatment (MMT) program.

The HTC program targets all MARPs, including IDUs, sex workers (SWs), MSM, clients of sex workers, sexual partners of MARPs and sexual partners of PLHIV. Alhough the program is well-established, data from recent surveys underscore the fact that there is still alarmingly low uptake of HTC services among MARPs. According to the IBBS 2009, 60-80% of MARPs have not recently been tested. In COP 12, building on COP 11 activities, SMART TA will strive to systematize PITC in methadone maintenance treatment (MMT) clinics, TB and ANC services to ensure the routine testing of vulnerable populations. The program will test different cost-effective initiatives that improve HTC service-uptake among MARPs and promote knowledge of ones HIV status. SMART TA will work with other partners to advocate for the widespread use of the rapid testing algorithm and flexible confirmation scenarios, which will increase access and uptake of this essential prevention service. In COP 12, transitioning of targeted HTC sites will commence, in consultation with the government of Vietnam (GVN), PEPFAR and other stakeholders. Although the number of HTC sites may decline in COP 12, the number of clients benefitting from HTC will remain stable due to improved efficiencies and interventions to improve service access and uptake. Approximately 45,000 MARPs and vulnerable people are expected to avail HTC services in COP 12. SMART TA will continue closing and/or consolidating overlapping or inefficient HTC sites, pilot strategic mobile services, pilot a pre-ART initiative and HTC-OPC tracking system to reduce loss to followup, and integrate services in preparation for transitioning. SMART TA will continue to focus on technical assistance (TA) in the standardization of core HTC services and HTC QI, building HTC training capacity to mentor, monitor and supervise HTC programs. Using the standardized national HTC electronic data collection and reporting system (PrevenHIV software), SMART TA also will support improved HTC data use at both site and provincial levels for program improvement. SMART TA will work with partners to conduct a mapping and analysis of all HTC sites in PEPFAR-focus provinces to 1) identify service overlaps across funding sources; 2) identify efficiency gains through service integration and task sharing; 3) articulate strategic HTC delivery models and communication strategies that increase HTC uptake; and 4) promote continuum from prevention to care (COPC) service linkages in an effort to reduce loss to follow-up for recently diagnosed HIV-positive clients.

In COP 12, SMART TA will continue to work with the government of Vietnam (GVN), PEPFAR and other donors to standardize efficient and cost-effective prevention models that can be sustained with GVN financing. In COP 12, $206,827 will be spent to provide 17,751 MSM to develop and deliver the core package of prevention services; $347,930 to provide 32,338 SWs with the core prevention service package; $30,000 technical experience sharing consultations for MSM; and $104,001 to develop and pilot strategies and interventions to better link MARPS to comprehensive services and for technical experience sharing consultation for MARPs. Building on work initiated in COP 11, SMART TA will support provinces to analyze their HIV epidemic and articulate evidence-based responses based on the size of MARP subpopulations, the epidemic burden and available resources. This will include calculating rational numbers of peer outreach workers needed for FSW, IDU and MSM prevention interventions based on provincial size estimation data. SMART TA will further work with GVN, PEPFAR partners, MARP subpopulations and other key stakeholders to develop targeted behavioral communications and tripilotal cost-effective approaches (e.g. peer-driven interventions, use of digital technologies, private sector partnerships, strategic mobile services) that strive to increase programmatic reach and continuum of prevention to care (COPC) service-uptake. Advocacy work to strengthen structural interventions, like the 100% Condom Use Program (CUP), and promote MARPs and civil society engagement in the response likewise will be stressed.Transitioning of targeted prevention interventions will be initiated in COP 12, in consultation with GVN, PEPFAR and other key stakeholders. While the number of sites will decrease, coverage is expected to remain stable, as a result of improved efficiencies, innovative programming and service-uptake initiatives. SMART TA will provide technical assistance (TA) and QI to ensure that interventions are sound across sites and achieving impact. SMART TA also will conduct various costing studies and facilitate technical discussions to ensure that interventions are cost-effective, sustainable and institutionalized.

Although the coverage of IDU interventions has increased dramatically in Vietnam in the past few years, the success is threatened by: difficulties measuring and extending HIV prevention reach; the lack of segmented approaches to address clients with overlapping risks; and deficiencies in the structural and policy environments. In COP 12, SMART TA will address these gaps by continuing to provide financial, programmatic and technical support to the government of Vietnam (GVN) and CSO-implementing agencies. SMART TA will work closely with the Vietnam Administration for HIV/AIDS Control (VAAC), Provincial AIDS Committees (PACs), PEPFAR and other stakeholders to finalize a cost-effective, core package of prevention services for IDUs. This will form the basis by which to articulate core and supplementary IDU prevention service packages that can be sustained with GVN or CSO financing. New outreach models will be piloted in particular areas to test whether different approaches are needed to extend prevention coverage in cost-effective ways. SMART TA will continue to collaborate with others on piloting peer-driven interventions for IDUs. In COP 12, SMART TA will work with VAAC/Life-Gap, PSI, and other agencies to provide joint trainings in outreach strategies, including the use of new messages (i.e., encouraging early treatment; focusing on specific networks, such as IDUs-FSWs and IDUs-MSM; and enhancing the role of outreach workers in keeping HIV-positive individuals in continuum of prevention to care (COPC) services. To ensure access to and use of critical commodities, SMART TA will be moving from extensive free distribution of commodities to more sustainable social marketing and private-sector purchase efforts. In each targeted province, SMART TA will work closely with PSI and others to support implementing agencies and the private sector to develop, implement, manage and monitor commodity social marketing and total market approach (TMA) plans. SMART TA will continue to provide TA to PEPFAR and GVN on the development, standardization and roll-out of routine monitoring systems for the national methadone maintenance treatment (MMT) program, and will continue to develop and pilot the Management Information System (MIS) for methadone patients, including identification of appropriate interoperability use cases, piloting proof of concept, developing minimum requirements documents, and reviewing policies on security and confidentiality, as well as piloting the computer-based data management and reporting system at selected MMT sites. To strengthen demand for, and uptake of, comprehensive health and social services, SMART TA will work with GVN and CSO-implementing agencies to strengthen service referral linkages and consumer demand to ensure that IDU subpopulations avail critical health and social services. SMART TA will recommend closure of particular services and/or consolidation of services to make existing services cost-effective and sustainable. In certain areas, SMART TA will identify civil society or private-sector service-delivery outlets (and advocate for socialization models) that reduce the financial and administrative burden of operating GVN health service systems. Wherever possible, alternative service-delivery models will be piloted and compared with existing approaches to identify strategies that facilitate uptake and offer cost benefit and scale, according to targets established at the national, provincial and district levels.

Beginning in COP 11, SMART TA incrementally transitioned implementation support for 11 PMTCT sites currently supported by FHI 360 to the government of Vietnam (GVN). In COP 12, SMART TA will work with the Vietnam Administration of HIV/AIDS Control (VAAC), SCMS, LifeGAP, GF ATM, CHAI and provincial health authorities, providing technical assistance (TA) to scale-up a pilot system developed in COP 11, in which PMTCT ARV drugs for HIV-infected pregnant women and HIV-exposed infants will be housed in 1 provincial level health service where all identified HIV-pregnant women from that province are referred for PMTCT services. This will include scaling-up the province-wide emergency PMTCT ARV drug distribution system, which can distribute ARV drugs rapidly (within hours) to pregnant women who are identified as HIV-positive in labor by rapid testing ensuring that where possible, HIV-infected women receive PMTCT ARV drugs in labor and all HIV-exposed infants receive ART in line with national guidelines. SMART TA will include the finalization of SOPs, training curriculum, job aids and training support to support the scale-up of this system nationwide. Furthermore in COP 12, SMART TA will focus on strengthening referral linkages between commune/district ANC services, the HIV outpatient clinics, the reproductive health systems, district and provincial OB-GYN departments, and the private sector. All of these services will support the identification of pregnant women living with HIV and those at risk for HIV infection, referring these individuals for testing and then to the central provincial GVN-supported PMTCT service (or others identified during provincial mapping processes).

While supporting ongoing implementation and improving retention and treatment outcomes, SMART TA will prepare to transition sites to the government of Vietnam (GVN) administrative, financial and technical support. In preparation for transition and in accordance with key PEPFAR priorities, SMART TA will focus on reducing costs, improving cost-effectiveness and optimizing capacity of ART sites. This will take place as sites are identified and prepared for transition to government ownership, including the development, piloting and evaluation of models of transition, as well as the development and implementation of technical assistance (TA) models to improve program performance and patient outcomes across the spectrum of sites supported by PEPFAR, government, Global Fund (GF) or other donors. In COP 12, SMART TA will commence transitioning service sites across provinces while continuing the work initiated in COP 11 with GVN and other partners to institutionalize standardized, cost effective core packages of facility- and community based care and treatment (C&T). While the number of service-delivery sites may decline in COP 12 due to transitioning of sites, the number of clients enrolled in treatment will increase due to improved efficiencies and interventions to improve early enrollment in the HIV program and increased retention due to positive health programs. In COP 12, ART will be provided for 15,050 PLHIV. The challenge of transition is to maintain continuous improvement in volume and quality of care and patient outcomes, while reaping the benefits of cost-reduction, improved efficiency and cost-effectiveness. SMART TA anticipates that the TA, mentoring and QI it supports will incrementally increase the proportion of PLHIV alive and retained in care after 12 months of ART. SMART TA will work with GVN and other partners to improve service-delivery while focusing on the provision of high-quality, evidence-based services to facilitate early commencement of ARV and improved patient clinical and quality of life outcomes. Cost reductions and improvements in cost-effectiveness and efficiency will be achieved through appropriate service integration, leveraging of existing services, identification of core services, rationalization of existing service-delivery models including development and implementation of SOPs for patient flow, task shifting, and patient visit schedules. Sites will be selected for transition in consultation with the Ministry of Health (MOH), PEPFAR Vietnam and other key stakeholders based on assessment of readiness, capacity, availability of economic resources, political commitment, and local HIV epidemiology and unmet treatment need. Early sites will be used to pilot and evaluate the models of transition, including core service delivery and increased involvement of provincial authorities. TA models will focus on improved patient care through improved linkages and referrals, standardization of quality core care packages, and building the capacity of national and provincial authorities. The goal is to see the shared experience of the successful PEPFAR Vietnam ARV scale-up benefiting all sites, regardless of donor support.

While supporting implementation for pediatric care and support, SMART TA will increaingly focus on PEPFARs strategic goals to transition to country ownership and provision of technical assistance (TA). In COP 11, in conjunction with improvements in pediatric care and support services, SMART TA developed, implemented, operated and standardized a core package of care and treatment (C&T) services for HIV-infected children and affected families. This included early identification and referral into treatment, provision of TA to national and provincial authorities to manage and provide quality services in the continuum of patient care, and monitoring and improvement in the quality of services before, during and after transition to full government ownership and management while ensuring ongoing growth of the pediatric ART program. The focus for SMART TA during COP 12 will be on sustainability, improving cost-efficiency and improving program access for HIV-infected children and families. While the number of comprehensive service delivery sites may decline in year 2 due to transitioning of sites, the number of pediatric clients accessing ART in SMART TA-supported sites will increase due to improved efficiencies and interventions to improve early enrollment in the HIV outpatient clinic (OPC). During COP 12, up to 318 HIV-infected children will access ART in SMART TA-supported sites. The Global Fund (GF) has expressed an interest in providing integrated family centered care at its HIV clinics. SMART TA will standardize family centered care models and packages, developing simple tools to assist the government of Vietnam (GVN) and GF-supported healthcare providers to implement family centered HIV care throughout Vietnam. While supporting GVN and GF to scale-up family centered care approaches, SMART TA will prepare for transition of pediatric C&T, which may occur simultaneously or separately from the adult care and treatment, depending on the site and the existing resources. SMART TA will be active in the provision of services and TA in these key areas, in addition to the standardization and institutionalization of national training curricula and clinical care capacity-building and QI.