Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 3949
Country/Region: India
Year: 2009
Main Partner: Voluntary Health Services
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $4,400,000

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $108,328

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The following new activity will be undertaken in FY09:

ACTIVITY 4: Community Mobilization & Demand Generation Activities

APAC, in consultation with Tamil Nadu State AIDS Control Society (TNSACS), will support a rapid

assessment of the existing community mobilization and demand generation activities for PMTCT. Based on

the assessment's findings, appropriate communication tools will be developed for use in public and private

sector PMTCT centers. The communication tools will focus on: spouse counseling; minimizing risk of HIV

transmission during delivery; ARV prophylaxis for HIV-infected mother and newborn; maternal nutrition; safe

breast feeding; early infant diagnosis; and linkages with care continuum services.

APAC will also work with the auxiliary nurse mid-wives, anganwadi workers, link workers and NGOs

working in reproductive and maternal health programs, to create awareness and demand for PMTCT

services. At the district and block headquarter hospitals, the project will support street plays focusing on

PMTCT messages. Counselors will be oriented on counseling of sero-discordance and supported

disclosure. APAC will also review the existing systems available for HIV infected mother-baby follow-up,

and based on need will introduce a mother-child health follow-up card. Through these efforts the project

aims to: a) reduce the loss to follow-up cases from 15% to 5%; b) increase infant diagnosis from 70% to

85%; and c) increase the knowledge and skills of PMTCT staff on the full package of PMTCT services.

FY 2008 NARRATIVE

SUMMARY

Prevention of mother-to-child transmission (PMTCT) programs in the state of Tamil Nadu are relatively less

developed and are primarily implemented in public sector health care settings. Additionally, there is an

overall lack of expertise within the medical community in the area of PMTCT programs. In FY08, the AIDS

Prevention and Control (APAC) project will support comprehensive PMTCT initiatives in the private sector

through: supporting a network of 19 private hospitals, building the capacity of 300 private physicians

working with medical associations, and ensuring linkages of the trained physicians with PLHA networks and

other care continuum providers. The project will also build the capacity of the public sector through provision

of technical assistance (TA) to the local State AIDS authorities for comprehensive scale up of a quality

PMTCT program.

BACKGROUND

For the past twelve years, with USG support, Voluntary Health Services (VHS) has been implementing the

APAC project in the southern state of Tamil Nadu. APAC initially focused primarily on targeted interventions

for most-at-risk-populations (MARPs), but has expanded efforts over the last few years to support a more

comprehensive approach to HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in

controlling HIV (prevalence among antenatal women has dropped from 1.13% in 2001 to 0.5% in 2005) and

the APAC project has significantly contributed to this success. The National AIDS Control Organization

(NACO) has recognized the expertise and contributions of the APAC project and has requested APAC to

provide technical support to the State AIDS Control Societies (SACS) of Tamil Nadu, Puducherry and

Kerala by setting up a Technical Support Unit (TSU) in Tamil Nadu and Kerala, consisting of a core team of

consultants/experts co-located with the SACS, with a mandate to assist the SACS in scaling-up programs,

improving efficiency and quality. APAC also serves as the vice-chair on the Technical Working Group on

Targeted Interventions for the country.

PMTCT services for pregnant women in India are primarily concentrated in the public sector. Despite a high

proportion of pregnant women in India accessing antenatal services in the private sector, PMTCT has still

not received adequate emphasis from private sector health care providers. The national objective of

reducing infections in the newborn can be attained if access to PMTCT services is expanded to private

health care settings. Existing data from public sector health care institutions in Tamil Nadu indicate that

while there is an increase in the number of pregnant women getting counseled and tested, a large

proportion (more than 30%) of HIV-positive pregnant women do not receive ARV prophylaxis due to lack of

adequate follow-up. Data pertaining to the private sector is also sparse at best. The APAC project will

support activities that encourage the private sector to provide comprehensive PMTCT services, thereby

complementing public sector efforts. The APAC project will also coordinate with the SACS and other

stakeholders to evolve systems to increase the proportion of HIV positive pregnant women receiving

prophylaxis and follow-up care from public health care settings.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Increasing Access to Comprehensive PMTCT Services through a Network of Private Hospitals

The APAC project will support 19 private hospitals (16 secondary-level hospitals with provision for

institutional deliveries and three tertiary-level hospitals to provide comprehensive PMTCT services) in

selected high-prevalence districts in the states of Tamil Nadu and Puducherry. These hospitals will provide

PMTCT, TB-HIV co-infection management, and palliative care services including ARVs. Through this

initiative, APAC aims to increase the coverage of antenatal women in these high-prevalence districts,

motivate private sector health care institutions to get involved in HIV/AIDS management, and establish

sustainable models for replication. In each of the private hospitals, the project will support the services of

trained counselors who will provide counseling for antenatal, delivery and postnatal care for all pregnant

women. Counselors will be part-time. Each counselor will provide services to a minimum of two private

hospitals, each having a good client load of antenatal women. The PMTCT package of services will include

counseling and testing for pregnant women, ARV prophylaxis for HIV-infected pregnant women and

newborns, counseling and support for maternal nutrition, post delivery follow-up for safe infant feeding

practices, infant diagnosis and need-based linkages to care and treatment services for the mother, child and

family. Counselors will also focus on counseling and motivating the husbands of the antenatal women for

HIV testing.

Activity Narrative: APAC will train health care providers in private hospitals on: a) provision of comprehensive PMTCT

services; b) national PMTCT guidelines and standard operating protocols; c) universal precautions; and d)

establishing strong linkages with NGOs, PLHA networks and other care continuum providers. The private

hospitals will also provide palliative care services, thus ensuring that HIV-positive pregnant women and their

families have access to clinical services under one roof even after delivery. Quality assurance and

accreditation of the private hospitals is planned though State AIDS Control Societies and other agencies.

Demand generation for PMTCT services will be done through NGOs (both APAC- and SACS-supported),

networking with other health care providers, agencies and local communication campaigns. It is estimated

that nearly 6000 antenatal mothers will benefit annually through this initiative. This initiative is based on the

existing experience of APAC's support to IRT Perundurai Medical College, which is a tertiary care center

that has been supported by APAC since FY06.

ACTIVITY 2: Increase the Pool of Trained Health Care Providers Providing PMTCT Services

In two high-prevalence districts of Tamil Nadu, APAC plans to collaborate with the Federation of Obstetrics

and Gynecologists Society of India (FOGSI) to train obstetricians on comprehensive PMTCT services,

thereby increasing the pool of trained health care providers in the district. A total of 350 obstetricians will be

trained and followed-up. Existing training modules will be reviewed and modified to comply with the national

guidelines and protocols. The training curriculum will have a focus on: a) provider initiated counseling and

testing; b) counseling HIV- positive pregnant women on continuation of pregnancy and delivery; c) ARV

prophylaxis for HIV-infected pregnant women and newborns; d) counseling and support for maternal

nutrition and safe infant feeding practices; and e) referral for the continuum of care services. There will be

periodic follow-up of trained health care providers and experience-sharing meetings with other doctors in

the state. Linkages between the trained health care providers and local NGOs working on HIV programs

will be established. FOGSI will be the coordinating agency for training the doctors. Efforts will be begun to

mobilize support from leading pharmaceutical companies to sponsor training costs and the cost of providing

subsidized drugs to the trained health care providers. This initiative is designed to facilitate sustainable

networks between FOGSI, trained doctors, NGOs and pharmaceutical companies.

ACTIVITY 3: Strengthen Systems in the Public Sector for Comprehensive PMTCT Services through TSU

Support

APAC will provide assistance to the SACS through the TSU to scale up the PMTCT programs in Tamil

Nadu and Kerala. APAC, in coordination with SACS and other USG partners including CDC, will assess

gaps in the delivery of PMTCT services in public sector health care settings through a review of data from

public sector PMTCT sites, carry out joint field assessments, and develop a plan to improve systems for

delivery of comprehensive PMTCT services in public health care settings. APAC support will also include

strengthening the Management Information System at the state level to help better understand the program,

identify gaps, and facilitate timely and effective program-related decisions. The TSU will also assist the

District AIDS Prevention and Control Units to effectively monitor the quality of field-based PMTCT

programs.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14154

Continued Associated Activity Information

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

System ID System ID

14154 10933.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $148,500

International Services

Development

10933 10933.07 U.S. Agency for Voluntary Health 5604 3949.07 $245,000

International Services

Development

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* Safe Motherhood

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.01:

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $35,728

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The National AIDS Control Organization (NACO) continues to place emphasis on interventions with

truckers, migrants and youth populations as they act as a bridge population to the general population. The

approach for reaching these groups, however, has changed. NACO has withdrawn support to NGOs

engaged in interventions with these groups and is instead working closely with the related government

ministries to mainstream HIV/AIDS programs. NACO is also coordinating with the trucking associations to

roll-out a national program for truckers through the association. At the state level, the Tamil Nadu State

AIDS Control Society (TNSACS) plans to lead coordination efforts with different ministries, departments,

and associations to implement HIV/AIDS prevention programs among truckers, migrants and youth

populations. This is in-line with the USG policy of increased ownership of HIV/AIDS programs by the state

and using USG support for interventions in critical areas / target populations.

ACTIVITY 1: Community Outreach Services for Bridge Populations and Other Sub-Populations in High-

Prevalence Districts

This activity will not be continued in COP09 as TNSACS plans to support interventions with bridge and

vulnerable populations for the entire state.

ACTIVITY 2: Transitioning Targeted Interventions to the Private Sector and SACS

The project has developed a clear plan to transition the truckers, migrant and youth intervention programs

to TNSACS. The transition plan was developed in consultation with NGOs and SACS. A coordination

committee will oversee the transition process and ensure quality services are provided to these target

communities. As a result, APAC will not continue to support these activities in COP 09.

ACTIVITY 3: Technical Assistance to SACS on Targeted Interventions

APAC, through the Technical Support Units (TSUs) will continue to provide technical assistance to

TNSACS, NGOs, associations and different ministries for mainstreaming HIV/AIDS. APAC will also work

with TNSACS to develop gender specific policies and tools and to train NGOs and agencies on

incorporating gender into their HIV/AIDS initiatives.

ACTIVITY 4: Demonstration Projects for Mainstreaming HIV/AIDS Programs in Universities

APAC is working with TNSACS to mainstream HIV/AIDS into the University program, and will not support

any direct interventions for university youth in COP09. This shift aligns with the PEPFAR review team's

recommendation to focus on MARPs and mainstream programs for low-risk groups.

ACTIVITY 5: Promoting HIV/AIDS Prevention to Out of School Youth through Social Networks

The project is working with TNSACS to mainstream HIV/AIDS into existing youth programs, and will not

continue support for direct interventions for youth programs in COP09. This shift aligns with the PEPFAR

review team's recommendation to focus on MARPs and mainstream programs for low-risk groups.

ACTIVITY 6: Building the Capacity of NGO Staff and Peer Educators

This activity will not be continued in COP09, as TNSACS plans to support interventions with bridge and

vulnerable populations at the state level. The Technical Support Unit (TSU), in consultation with TNSACS

will, however, introduce appropriate modules on Abstinence and Be Faithful in the NGO staff and peer

educator training programs.

In COP 09 the following new activity will be supported by the project:

ACTIVITY 7: Demonstration Project on Short-Stay Migrant Intervention

In COP09, APAC will support one or two associations (construction sector / other sectors where large

numbers of short-stay migrants work) and demonstrate models of mainstreaming HIV/AIDS work. This

model project will be located in suburban areas of Chennai to address the migrant population. The project

will cover 10,000 migrants in partnership with local corporations / industries and infrastructure development

agencies. This project will also serve to demonstrate different best practices. The same will be

documented and shared with NGOs involved in interventions among migrants. Peer educators among the

migrants will be identified, recruited, and trained so as to more effectively reach migrants. Multi-lingual

outreach workers will be recruited for promoting behavior change. IEC materials will be designed / procured

in different languages.

FY 2008 NARRATIVE

SUMMARY

Interventions among bridge & other selected sub-populations continue to be a priority in the third phase of

the National AIDS Control Plan. The most recent Behavioral Surveillance Survey conducted in Tamil Nadu

indicates that a significant proportion of bridge populations and youth engage in risky sex behaviors.

Current interventions primarily focus on condom promotion with limited emphasis on other options. APAC

will promote expansion of options by providing comprehensive and gender sensitive information on

abstinence, fidelity, partner reduction, condom promotion for groups with established risk behaviors, and

promoting value-based lifestyles.

In FY08, APAC will support interventions among bridge and other selected populations through delivering a

behavior change communication (BCC) package based on risk assessment of these sub-populations.

Important strategies to address these populations will include supporting NGOs and social networks to

reach out to the selected target audience, and capacity enhancement of the NGOs to scale up and improve

the quality of interventions. APAC will support two model university programs and a limited number of

projects with truckers' associations for demonstrating effective mainstreaming strategies. As a Technical

Support Unit, APAC will also assist the State AIDS Control Societies of Tamil Nadu and Kerala to

strengthen their capacity for project management including evidence-based planning and monitoring, with

the aim of scaling up interventions at the state level and quality improvement.

BACKGROUND

Activity Narrative: VHS has been implementing the APAC project in Tamil Nadu for 12 years. APAC initially targeted most-at-

risk-populations, but has expanded efforts over the last few years to support a more comprehensive

approach to HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in controlling HIV

and APAC has significantly contributed to this success. The National AIDS Control Organization has

recognized the expertise and contributions of the APAC project and has requested APAC to provide

technical support to the SACS of Tamil Nadu, Puducherry and Kerala by setting up a Technical Support

Unit at Tamil Nadu and Kerala, consisting of a core team of consultants/experts co-located with the SACS,

with a mandate to assist the SACS in scaling-up programs, improving efficiency and quality. APAC also

serves as the vice-chair for the Technical Working Group on targeted interventions for the country.

In a recent development, the Tamil Nadu State AIDS Control Society has taken a decision that it would take

the lead to support bridge and vulnerable population interventions for the entire state of Tamil Nadu, and

has requested the other stakeholders to saturate coverage of MARPs in their respective districts. As a

follow-up of this decision, APAC starting Oct 08, will transition all its bridge and vulnerable population

intervention programs in Tamil Nadu and support more NGOs / CBOs to saturate coverage of MARPs.

Only one migrant intervention will be supported by the project. Due to this change the overall budget and

targets in the Abstinence and Be Faithful program area have been decreased.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Community Outreach Services for Bridge Populations and Other Sub-Populations in High-

Prevalence Districts

Eight NGO sub-partners will use peer educators to deliver A and B messages to target populations in

selected high-prevalence districts of Tamil Nadu and Puducherry. Peer educators will strategically

encourage unmarried young adults to abstain from sex, married adults to remain faithful, and those with

established high-risk behavior to use condoms and access VCT services. USG funds will support capacity

building of NGO staff and peer educators, increase access to preventive services through community-based

peer educator programs, create an enabling environment for behavior change and support advocacy efforts

for stigma reduction. Community drop-in-centers will be established by APAC's sub-partners to provide

space for the community to share experiences, as well as offer counseling and testing and basic medical

support to the target populations. APAC will build the capacity of sub-partners through regular training,

exposure visits and monitoring, and will support 1320 peer educators with motivational strategies. This

activity aims to reach nearly 69,000 individuals from bridge and other populations with A and B messages.

Efforts to reach women (spouses of truckers and migrating women involved in construction, agriculture

work) will also be supported through NGO outreach and workers' associations.

ACTIVITY 2: Transitioning Targeted Interventions to the Private Sector and SACS

Since 1996, APAC has supported NGOs by building their capacity to manage projects and mobilize

resources from other donors. In FY08, APAC will support initiatives to transition 16 NGO sub-partners

(involved in interventions with bridge and other selected populations at risk) to SACS and other agencies.

APAC will build the capacity of sub-partners to showcase achievements and leverage resources from

private companies through tapping corporate social responsibility opportunities. APAC will establish a

coordination team to develop mechanisms for transition and follow-up of transitioned projects to ensure

continuance of the quality and scale of interventions.

ACTIVITY 3: Technical Assistance to SACS on Targeted Interventions

In line with the NACP-III policy, NACO has designated APAC to be the Technical Support Unit to provide

ongoing technical assistance to the SACS of Tamil Nadu and Kerala and build capacity for effective

interventions among bridge and selected sub-populations. Technical support to SACS will cover a range of

areas such as a) strengthening project management systems; b) standardizing training modules consistent

with the national guidelines and strengthen the capacity of NGO and CBO training institutions; c) evidence-

based planning including periodic mapping, size estimation and need assessment of target populations; d)

documentation and dissemination of best practices for learning and replication; e) development of a

mainstreaming strategy; and f) periodic evaluation and behavioral impact assessments. APAC and SACS

will develop a joint technical support plan and technical assistance will be provided based on the plan.

APAC will also build NGO capacity by supporting two demonstration projects (one each for truckers and

migrants) as centers of learning.

ACTIVITY 4: Demonstration Projects for Mainstreaming HIV/AIDS Programs in Universities

APAC will support two model projects in universities to integrate HIV/AIDS programs for HIV/AIDS

prevention education, with an emphasis on abstinence. Volunteer peer educators will be selected and

trained to deliver appropriate HIV/AIDS information to the students. The training content will particularly

emphasize the vulnerability of women to HIV/AIDS and build their skills in handling risky situations. A few

peer educators will be trained as peer counselors to provide counseling to at-risk youth and link them with

NGOs and other support agencies. An infotainment troupe will provide HIV information through traditional

and modern media. Two youth-friendly centers offering holistic youth services (career guidance, personality

development, sexual and premarital counseling, fitness and personal care) will be established in partnership

with private companies to serve as a pull factor and help leverage resources from the private sector.

APAC will collaborate with the Ministry of Parliamentary Affairs to conduct youth parliaments on HIV/AIDS

issues in colleges. District-level competitions will be conducted in various colleges with awards given to the

teams. Winners from each district will participate in state-level youth model parliaments. An estimated 5000

college youth will be reached through these model projects. To ensure greater ownership and sustainability,

the project will involve the principals and key faculty in designing college-specific interventions and a

monitoring strategy, and build the capacity of the faculty in counseling and handling youth-specific issues.

The experience of these model projects will be disseminated to NACO, SACS and the Ministry of Youth for

replication.

ACTIVITY 5: Promoting HIV/AIDS to Out Of School Youth through Social Networks

APAC will support a pilot project in one high-prevalence district to mainstream HIV/AIDS within Nehru Yuva

Kendra, a large social network. The project will address out-of-school youth in 25 large slums of Tamil

Nadu. NYK will establish Youth Health and Development Clubs in these slums to promote awareness on a

Activity Narrative: range of HIV/AIDS and social issues, and link out-of-school youth to various government-aided programs.

Through this initiative, over 1250 out-of-school youth will be reached. In each slum, 25 male and female

youth will be identified as peer educators and trained on HIV/AIDS prevention messages, life-skills

education, and other social and health issues. Efforts will be made to sustain the activities by ensuring

coordination with local NGOs, FBOs, the Tamil Nadu slum clearance board, the Women's Development

Corporation and other social networks.

ACTIVITY 6: Build the Capacity of NGO Staff and Peer Educators

APAC will identify and support strong organizations to build the capacity of NGO staff and peer educators in

interventions among selected populations focusing on promoting A and B messages. Risk assessment tools

will be developed for outreach workers and peer educators to ascertain the risk behavior of bridge and other

populations. NGO staff and peer educators will be provided a series of trainings focusing on issues such as

participatory mapping and needs assessment, risk assessment, interpersonal communication, gender, and

project management. The project will train 176 NGO staff and 1320 peer educators.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14155

Continued Associated Activity Information

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

System ID System ID

14155 10936.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $68,200

International Services

Development

10936 10936.07 U.S. Agency for Voluntary Health 5604 3949.07 $821,000

International Services

Development

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.02:

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $1,540,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

Tamil Nadu (TN) has the largest number (140) of NGOs and CBOs working in HIV/AIDS prevention

programs among MARPs, bridge and vulnerable populations in the country. Nearly 76% of the estimated

81,000 female sex workers (FSWs) in TN and 80% of the estimated 48,500 men having sex with men

(MSMs) are covered through the joint efforts of Tamil Nadu State AIDS Control Society (TNSACS), USG

and The Bill & Melinda Gates Foundation programs. The concentrated efforts of all agencies engaged in

HIV/AIDS programs have helped in controlling the epidemic in the state and the adult prevalence has

dropped from 1.13 percent in 2001 to 0.38 percent in 2006. Trends indicate that prevalence among FSWs

(3.6%) and MSMs (5.6%) are also on the decline and are lower than the national average of 4.9% and 6.4%

respectively.

Many challenges still persist in sexual prevention programs. Less than 50% of FSWs have correct

knowledge on HIV and 30% report suffering from STIs in the last 12 months (NACO 2006 BSS). There are

concerns about a lack of timely treatment-seeking behaviour and consistent condom use. Nearly 60% of

sex workers have never had an HIV test and only 60% report having been reached by an HIV/AIDS

intervention program. 5% of sex workers consume alcohol during sex and a high proportion report injecting

drugs in the last 12 months.

Current programs are not structured to meet the needs of specific sub-groups of MSMs, based on identities

and sexual behaviour patterns. MSMs, in particular transgenders, face a high level of stigma and violence.

Furthermore, interventions among MARPs have not addressed structural issues and have been primarily

limited to urban settings.

All activities planned in COP 08 will be continued in COP 09 except for Activity 3.

In addition, the following new activities are planned in COP 09:

ACTIVITY 7: Interventions with Non-Brothel and Non-Street Based Sex Workers

The dynamics of sex work is changing rapidly across the country; sex workers now operate from diverse

settings including homes, parlors, vans, etc. Anecdotal information indicates that women in certain

professions, such as the film industry, operate as part time sex workers. Information on sex workers in

these unique settings is very limited. Due to this lack of information, NACO and SACS have asked APAC to

study the changing dynamics of sex work and to implement a pilot project for interventions among non-

brothel, non-street based sex workers. The pilot project will be implemented in one district after assessing

the estimated population size, needs, and opportunities for intervention. The assessment findings and

experience of interventions will be shared with NACO, SACS and other NGOs for necessary policy and

programmatic changes.

ACTIVITY 8: Comprehensive Services to MARPs

Most interventions currently focus only HIV/AIDS messages and services. APAC MARP interventions,

however, strive to support comprehensive needs of MARPs and will: a) ensure active participation of the

target community in the development, implementation and monitoring of project activities; b) increase

access to male and female condoms and promote consistent use of condoms with all partners; c) promote

periodic medical check-ups for STIs; d) promote counseling and testing (CT) and increase access to CT

services; e) establish appropriate linkages of HIV-infected MARPs with care, support and treatment service

providers and regular follow-up to ensure quality of services; f) integrate gender and violence reduction

strategies in programs; g) establish linkages with social welfare services for MARPs and their families

(particularly to prevent second-generation sex work); h) provide vocational training and pilot community -

health financing options.

APAC, in coordination with TNSACS, will establish appropriate policies and mechanisms for addressing

sexual abuse, violence and legal issues of MARPs. The project will train NGO staff to address broader

concerns including dealing with trafficked sex workers. A state-level Watchdog Committee on Sexual

Abuse, Violence and Human Rights will be formed.

ACTIVITY 9: Transition Program Management to Community Based Organizations (CBOs)

The third phase of the National AIDS Control Program (NACP-III) places greater emphasis on CBO

managed programs and a target has been fixed where by 50 percent of targeted interventions projects will

be managed by CBOs by 2012. As part of APAC's transition plan, the project will train core groups of

community members on community mobilization, project management, advocacy and leadership initiatives.

An expert team of consultants and NGOs will be formed to guide the process of transitioning and to support

the community members in complex and challenging areas. Task shifting will also be introduced in a

phased manner. Peer counselors will be identified and trained in each intervention. The transition process

will be documented and disseminated to NGOs, CBOs, SACS and NACO.

FY 2008 NARRATIVE

SUMMARY

Mapping studies estimate there are 80,000 female sex workers and 35,000 men who have sex with men in

Tamil Nadu. Sex work in Tamil Nadu is not brothel-based, but rather street and home-based. Currently the

AIDS Prevention and Control project, through Voluntary Health Services, the Tamil Nadu State AIDS

Control Society, and the Bill and Melinda Gates Foundation are the three major agencies involved in

targeted interventions among Most At-Risk Populations reaching 60-70% of FSW. However, coverage of

MSM and injecting drug users continues to be low.

In FY08, the APAC project implemented by VHS in Tamil Nadu, will support a variety of behavior change

interventions addressing MARPs implemented through a network of 16 NGOs and civil society. The

interventions will include: behavior change communication through community outreach, increasing access

to condoms, building capacity of NGO staff and retailers on social marketing of condoms, linking MARPs

and their partners to counseling and testing and STI services, and promoting risk reduction strategies

Activity Narrative: among IDU. The APAC project will also provide technical assistance to the State AIDS Control Societies in

Tamil Nadu and Kerala to enhance their capacity and systems for effective interventions with MARPs.

BACKGROUND

For the past twelve years, with USG support, VHS has been implementing the APAC project in the southern

state of Tamil Nadu. APAC initially focused on targeted interventions for MARPs, but has expanded its

efforts over the last few years to support a more comprehensive approach to HIV/AIDS prevention, care and

treatment. Tamil Nadu has been successful in controlling HIV and the APAC project has significantly

contributed to this success. The National AIDS Control Organization has recognized the expertise and

contributions of the APAC project and has requested APAC to provide technical support to the SACS of

Tamil Nadu, Puducherry and Kerala by setting up a Technical Support Unit at Tamil Nadu and Kerala,

consisting of a core team of consultants/experts co-located with the SACS, with a mandate to assist the

SACS in scaling-up programs, and improving efficiency and quality. APAC also serves as the vice-chair on

the national Technical Working Group on Targeted Interventions.

The third phase of the National AIDS Control Program aims to halt and reverse the epidemic. A key strategy

to achieve this objective is to saturate coverage of MARPs including FSW, MSM, and IDU by tripling the

number of targeted interventions amongst MARPs from 700 to 2100, and engaging community-based

organizations more intensively. Estimates indicate that there are 1.2 million FSW, 2.3 million MSM, and

220,000 IDU in the country and nearly 10% of these MARPs are estimated to be HIV infected. Recent

studies also indicate that sex work is no longer confined to urban areas but has spread to rural areas,

making interventions with MARPs more complex and challenging.

In a recent development, the Tamil Nadu State AIDS Control Society has taken a decision that it would take

the lead to support bridge and vulnerable population interventions for the entire state of Tamil Nadu, and

has requested the other stakeholders to saturate coverage of MARPs in their respective districts. As a

follow-up of this decision, APAC starting Oct 08, will transition all its bridge and vulnerable population

intervention programs in Tamil Nadu and support more NGOs/CBOs to saturate coverage of MARPs. Only

one migrant intervention will be supported by the project.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Community Outreach for Most-at-Risk Populations in Selected High-Prevalence Districts

The APAC project will support 16 sub-partners to implement comprehensive HIV/AIDS interventions with

MARPs in selected high-prevalence districts of Tamil Nadu and Puducherry. The project will make

additional efforts to improve coverage of MSM by increasing the number of interventions. NGO staff will

impart behavior change messages to MARPs through interpersonal communication, and will promote

consistent condom use, and encourage periodic STI check-ups and HIV testing. Sub-partners will identify

community-preferred health care providers for STI treatment, refer MARPs for periodic STI check-ups and

follow up for treatment adherence. Periodic NGO and Health Care Provider meetings will be organized for

coordination and sharing of information. In FY06, the Gates Foundation supported the establishment of STI

clinics in APAC-supported NGO sites. During FY08, APAC will continue to leverage support from the Gates

Foundation for STI treatment for MARPs. Community drop-in-centers will be established by sub-partners to

provide space for the community to share experiences as well as to offer user friendly counseling and

testing and basic medical services to MARPs. APAC sub-partners will establish linkages with the Link

Workers to reach-out to MARPs and bridge populations in rural areas.

MARPs infected with HIV will be linked to a continuum of care services and followed-up for ART adherence.

APAC's sub-partners will coordinate with APAC-supported and other care and support NGOs to ensure that

family members of PLHAs are trained to provide home care and to ensure a good quality of life for PLHAs.

USG funds will support: capacity building of NGO staff and peer educators, increased access to preventive

services through community-based peer education programs, creation of an enabling environment for

behavior change and advocacy with stakeholders. APAC will build the capacity of its sub-partners through

regular training, exposure visits and monitoring. The project will support 960 peer educators and adopt

motivational strategies for their continued involvement in the program. Through this activity, the project

plans to reach 20,000 MARPs and 46,000 high-risk individuals from bridge and other selected risk

populations.

ACTIVITY 2: Increasing Access to Condoms by MARPs in Selected High-Prevalence Districts

APAC will support leading condom manufacturers to strengthen condom distribution networks and promote

condoms in NGO intervention areas in the high-prevalence districts. This will be achieved through

promoting condom sales through non-traditional outlets and by increasing demand. The project will support

linkages between NGOs and condom manufacturers to service outlets in intervention areas thereby

ensuring increased access and expanding product range to MARPs and bridge populations. This initiative

will also ensure sustainability of services and greater coordination between condom manufacturers and

NGOs in condom social marketing. Successful interventions between APAC and condom manufactures in

the past have resulted in tripling of commercial condom sales in Tamil Nadu from 17 million in 1996 to 54

million in 2006. Innovative marketing initiatives by NGOs to enhance condom distribution to MARPs will be

explored. Condoms for free distribution and demonstration will be leveraged from the Government of India.

Retail audit reports will be used to assess trends in the condom market, and for reporting to USG and other

agencies.

ACTIVITY 3: Assessments of Condom Use among MARPs and Sero-Discordant Couples

Behavioral Surveys indicate the nearly 36% of FSW and 40% MSM report inconsistent condom use, citing

objections due to reduced pleasure. APAC will support pilot initiatives to market lubricants among MSM and

female condoms among FSW while assessing the impact on consistent condom use. An assessment of

condom use patterns among sero-discordant couples, including motivating factors and constraints, will be

also undertaken by APAC.

ACTIVITY 4: Build Capacity of NGOs and Retailers for Condom Social Marketing

In FY08, a capacity-building agency will be contracted by the project, as in the past year, to train 400 NGO

staff on the concepts and the processes of condom social marketing and train 500 potential retailers in

marketing techniques.

Activity Narrative: ACTIVITY 5: Technical Support to SACS to Strengthen State-Wide Interventions with MARPs

In line with the NACP-3 policy, NACO has designated APAC to be the Technical Support Unit to provide

continuous technical assistance to the SACS of Tamil Nadu and Kerala and build capacity for effective

targeted interventions. Technical support to SACS will cover a range of areas such as: a) strengthening

project management systems for targeted interventions; b) standardizing training modules and

strengthening the capacity of training institutions involved in training NGOs and CBOs; c) evidence-based

planning, including periodic mapping, size estimation and needs assessment of target populations; d)

documentation and dissemination of best practices for learning and replication; e) developing a

mainstreaming strategy; and f) periodic evaluation and behavioral impact assessments. APAC and SACS

will develop a joint technical support plan and specific areas of technical assistance will be determined.

APAC will also support three demonstration projects as learning sites (one each for FSW, MSM and IDU) to

build the capacity of NGO staff.

ACTIVITY 6: Build Capacity of NGO Staff in Enhancing the Quality of Interventions

The APAC project will identify and support training institutes to build the capacity of NGO staff and peer

educators on targeted interventions. The areas of training, conforming to national standards, will include a)

participatory mapping and needs assessment; b) risk assessment; c) interpersonal communication; d)

gender; e) condom social marketing; f) CBO formation and management; g) project management; and g)

reporting and management information systems. The project will train 128 NGO staff and 960 peer

educators.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14156

Continued Associated Activity Information

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

System ID System ID

14156 6150.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $2,158,800

International Services

Development

10826 6150.07 U.S. Agency for Voluntary Health 5604 3949.07 $1,029,000

International Services

Development

6150 6150.06 U.S. Agency for Voluntary Health 3949 3949.06 $1,306,560

International Services

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Increasing women's access to income and productive resources

* Increasing women's legal rights

* Reducing violence and coercion

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $96,548

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.03:

Funding for Prevention: Injecting and Non-Injecting Drug Use (IDUP): $153,076

NEW ACTIVITY NARRATIVE

SUMMARY

Injecting Drug Use is no longer limited to the north-east of India. Many towns in the country have now

reported the presence of Injecting Drug Users (IDUs). Coverage of IDUs has been minimal with only 44%

of the estimated IDUs (0.22 million) reached through interventions. A major development in the recent past

is the approval by the Government of India (GOI) to introduce oral substitution therapy for IDUs. GOI plans

to provide Buprenorphine to more than 10,000 IDUs by March 2009 and to an additional 30,000 IDUs by

2012.

Current interventions among IDUs primarily focus on HIV/AIDS awareness, condom distribution, STI

treatment, needle exchange, abscess management and counseling. Greater emphasis must be placed on

the promotion of CT services among IDUs; reaching IDUs with multi-partners for consistent condom use ;

periodic STI check-ups; referrals for medication assisted treatment programs; linkages with care and

support programs for HIV infected IDUs; advocacy with law enforcement agencies; and counseling family

members of IDUs.

Tamil Nadu has an estimate of 8,000 injecting drug users. There are currently only five IDU programs

(proposed six partners) covering 50 percent of the estimated IDUs. The National Behavioral Surveillance

Survey (BSS) (2006) indicated that less than 33% of IDUs have undergone HIV testing. The HIV Sentinel

Surveillance (HSS) (2006) also reveals that the HIV prevalence among IDUs in Tamil Nadu is the highest in

the country. There is therefore a definite need to scale-up IDU interventions providing comprehensive and

quality services.

ACTIVITY 1: Learning Site for Interventions Among IDUs

APAC will identify one NGO/CBO and build its capacity to function as a nodal agency for the state to train

other NGOs/CBOs on interventions among IDUs. The learning site will reach a large number of IDUs, offer

comprehensive services (including the provision of medication assisted treatment), advocate with law

enforcement agencies and policy makers, and demonstrate strong linkages with care and other social

development programs. The learning site will also convene a national annual meeting of NGOs/CBOs

implementing IDU programs and disseminate experience and concerns to NACO, SACS and TSUs.

ACTIVITY 2: Saturate Coverage of IDUs in Intervention Districts (linked to Act.1 of OP08)

APAC is engaged in the provision of prevention to care continuum programs in seven high prevalence

districts of Tamil Nadu. In these districts, the project plans to build the capacity of existing NGO/CBO

implementing interventions with female sex workers and MSMs, to identify and reach-out to IDUs with

comprehensive services. A special training on this will be provided by the project to the NGOs/CBOs. This

is a new approach and can be a model for places where the IDU population is small and spread-out.

ACTIVITY 3: Technical Support to SACS

APAC's Technical Support Units (TSUs) will support SACS to scale-up IDU interventions based on the

mapping data collected by the APAC project. The TSUs will also work for a faster roll-out of the medication

assisted treatment to IDUs in the state and to develop a package of comprehensive services in IDU

programs.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Addressing male norms and behaviors

Human Capacity Development

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: $3,205,158

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Overview: The burden of HIV/AIDS on the health system in India remains a major challenge, though the estimated number of

persons living with HIV/AIDS (PLHAs) was recently revised down to 2.47 million. Compared to many developing countries, India

has a large, vibrant health sector with an estimated 200,000 licensed physicians and a larger number of unlicensed medical

practitioners. However, major systems issues persist, including poor infrastructure, continuing stigma among medical

practitioners, limited medical education on HIV/AIDS, and a lack of government regulation of private sector services.

The use of care and treatment services by PLHAs has been reported to be low. Women PLHAs face special challenges in

accessing services, as they often are constrained from leaving their villages to seek treatment by the responsibilities of managing

their families, and in many cases, caring for a sick husband. There is limited data on the use of care and treatment services by the

marginalized, most-at-risk populations (MARPs) most affected by the epidemic. NGO experience reveals that the proportion of

these groups using HIV/AIDS services is less than 5%.

Over the past five years, the National AIDS Control Organization (NACO) has dramatically scaled up care and treatment

programs especially in the higher-prevalence states, with support from the Global Fund. Under the third National AIDS Control

Plan (NACP-III), 10-20 bedded NGO/FBO-run inpatient care facilities, called community care centers (CCCs) were established in

over 100 districts. Several functioned primarily as end-of-life care centers and were not linked to counseling and testing (CT) or

antiretroviral therapy (ART) services. After a recent review, 30% of centers were discontinued because of lack of quality in

provision of services and poor accessibility and linkages to CT and ART centers. The CCC concept has been redesigned to

provide more comprehensive services, including pre-ART outpatient care, management of opportunistic infections (OIs) including

TB, inpatient services, maintenance of stable ART patients, and psychosocial support and prevention for PLHA. NACO will open

250 centers over the next two years and this number may expand to 500 centers by 2012.

Developing systems to provide ART to a significant fraction of those who require it is daunting, given the continuing levels of

stigma against HIV in the medical community and the functional limits of India's public health manpower and infrastructure. Yet

significant strides have been made over the four-year history of the ART program: drug procurement systems have improved,

M&E indicators have been standardized, and operational and technical guidelines published. From 8 centers in 2004 the number

has increased to 174 centers in 2008 (the goal is to set up 250 by 2012). Similarly, the number of patients receiving ART has

increased from 24,400 in 2005 to 146,600 in 2008 (the goal is to treat 300,000 adult by 2012). NACO estimates that another

35,000 seek ART services from the private sector. The current cost for first-line ART is $155 per year per patient. Over 71% of

patients put on treatment are alive.

With plans to reach 300,000 by 2012, alternative strategies besides GOI-funded free ART must be developed and scaled up. In

India, the private sector accounts for 87% of the total health expenditure and hence plays a significant role in meeting the demand

for care and treatment services. Despite the size and complexity of the private sector, the services it offers and its general

structure are poorly understood. Public health experts are concerned by the potential for the unregulated private sector providing

ART in India, which could lead to increased drug resistance. Although NACO had initially restricted support for ART to the public

sector, it is now supporting 10 private sector ART programs under Global Fund Round 6.

While the number of ART patients has been constantly increasing over the years, 40% of HIV-positive CT patients still do not

reach the ART centers. The reasons are lack of demand generation efforts commensurate to expansion; poor accessibility due to

distance and inadequate referral systems. In order to reduce barriers and improve accessibility to ART services, NACO has rolled

out Link ART Centers at sub-district hospitals and plans to establish 250 centers by 2009. NACO has also initiated efforts to

improve access to care and treatment for MARPs such as accompanied referral to ART centers and monthly reporting of the

number of MARPs treated.

NACO has also stepped up national monitoring efforts in order to reduce the drop-out rates at ART centers. Of the registered

patients for ART, 83% are on treatment, 7.5% are lost to follow up, 6% have died and 3.5% are defaulters. Yet another concern is

adherence to treatment. In a qualitative study examining adherence in India, patients currently not taking ART identified the high

cost of travel to ART center including food, family commitments, and having more than one person in the household infected with

HIV as barriers. The Link ART Centers were established to reduce the barriers to treatment.

The extent of treatment failure/drug resistance is estimated at 2.8% per year but may be higher in the private sector. Currently,

viral load testing is not part of the ART monitoring system and is not widely available, limiting the ability to accurately identify

PLHAs failing first-line therapy. NACO understands this problem and will establish 10 centers throughout the country to address

drug resistance. NACO has started second-line ART in two sites and plans to expand to eight more sites.

Although the present emphasis on ART access and adherence is crucial, appropriate and timely prophylaxis of opportunistic

infections must also be a part of HIV clinical management. NACO is currently piloting cotrimoxazole prophylaxis in one state to

understand the implementation mechanism and based on the findings will scale up to the entire country.

Coordination and Other Donor Support: The Government of India (GOI) and several donors support the care and treatment

programs in India: the ART program is supported by the World Bank, Global Fund, and the World Health Organization; the Global

Fund (Round 6) supports the CCCs in several states and community-based care is supported by HIV/AIDS Alliance in two states.

USG programs coordinate with the government and donor supported HIV/AIDS care and support services, including private sector

services, to ensure each patient can access the services he/she needs and minimize duplication.

Current USG Activities: USG partners have played a key role in developing NACP-III's care and treatment strategy, including

chairing the Care and Treatment Technical Working Groups at national and state levels and helping NACO to develop overall

quality standards and clinical care guidelines. USG has developed various models of care in community, public and private

hospital settings. Great emphasis has been placed on supporting patients throughout their illness by linking clinical facilities with

community support. This concept has been incorporated into NACP-III.

In Tamil Nadu (TN), USG has pioneered care and treatment services in public and private health care institutions. At the

Government Hospital for Thoracic Medicine (GHTM) in TN, USG has established an ART outpatient center, state-of-the-art

laboratory, training center, computerized patient information system, counseling center for couples and families, staff trainings and

leadership development, and a hands-on fellowship in HIV/AIDS clinical medicine and leadership for 14 young physicians per

year. This effort has led to GHTM being labeled a Center of Excellence in HIV by NACO. The USG is also supporting IRT

Perundurai Hospital, a large tertiary health care institution, to expand care and treatment services through a network of 50

secondary-level private hospitals in a district.

NACO has nominated USG as the lead for public-private-sector partnership (PPP) programs in HIV/AIDS prevention, care and

treatment. In this role, USG has developed the draft national PPP policy and operational guidelines. The PPP policy will be

launched by the Prime Minister of India at the National AIDS Council meeting in late 2008. Following this meeting, USG will assist

NACO in scaling up PPP programs in the area of care and treatment.

A critical gap identified by NACO is a lack of demand for the care and treatment services provided by CCCs and ART centers.

Hence, NACO recommended that the Avert project in Maharashtra develop a demonstration program on community mobilization

to increase the uptake of services in six districts and assist the State AIDS Control Society (SACS) and the national program in

scaling-up lessons learned through this effort. USG will support six programs that use link workers to increase access to care and

treatment and provide home-based care and support. The link workers will develop systems to improve access to services by

establishing linkages between ICTCs and care and treatment centers. The link workers will also facilitate access to user friendly

services for MARPs.

In FY08, USG provided care and support for over 100,000 individuals at 211 service outlets at the tertiary, secondary, and

community levels. More than 16,500 PLHAs were reached in USG-funded home and community care projects. A key strength of

the USG program has been the active involvement of PLHAs in the program. In Maharashtra, the USG program has successfully

demonstrated expanded and improved access to care by supporting nine networks of positive people reaching to sub-district and

village level.

USG support has also focused on providing ART-related technical support to NACO as well as to the SACS in high-prevalence

states. USG is not purchasing ART drugs due to our limited budget. Key USG ART-related technical support activities include: 1)

Representation on the national ART Technical Working Group. 2) USG staff and technical support to SACS. 3) USG led the

development and implementation of a 4-day and 12-day national ART training curriculum.

FY09 Support:

1. Develop and scale up private (for-profit) models for HIV care services: USG's goal is to increase the level of engagement and

quality of HIV services among private sector physicians and hospitals.

a) USG, as the lead for the PPP program on HIV/AIDS, will guide the expansion of the national PPP activities in care and

treatment. USG will assist NACO in developing PPP plans and in the selection of an institution to manage the network of private

partners. USG will also assist in developing a PPP advocacy package, capacity building, and M&E of care and treatment PPP

programs.

b) At the state level, USG will strengthen the APAIDSCON consortium of 15 private medical colleges in Andhra Pradesh (AP) and

the collaboration with 19 private medical hospitals by the AIDS Prevention and Control (APAC) project in TN to expand access to

and strengthen the quality of private sector care and treatment services. Similarly, the model center of training for the private

sector at Perunderai Medical College in TN will be further strengthened. These will serve as models for scaling-up private sector

involvement.

2. Support and strengthen NACO-funded CCCs: Under NACP-III, these centers will be scaled up and will play a more significant

role in meeting the overall care and support needs of PLHAs. NACO has developed operational guidelines to ensure

comprehensiveness of CCC services, including standardization, staff training, and monitoring. In the six states where USG is

supporting Technical Support Units (TSUs), technical assistance (TA) will be provided to the SACS in identifying training

institutions, developing training curricula and supporting them to build the capacity of over 130 CCCs including monitoring the

quality of training programs.

3. Link PLHAs in the community to services: USG has historically supported strong community and home-based care programs.

Direct support for home and community care will be reduced in FY09 in response to the need under NACP-III for USG to build

sustainable institutional care capacities. Under NACP-III, NACO will focus on establishing link workers in high-prevalence

communities who will assist and empower PLHAs to seek care and treatment services. USG will play a key role in developing and

implementing this link worker scheme in priority districts. In Maharashtra, USG will support link worker programs in six districts

that will mobilize PLHAs to access care and treatment services through networking with the government Integrated Counseling

and Testing Centers (ITCTs), PLHA networks and prevention programs for MARPs. Based on lessons learned, USG will provide

TA at the state level in Maharashtra and Goa and at the District level in Mumbai to implement community mobilization programs to

increase the uptake of care and treatment services. Additionally, the Avert project will share best practices in community

mobilization with NACO and USG partners and provide technical support for implementation.

4. USG will play a critical role in improving access for MARPs to care and treatment services: USG will enhance the capacity of

NGOs in the focus states to establish effective referral linkages with ICTCs, care and support and ART services. TSUs in USG

focus states will assist the SACS in developing referral systems and monitoring the utilization of care and treatment services by

MARPs.

5. USG will continue to support GOI's ART program through TA, capacity building, and addressing selected critical issues in

service delivery. These include ensuring quality ART in the private sector and strengthening linkage of vulnerable populations to

ART services. USG will contribute to revisions/additions to the national ART curriculum as requested by NACO. USG will plan

training programs and workshops on ART operational and technical challenges, including second-line therapy policies and

guidelines. USG will help the GOI to develop an accreditation process for publicly-funded ART to improve quality and

standardization of services. The USG-developed fellowship in clinical medicine and leadership will expand to 18 fellows per year

and may be replicated in one other institution.

6. USG will address gender concerns in the delivery of care and treatment services: Women PLHA experience a high degree of

stigma and discrimination which may involve forced estrangement from their marital homes, physical and psychological abuse,

loss of property rights, and custody of their child. In order to address these concerns, USG will support innovative outreach and

community support strategies for women PLHA to offer them physical, psychological and economic protection and support.

Table 3.3.08:

Funding for Care: Adult Care and Support (HBHC): $550,966

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

Based on the latest (2006) HIV prevalence rate among adult population (0.38%) it is estimated that there

are 100,000 People Living with HIV/AIDS (PLHAs) in Tamil Nadu. Of this, 96% are adults (Males - 49,000

and Females 51,000) and 4% are children below 15 years. Due to the rapid scale-up of care, support and

treatment centers, the state now has 27 Adult Community Care Centres, 5 Pediatric Community Care

Centres, 27 ART centres and 7 PLHA drop-in-centres.

However there are still many challenges remain. Nearly 30% of the estimated PLHAs are yet to be

identified and even among those identified, only a small proportion are in regular contact with the care and

treatment centers. Other challenges include: a) continued stigma and discrimination of PLHAs in education,

workplace and health care settings; b) limited engagement of the private medical sector to provide care,

support and treatment services to PLHAs; c) discriminatory treatment practices by private health care

providers; d) quality of care provided at public and private health care centers, e) adherence to ART; f)

stock-out situations of OI drugs and supply chain management, and g) limited focus on positive prevention.

The APAC project currently supports 10 NGOs for implementing Home Based Care (HBC) Projects in

selected high-prevalence districts of Tamil Nadu. The project also supports the Institute of Road Transport

Perundurai Medical College Hospital for provision of secondary and tertiary care to PLHAs. Together these

projects have been able to reach out to 7,000 Adult PLHAs in the last two years.

All activities in COP 08 will be continued in COP 09. In addition, the following new activities are planned:

ACTIVITY 5: Expanding Access to Adult Care, Support and Treatment Services Beyond the District

Headquarters

Most of the care, support and treatment services are located at district headquarter hospitals. The Tamil

Nadu State AIDS Control Society (TNSACS) plans to expand these and to provide care, support and

treatment at the primary health center level located at the sub-block level catering to 30,000 people.

TNSACS has requested APAC to undertake a facility and need assessment of the primary health centres

and to develop a district plan for saturation of services. APAC will also be engaged in building the capacity

of the heath care providers in the primary health centers. APAC will monitor their progress and disseminate

this experience with other districts in the state and at the national level.

ACTIVITY 6: Model Project to Demonstrate Convergence of HIV/AIDS Activities at the District Level

In two high-prevalence districts of Tamil Nadu, APAC and TNSACS will jointly implement a model project to

demonstrate convergence of HIV/AIDS activities. Most HIV/AIDS activities (prevention and care) currently

implemented in the district operate on their own and there is limited coordination between these programs.

A team of expert consultants will be located in the pilot districts and will coordinate with the District AIDS

Prevention and Control Units (DAPCUs) and the different agencies implementing HIV/AIDS programs

(prevention, care) to: a) identify gaps and overlaps; b) establish optimal targets for each program area

(PMTCT, Adult care, Pediatric care, ART, TB-HIV co-infection management etc.); c) refine strategies and

specific roles and responsibilities for the different agencies for achieving the targets; and d) establish

mechanisms for coordination, stock-taking and grievance redressal. The team will also support DAPCUs in

mainstreaming activities within the district rural health mission programs, women child development

programs, etc. to leverage their infrastructure and increase their ownership of and engagement in HIV/AIDS

programs. Community mobilization and demand generation for different HIV/AIDS care and support

services will also be supported by APAC in these selected districts.

FY 2008 NARRATIVE

SUMMARY

Palliative care services for people living with HIV/AIDS (PLHA) are primarily provided through the public

health care system. Many private health care institutions do not treat PLHA due to inadequate knowledge,

stigma, and lack of infrastructure. In FY08, the AIDS Prevention and Control (APAC) project will support 18

home-based care projects in selected high-prevalence districts to provide palliative care services to 6000

PLHAs and their family members. The project will also support a network of 19 private health care

institutions in these high-prevalence districts to provide facility-based clinical care and psychosocial support

to PLHAs. The project will train private physicians on palliative care, link them up with NGOs and PLHA

networks and follow up these physicians periodically. As the Technical Support Unit, APAC will build the

capacity of the State AIDS Control Societies (SACS) in the states of Tamil Nadu and Kerala to increase

demand for palliative care services, implement national guidelines and deliver comprehensive palliative care

services to PLHAs.

BACKGROUND

For the past twelve years, with USG support, Voluntary Health Services (VHS) has been implementing the

APAC project in the southern state of Tamil Nadu. APAC, which initially focused on targeted interventions

for most-at-risk-populations (MARPs), has expanded its efforts over the last few years to support a more

comprehensive approach to HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in

controlling HIV (prevalence among antenatal women has dropped from 1.13% in 2001 to 0.5% in 2005) and

the APAC project has significantly contributed to this success. The National AIDS Control Organization

(NACO) has recognized the expertise and contributions of the APAC project and has requested APAC to

provide technical support to the State AIDS Control Societies (SACS) of Tamil Nadu, Puducherry and

Kerala by setting up a Technical Support Unit at Tamil Nadu and Kerala, consisting of a core team of

consultants/experts co-located with the SACS, with a mandate to assist the SACS in scaling-up programs,

improving efficiency and quality. APAC also serves as the vice-chair of the national Technical Working

Group on Targeted Interventions.

The recent findings of the third National Family Health Survey estimated there are 170,000 to 200,000

Activity Narrative: PLHAs in the states of Tamil Nadu and Kerala. Palliative care services supported by the SACS include

community care centers and PLHA drop-in-centers. Less than 40% of the estimated PLHAs are currently

registered with the SACS and receive palliative care services. Major gaps include the limited awareness of

the palliative care service providers, and the quality and comprehensiveness of the services.

Provision of palliative care services will be an ongoing activity funded by APAC. In FY06, APAC supported

five NGOs to deliver home-based care, providing 6,000 PLHAs with clinical care and psychosocial support.

Of the 6,000 PLHAs reached by the project, 10% were treated for TB and 10% are on ART. In FY06, the

project also supported a private medical college in a high-prevalence district, Perundurai, for diagnosis,

monitoring and institutional care of PLHA, resulting in 3,000 PLHAs getting clinical services.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Improving Access to Home and Community Care for PLHAs and their Family Members

APAC will support 18 NGOs to provide home and community care to people living with HIV in selected high-

prevalence districts of Tamil Nadu and Puducherry. The NGO staff (which includes outreach workers and

nurses) will sensitize community leaders, and coordinate with Government of India Link Workers and PLHA

networks to create demand for a continuum of care services in public and private health care settings. At

the community level, the NGO staff will be involved in strengthening HIV/AIDS awareness among

community leaders, advocacy with community leaders concerning stigma and discrimination affecting

PLHA, and mobilizing community support for PLHA and their family members. The NGO team will visit

PLHA homes at regular intervals to: a) counsel PLHA and family members on health monitoring and

periodic medical check-ups; b) identify opportunistic infections (OI) and assist with possible management at

home; c) train and follow-up PLHA and their family members on self-care, care-giving, positive living, and

treatment adherence for DOTS and ARV; d) refer for medical and non-medical needs to secondary and

tertiary level institutions; and e) provide end of life care. The home and community based care NGOs will

also network with other agencies involved in issues such as nutritional care and legal aid, to provide wrap-

around services. All these services will also be provided by the NGOs and PLHA networks at selected

project supported drop-in-centers. Though this initiative, 6000 PLHA will be able to get quality palliative

care services at different locations and 1200 PLHAs will be treated for TB infection through public and

private sector hospitals.

ACTIVITY 2: Increasing Access to Palliative Care for PLHAs through Facility-Based Private Sector Support

To increase access to care, and model the involvement of private physicians, APAC will train and support a

network of 100 private physicians in selected high-prevalence districts to provide medical care to PLHA.

The physicians will be trained in HIV/AIDS management including management of OI and counseling, and

linked to NGOs and other care continuum providers in the district. APAC will support the physicians by

providing basic infrastructure (for ensuring confidential counseling and treatment), and nominal

remuneration for maintenance of quality standards at their clinic and for reporting to APAC. The

experiences of these physicians will be shared with physicians' associations, SACS and other stakeholders

for learning and replication.

APAC will also support a network of 16 private hospitals for secondary care and three private hospitals for

tertiary care. In these hospitals, APAC will support a part-time counselor and train related health care

providers. The trained counselors will counsel antenatal women, TB patients attending the hospital and

PLHAs. Linkages will be established between these private hospitals, NGOs and other care continuum

service providers. In FY06, APAC's support to IRT Perundurai Medical College resulted in increased

coverage of PLHA. The approaches adopted by APAC include: a) supporting medical camps to promote

health care services including HIV/AIDS services; b) strong networking with private physicians, NGOs, and

PLHA networks to refer PLHA for treatment; c) training health care providers based on national guidelines

for quality of health care; d) supporting the cost of counselors for antenatal women, TB patients and PLHA;

e) strengthening management information systems; and f) subsidizing the cost of clinical diagnosis and

treatment for needy PLHAs. In FY08, using a similar approach, APAC will support two more private

hospitals for tertiary care services, but it will be on a smaller scale in terms of coverage of PLHA and range

of services. Through this initiative, over 5,000 PLHA will be provided with palliative care services and 1000

PLHAs will be treated for TB infection from the project supported private sector hospitals. About 9,500

registered TB patients will receive HIV counseling and testing under this initiative.

ACTIVITY 3: Building the Capacity of Private Sector Health Care Providers in Palliative Care

APAC will support one state-of-the-art training institute to build the capacity of private physicians on

HIV/AIDS palliative care, thereby expanding the pool of qualified and trained health care providers. An

estimated 300 physicians will be trained by the project, focusing on building the knowledge and skill of

health care providers. Due focus will be given to gender-based inequities and special needs for women on

palliative care. The trained doctors will be periodically monitored by APAC consultants and through a

system of self-assessment checklists/toolkits. The training of private health care providers complements the

SACS' initiative on providing quality clinical care for PLHA. Partnerships will be established with private

pharmaceuticals for the supply of basic medicines at subsidized rates. Similarly local philanthropists,

advocates and village volunteers will be coordinated to mobilize resources to support the nutritional,

livelihood and legal needs of PLHA.

ACTIVITY 4: Technical Support to SACS

APAC will provide technical support to SACS to strengthen their systems on palliative care as part of

APAC's role as the Technical Support Unit for the states of TN and Kerala. Technical assistance will include

training the SACS team on palliative care policies and guidelines, technical updates through national and

international consultants, exposure visits, monitoring of community care centers, and technical assistance to

training institutes (those involved in training NGOs) and public health care institutes (involved in training on

HIV/AIDS care and treatment).

New/Continuing Activity: Continuing Activity

Continuing Activity: 14157

Continued Associated Activity Information

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

System ID System ID

14157 6151.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $970,000

International Services

Development

10827 6151.07 U.S. Agency for Voluntary Health 5604 3949.07 $682,000

International Services

Development

6151 6151.06 U.S. Agency for Voluntary Health 3949 3949.06 $739,950

International Services

Development

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

* Increasing women's legal rights

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Malaria (PMI)

* Safe Motherhood

* TB

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $283,020

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): $188,058

CONTINUTING ACTIVITY - NEW NARRATIVE

SUMMARY

Since the role-out of NACP-III in 2006, the National AIDS Control Organization has taken serious efforts to

increase access to ARV services nationally, and in particular, in the six high-prevalence states. These

services are however limited to public health care settings and there are several areas which need

strengthening such as: quality assurance, follow-up, supply chain management and monitoring and

evaluation. The APAC project through the Technical Support Units will support the State AIDS Control

Societies (SACS) of Tamil Nadu and Kerala to increase demand for ARV services and address these

issues. The APAC project will also improve access to ARV services by focusing its efforts on the private

medical sector through its support to the network of private hospitals and physicians.

BACKGROUND

Tamil Nadu has an estimated 100,000-150,000 people infected by HIV/AIDS and of this nearly 25,000

individuals are currently on ART. The state has scaled-up access to ART and 29 of the 30 districts in Tamil

Nadu now have a government-run ART center. ART drug adherence in the state is above the national

standard, however, private sector involvement in ART services can be described as sparse at best. In COP

09 the APAC project plans to support the following activities:

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Provision of Comprehensive HIV/AIDS Treatment through Private Medical Institutions

APAC will support the Institute of Road Transport (IRT), Perundurai Medical College for comprehensive

clinical management of PLHA focusing on ARV therapy. This institute will be supported for HIV-related

disease and response monitoring (such as CD4 testing, liver function, and lipid profiles), counseling for ART

initiation and adherence. ARV drugs will be available at the hospital at subsidized rates and patients will be

required to pay for the drugs. For those unable to afford them, patients will be referred to the Government

of India's ART centers for drugs but monitoring of drug response, adherence, and follow up will be done by

the institute. An estimated 750 new PLHAs will be provided services through the hospital. The project will

build the capacity of the center through infrastructure strengthening, laboratory support, quality assurance,

systems strengthening and onsite supervision by consultants. The project will subsidize the cost of

diagnostics for a limited number of PLHAs who are unable to afford this service.

ACTIVITY 2: Capacity Building of Private Health Care Providers on ARV Services

The APAC project will support IRT Perundurai Medical College to train 120 physicians on ARV services.

Training will be based on nationally approved guidelines. These trainings will provide the physicians with

hands-on experience of HIV disease management and will be conducted at the IRT campus. The project

will coordinate with SACS to ensure services of the trained private physicians are utilized. The project will

also establish mechanisms for periodic follow-up and experience sharing among the trained physicians. The

project will place greater emphasis on the identification of HIV infected MARPs and, once identified, to link

them with public and private health care providers for HIV treatment.

ACTIVITY 3: Technical Assistance to SACS for Strengthening ARV Services

Technical support will be provided to SACS to strengthen and operationalize standard operating

procedures, increase demand for ARV services, improve supply chain management and strengthen

management information systems. The project will also support the SACS to develop prototype materials,

which aim to create demand for ARV services with an emphasis on drug adherence, nutrition and other

critical aspects of ARV services.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14163

Continued Associated Activity Information

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

System ID System ID

14163 6154.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $34,100

International Services

Development

10829 6154.07 U.S. Agency for Voluntary Health 5782 5782.07 $196,000

International Services

Development

6154 6154.06 U.S. Agency for Voluntary Health 3949 3949.06 $194,300

International Services

Development

Emphasis Areas

Health-related Wraparound Programs

* Safe Motherhood

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $96,602

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Care: Pediatric Care and Support (PDCS): $38,896

CONTINUNING ACTIVITY - NEW NARRATIVE

BACKGROUND

Voluntary Health Services (VHS) has been implementing the AIDS Prevention and Control (APAC) project

in the southern state of Tamil Nadu for 12 years. APAC initially targeted most-at-risk-populations (MARPs),

but has expanded efforts over the last few years to support a more comprehensive approach to HIV/AIDS

prevention, care and treatment. Tamilnadu has been successful in controlling HIV (prevalence among

antenatal women has dropped from 1.13% in 2001 to 0.38% in 2007) and APAC has significantly

contributed to this success. NACO has recognized the expertise and contributions of the APAC project and

has requested APAC to provide technical support to the SACS of Tamilnadu, Puducherry and Kerala by

setting up a Technical Support Unit (TSU) in each state, consisting of a core team of consultants/experts co

-located with the SACS, with a mandate to assist the SACS in scaling-up programs, improving efficiency

and quality. APAC also serves as the vice-chair for the Technical Working Group on targeted interventions

for the country.

Based on the existing HIV prevalence rate, it is estimated that there are 100,000 to 150,000 PLHAs in Tamil

Nadu. Of this 96% are adults (Males - 49,000 and Females 51,000) and 4% are children below 15 years.

In the last two years the state has significantly scaled-up the number of centers providing care, support and

treatment. There are now 27 Adult Community Care Centres, 5 Pediatric Community Care Centres, 27 ART

centres and 7 PLHA drop-in-centres. Despite the increase in the number of centers providing care, support

and treatment, many challenges continue in this area. Nearly 30% of the estimated PLHAs are yet to be

identified as of Sept 2007 and even amongst them a very small proportion are in regular contact with the

agencies involved in provision of care, support and treatment. Other major challenges include: stigma and

discrimination; limited engagement of the Private Medical Sector, discriminatory treatment practices by

private health care providers; quality of care; adherence; supply chain management; and a limited focus on

positive prevention.

In the last few years considerable work has been done with regard to pediatric care. Of the estimated 6,000

infected children, nearly 5,000 children have been identified by Clinton Foundation through a special drive

for Pediatric ARV. In addition, in all pediatric wards at the district headquarters hospital, the Clinton

Foundation has placed two outreach workers for identifying children with symptoms of HIV and for referral

to CT and care continuum services. 750 children have benefited through this initiative to date. The UK-

based Children Investment Fund Foundation has supported child counselors in three ART centres and also

supplies micro and macro nutrients to infected children.

The gaps identified in the current programs include: lack of demand generation activities, limited follow-up

of children born to HIV positive mothers, and lack of monitoring. Some of the main problems are

transportation costs, Pediatricians lack skills in proper treatment and psycho-social support of children with

HIV, Counselors are not trained in Pediatric counseling, and there is a lack of community-based models on

Care and support for children. In schools there is still stigma. Nutrition and psychosocial needs must be

addressed. Outreach plans need to be further strengthened to ensure continuous adherence of ART.

There is a need for developing a systematic training plan for care givers.

The APAC project currently supports ten NGOs for implementing Home Based Care (HBC) Projects in

selected districts of Tamilnadu. The project also supports the Indian Road Transport Perundurai Medical

College Hospital for provision of secondary and tertiary care to PLHAs. Together these projects have been

able to reach out to 7,000 PLHAs in the last two years. (88% being adults and 12% children below 15)

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Improve Access to Home and Community Care for Children with HIV

The APAC project will support prevention to care continuum in selected high prevalence districts. In these

districts the project will support NGOs for provision of home-based care and support services to PLHAs.

The project will train the NGO staff on the issues of pediatric care and support and take a proactive role to

identify children infected with HIV/AIDS care and support services. Individual pediatric records will also be

maintained to ensure the provision of quality services and regular follow-up.

ACTIVITY 2: Increasing Access to Palliative Care for HIV-Infected Children Through Facility-Based Private

Sector Support

In selected high-prevalence districts, the APAC project plans to support a network of 19 private hospitals

and 50 physicians to provide care, support and treatment services. This would increase the access to

quality care and support services. The private hospitals and physicians will be trained specifically on

pediatric counseling and provision of care and support. The hospitals and physicians will also be linked with

other non-health service providers to cater to the needs of pediatric PLHAs.

ACTIVITY 3: Technical Support through SACS

The Technical Support Units in Tamil Nadu and Kerala will update the SACS team on the issues and

success stories in provision of care and support services to PLHAs. They will also work with SACS to

develop appropriate strategies to address the issues.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

Human Capacity Development

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 Care: TB/HIV (HVTB): $171,908

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The TB/HIV activities undertaken by APAC in FY08 will continue, as mentioned in the FY08 Palliative Care

narrative (below). In addition to these activities, APAC will support the following two new activities in FY09.

ACTIVITY 5: Capacity Building of Lab Technicians at TB Centers

Training will be provided to Counseling and Testing staff and TB clinic lab technicians on HIV/TB

coordination through a nodal agency. Onsite mentorship will be provided on a regular basis to all TB clinics,

thereby strengthening the coordination between HIV/AIDS and TB programs. It is expected that 1,000 lab

technicians will be reached through this initiative.

ACTIVITY 6: Capacity Building of Nurses to Deliver Quality Care on TB

40 nurses from APAC NGOs will be trained in a) identifying TB cases and assist with possible management;

b) networking with DOTS center/provider c) adherence to Anti Tuberculosis Treatment.

FY08 NARRATIVE

SUMMARY

Palliative care services for people living with HIV/AIDS (PLHA) are primarily provided through the public

health care system. Many private health care institutions do not treat PLHA due to inadequate knowledge,

stigma, and lack of infrastructure. In FY08, the AIDS Prevention and Control (APAC) project will support 18

home-based care projects in selected high-prevalence districts to provide palliative care services to 6000

PLHAs and their family members. The project will also support a network of 19 private health care

institutions in these high-prevalence districts to provide facility-based clinical care and psychosocial support

to PLHAs. The project will train private physicians on palliative care, link them up with NGOs and PLHA

networks and follow up these physicians periodically. As the Technical Support Unit, APAC will build the

capacity of the State AIDS Control Societies (SACS) in the states of Tamil Nadu and Kerala to increase

demand for palliative care services, implement national guidelines and deliver comprehensive palliative care

services to PLHAs.

BACKGROUND

For the past twelve years, with USG support, Voluntary Health Services (VHS) has been implementing the

APAC project in the southern state of Tamil Nadu. APAC, which initially focused on targeted interventions

for most-at-risk-populations (MARPs), has expanded its efforts over the last few years to support a more

comprehensive approach to HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in

controlling HIV (prevalence among antenatal women has dropped from 1.13% in 2001 to 0.5% in 2005) and

the APAC project has significantly contributed to this success. The National AIDS Control Organization

(NACO) has recognized the expertise and contributions of the APAC project and has requested APAC to

provide technical support to the State AIDS Control Societies (SACS) of Tamil Nadu, Puducherry and

Kerala by setting up a Technical Support Unit at Tamil Nadu and Kerala, consisting of a core team of

consultants/experts co-located with the SACS, with a mandate to assist the SACS in scaling-up programs,

improving efficiency and quality. APAC also serves as the vice-chair of the national Technical Working

Group on Targeted Interventions.

The recent findings of the third National Family Health Survey estimated there are 170,000 to 200,000

PLHAs in the states of Tamil Nadu and Kerala. Palliative care services supported by the SACS include

community care centers and PLHA drop-in-centers. Less than 40% of the estimated PLHAs are currently

registered with the SACS and receive palliative care services. Major gaps include the limited awareness of

the palliative care service providers, and the quality and comprehensiveness of the services.

Provision of palliative care services will be an ongoing activity funded by APAC. In FY06, APAC supported

five NGOs to deliver home-based care, providing 6,000 PLHAs with clinical care and psychosocial support.

Of the 6,000 PLHAs reached by the project, 10% were treated for TB and 10% are on ART. In FY06, the

project also supported a private medical college in a high-prevalence district, Perundurai, for diagnosis,

monitoring and institutional care of PLHA, resulting in 3,000 PLHAs getting clinical services.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Improving Access to Home and Community Care for PLHAs and their Family Members

APAC will support 18 NGOs to provide home and community care to people living with HIV in selected high-

prevalence districts of Tamil Nadu and Puducherry. The NGO staff (which includes outreach workers and

nurses) will sensitize community leaders, and coordinate with Government of India Link Workers and PLHA

networks to create demand for a continuum of care services in public and private health care settings. At

the community level, the NGO staff will be involved in strengthening HIV/AIDS awareness among

community leaders, advocacy with community leaders concerning stigma and discrimination affecting

PLHA, and mobilizing community support for PLHA and their family members. The NGO team will visit

PLHA homes at regular intervals to: a) counsel PLHA and family members on health monitoring and

periodic medical check-ups; b) identify opportunistic infections (OI) and assist with possible management at

home; c) train and follow-up PLHA and their family members on self-care, care-giving, positive living, and

treatment adherence for DOTS and ARV; d) refer for medical and non-medical needs to secondary and

tertiary level institutions; and e) provide end of life care. The home and community based care NGOs will

also network with other agencies involved in issues such as nutritional care and legal aid, to provide wrap-

around services. All these services will also be provided by the NGOs and PLHA networks at selected

project supported drop-in-centers. Though this initiative, 6000 PLHA will be able to get quality palliative

care services at different locations and 1200 PLHAs will be treated for TB infection through public and

private sector hospitals.

ACTIVITY 2: Increasing Access to Palliative Care for PLHAs through Facility-Based Private Sector Support

To increase access to care, and model the involvement of private physicians, APAC will train and support a

network of 100 private physicians in selected high-prevalence districts to provide medical care to PLHA.

Activity Narrative: The physicians will be trained in HIV/AIDS management including management of OI and counseling, and

linked to NGOs and other care continuum providers in the district. APAC will support the physicians by

providing basic infrastructure (for ensuring confidential counseling and treatment), and nominal

remuneration for maintenance of quality standards at their clinic and for reporting to APAC. The

experiences of these physicians will be shared with physicians' associations, SACS and other stakeholders

for learning and replication.

APAC will also support a network of 16 private hospitals for secondary care and three private hospitals for

tertiary care. In these hospitals, APAC will support a part-time counselor and train related health care

providers. The trained counselors will counsel antenatal women, TB patients attending the hospital and

PLHAs. Linkages will be established between these private hospitals, NGOs and other care continuum

service providers. In FY06, APAC's support to IRT Perundurai Medical College resulted in increased

coverage of PLHA. The approaches adopted by APAC include: a) supporting medical camps to promote

health care services including HIV/AIDS services; b) strong networking with private physicians, NGOs, and

PLHA networks to refer PLHA for treatment; c) training health care providers based on national guidelines

for quality of health care; d) supporting the cost of counselors for antenatal women, TB patients and PLHA;

e) strengthening management information systems; and f) subsidizing the cost of clinical diagnosis and

treatment for needy PLHAs. In FY08, using a similar approach, APAC will support two more private

hospitals for tertiary care services, but it will be on a smaller scale in terms of coverage of PLHA and range

of services. Through this initiative, over 5,000 PLHA will be provided with palliative care services and 1000

PLHAs will be treated for TB infection from the project supported private sector hospitals. About 9,500

registered TB patients will receive HIV counseling and testing under this initiative.

ACTIVITY 3: Building the Capacity of Private Sector Health Care Providers in Palliative Care

APAC will support one state-of-the-art training institute to build the capacity of private physicians on

HIV/AIDS palliative care, thereby expanding the pool of qualified and trained health care providers. An

estimated 300 physicians will be trained by the project, focusing on building the knowledge and skill of

health care providers. Due focus will be given to gender-based inequities and special needs for women on

palliative care. The trained doctors will be periodically monitored by APAC consultants and through a

system of self-assessment checklists/toolkits. The training of private health care providers complements the

SACS' initiative on providing quality clinical care for PLHA. Partnerships will be established with private

pharmaceuticals for the supply of basic medicines at subsidized rates. Similarly local philanthropists,

advocates and village volunteers will be coordinated to mobilize resources to support the nutritional,

livelihood and legal needs of PLHA.

ACTIVITY 4: Technical Support to SACS

APAC will provide technical support to SACS to strengthen their systems on palliative care as part of

APAC's role as the Technical Support Unit for the states of TN and Kerala. Technical assistance will include

training the SACS team on palliative care policies and guidelines, technical updates through national and

international consultants, exposure visits, monitoring of community care centers, and technical assistance to

training institutes (those involved in training NGOs) and public health care institutes (involved in training on

HIV/AIDS care and treatment).

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Health-related Wraparound Programs

* TB

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.12:

Funding for Care: Orphans and Vulnerable Children (HKID): $168,960

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

SUMMARY

APAC has been supporting Orphan and Vulnerable Children (OVC) initiatives over the last three years, with

more than 800 OVCs reached through the project-supported home and facility based programs. The

response from the state government to OVC programs is encouraging: pediatric ART has been made

available in all government medical hospitals. The State has also planned to form a separate HIV/AIDS

OVC Trust to meet the health and socio-economic needs of OVCs. The concept of the OVC Trust was

initiated by APAC and has been taken over by the State, thereby ensuring sustainability and greater

ownership. There are still many challenges, however. Data on the number of HIV-infected and affected

children are not available to plan comprehensive programs. Issues pertaining to stigma and discrimination

in schools and access to quality education and job-oriented training are yet to be addressed more

effectively.

ACTIVITIES AND EXPECTED RESULTS

All activities in COP 08 except for Activity 3 will be continued in COP 09. APAC will not undertake Activity 3

(Developing a Community Based Model Project for OVC) because the state plans to roll-out the Trust for

Children Affected by AIDS (TFCAA). APAC will, however, support the Trust in the following new activity:

ACTIVITY 5: Support to the Trust for Children Affected by AIDS (TFCAA)

The Tamil Nadu State AIDS Control Society (TNSACS) has initiated an OVC Trust with a vision to support

all infected and affected children in the state by addressing their basic needs. The Trust will be chaired by

the project director of TNSACS and will include both government officials and major funding partners as

advisory members. The state government will support the Trust with Rs Five crores ($1.25 million) to

address the basic needs of OVCs in areas such as education, clinical care, nutrition and economic

strengthening of families. The Trust will also seek support and involvement from the private sector. APAC

will support TNSACS in developing relevant strategy and operational guidelines for effective roll-out of the

trust activities. APAC will also assist in: estimating the OVC population in the state; conducting a needs

assessment; mobilizing private sector resources for the Trust; monitoring the implementation of the OVC

Trust activities; and in the documentation and dissemination of lessons learnt and best practices to policy

makers and implementers at state and national level. The Trust will reach 5,000 children within the first two

years of the project.

The Trust also seeks to give equal attention to girl children by motivating their parents/ guardians to send

their girl children to school by providing school fees and other educational materials to help girls complete at

least secondary level of education. The support from the government will ensure that the Trust will function

beyond the life of the project period of SACS or any funding agency and thereby ensuring continuous and

uninterrupted support to needy children.

FY 2008 NARRATIVE

SUMMARY

In the second phase of the National AIDS plan, there was minimal emphasis on the issue of OVCs. During

the same period, the USG took the lead in developing models of OVC programming. In the current, third

phase of the National AIDS Control Program (NACP-3), there is now an emphasis on supporting activities

on orphans and vulnerable children (OVC) who are infected or affected by HIV/AIDS. Much of the guidance

in this new area for national policy has been provided by USG. In FY08, the AIDS Prevention and Control

(APAC) project will provide comprehensive home-based OVC services to over 1000 children. It will support

two demonstration projects on OVC, one being a faith-based initiative and the other led by the NGO

community. The project will also provide technical assistance to build the capacity of State AIDS Control

Societies (SACS) to promote OVC programs in the state.

BACKGROUND

For the past twelve years, with USG support, Voluntary Health Services (VHS) has been implementing the

APAC project in the southern state of Tamil Nadu. APAC, which initially focused on targeted interventions

for most-at-risk-populations (MARPs), has expanded its efforts over the last few years to support a more

comprehensive approach to HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in

controlling HIV (prevalence among antenatal women has dropped from 1.13% in 2001 to 0.5% in 2005) and

the APAC project has significantly contributed to this success. The National AIDS Control Organization

(NACO) has recognized the expertise and contributions of the APAC project and has requested APAC to

provide technical support to the State AIDS Control Societies (SACS) of Tamil Nadu, Puducherry and

Kerala by setting up a Technical Support Unit at Tamil Nadu and Kerala, consisting of a core team of

consultants/experts co-located with the SACS, with a mandate to assist the SACS in scaling-up programs,

and improving efficiency and quality. APAC also serves as the vice-chair of the national Technical Working

Group on Targeted Interventions.

In general, little importance was given to the issue of OVC in the second phase of the National AIDS Plan.

Consequently, except for support from USG and a handful of other agencies, there were minimal activities

addressing OVC, both nationally and in Tamil Nadu. It is recognized that limited information is available on

OVC, however, broad estimates suggest there are 3500 HIV- infected children in Tamil Nadu. In FY06,

APAC supported six NGOs to provide primary and secondary services to OVCs, reaching 400 HIV infected

and 2000 affected children with OVC services. Of the total of 2000 infected and affected children, 1000

children were provided support for education, 10 for shelter and 100 for other support services.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Provision of OVC Services through Home Based Care Projects

The project will continue to provide comprehensive OVC services to over 1000 children, in their homes,

Activity Narrative: through existing and proposed home-based care projects providing palliative care services. USG funds are

used to provide medical/clinical care to the children who are also regularly monitored in all six of the core

PEPFAR OVC areas. Other needs of the children such as education, nutrition, and child protection are

fulfilled by leveraging resources through linkages or local fund generation. This home-based care OVC

project utilizes the medical care team of the palliative care intervention to provide clinical services to the

children, thus saving resources and promoting synergy for the program.

ACTIVITY 2: Develop a NGO-Managed Model OVC Project

APAC will support one sub-partner with long experience of working with OVC to become a model project on

OVC. This program will reach 500 HIV/AIDS infected and affected children. The activities will include life

skills education training for children, provision of medical, nutritional and educational aid, linkages with CT

services, and strengthened referral linkages with government, corporates and other stake holders to

leverage resources. The project will become a learning site and a training center to build the capacity of the

State and will provide support to the APAC project in its role as the manager of the State's Technical

Support Unit.

ACTIVITY 3: Developing a Community Based Model Project for OVC

The APAC project will support one Faith-Based Organization (FBO) as a model community based project to

provide care for OVC. In this project, faith leaders will take the lead in planning and providing support for the

OVC program. The faith leaders will assist in undertaking stigma reduction activities, and will facilitate

support for wrap-around activities such as nutrition support, provide admissions for OVCs to schools

managed by the FBOs, and promote adoption and foster care. The OVC programs will primarily focus on

health, education and nutrition, and will reach 200 OVC. The APAC project will provide assistance to the

FBO for system strengthening, quality of programming including counseling for children, and monitoring and

evaluation.

ACTIVITY 4: Technical Support to SACS

SACS has limited experience in supporting OVC projects and needs a considerable amount of capacity

building. Since there is an increased emphasis on this activity in the national plan, APAC, as part of its role

as manager of the State Technical Support Unit, will build the capacity of SACS staff and their NGO

partners on the national OVC policy, guidelines and OVC programming and expose them to some of the

important OVC projects in the state and country.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14158

Continued Associated Activity Information

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

System ID System ID

14158 6155.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $297,000

International Services

Development

10830 6155.07 U.S. Agency for Voluntary Health 5604 3949.07 $146,000

International Services

Development

6155 6155.06 U.S. Agency for Voluntary Health 3949 3949.06 $233,390

International Services

Development

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Health-related Wraparound Programs

* Child Survival Activities

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

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

Total Planned Funding for Program Budget Code: $1,655,939

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Overview: Though HIV counseling and testing (CT) services are available throughout the country, only 25-30% of those who are

HIV positive are aware of their status (National AIDS Control Organization [NACO] report, 2008). The continued low uptake of HIV

counseling and testing has limited the scale-up of HIV care and treatment for the estimated 2.47 million infected persons.

Increasing the number of people, especially most-at-risk populations (MARPs), who know their HIV status is key to expanding

access to HIV prevention, care and treatment. According to the National Behavioral Surveillance Survey study (2006), only 14.4 %

of sex workers have been tested for HIV. Similarly, only 17.9% of the clients of the brothel-based and 12.7 % of non-brothel based

sex workers have been tested.

Uptake of client-initiated HIV CT has been limited by low coverage of services, fear of stigma and discrimination, and the

perception by many people, including those in high prevalence areas, that they are not at risk. Other challenges to expanding CT

services are the highly variable patient load, lack of referral services and inadequate systems to monitor counseling quality. NACO

is starting to address these issues. Rapid test kits have been supplied to CT centers to facilitate same-day results. A national HIV

testing quality assurance system is in place. NACO has developed a trainer's manual and guidelines for CT in collaboration with

WHO and USG.

Under the National AIDS Control Program phase three (NACP-3), existing CT services and PMTCT centers are being remodeled

to serve as a hub that integrates all HIV-related services, called Integrated Counseling and Testing Centers (ICTCs). ICTCs are

envisaged to be the key entry point for both men and women for a range of HIV/AIDS services. NACO has rapidly scaled up ICTC

services across the country. Currently, there are 4,567 ICTCs and the number of people tested has taken a quantum leap from

4.3 million in 2006 to 7.6 million in 2007 (surpassing the national target of 7 million). As part of the integration plan with the

National Rural Health Mission (NRHM), CT services are now being expanded to over 2000 24-hour Primary Health Centers

(PHCs), the lowest unit of care in the Indian administrative system. In collaboration with NRHM, a nurse and laboratory technician

are being trained in these PHCs to reach the rural underserved high-risk populations. NACO is also promoting public-private-

partnerships (PPP) to expand the reach of CT services. Over 100 PPPs have been established in private/non-profit hospitals (to

be expanded to over 860 in FY08).

Pediatric CT has not received attention nationally despite the need to diagnose early and provide care and treatment to children.

Similarly, there has been limited attention to family-centered and couple-centred CT. USG supports a family and couple-centred

approach at the General Hospital for Thoracic Medicine in Tamil Nadu and the Government Chest Hospital in Andhra Pradesh but

this approach needs to be expanded.

NACO is investing intense resources in strengthening the capacity of SACS to improve the quality of CT programs. NACO has

identified 40 centers of excellence to deliver quality training. In 2008, over 4290 counselors were trained with a 12-day induction

training module. Similarly, 3282 out of 4462 laboratory technicians have taken a five-day induction training in NACO-identified

State reference laboratories. The quality of the testing program is improving, as shown by a continuing decline in the drop-out rate

between pre-test, test and post test counseling.

To ensure quality of HIV testing an External Quality Assessment Scheme (EQAS) is implemented in most states in which all

ICTCs participate. A quality assessment of the national reference laboratories was carried out in July 2008 by USG: findings from

this study will guide NACO in further strengthening the quality of HIV testing.

A major concern identified by NACO is that high-risk populations are not accessing public-sector CT services. One possible

reason for the low utilization of CT services is assumed to be the discriminatory attitude of health workers towards FSW and

MSM. NACO is developing systems for referral linkages between NGOs implementing prevention programs and the ICTCs to

increase coverage of CT services for MARPs. ICTCs conduct a sensitization program every year for their staff on issues such as

stigma and discrimination against MARPs and people living with HIV/AIDS (PLHA). From January to March 2008, over 14,000

male referrals to CT centers from MARP prevention programs were tested throughout the country and the positivity rate was

14.3%. This high reported rate underscores the importance of scaling up CT services among MARPs and establishing linkages for

care and treatment to those tested positive.

In most settings, instituting routine provider-initiated counseling and testing (PICT) can prevent missed opportunities to diagnose

and counsel individuals attending health facilities and facilitate access to HIV-related services. In a concentrated epidemic such as

India's, a high priority is provider-initiated CT in STI clinics, health clinics for high-risk populations, TB clinics and ANC centers. In

line with WHO guidance, NACO has introduced PICT in TB, STI and ANC clinics in over 200 high prevalence districts. WHO and

UNAIDS have issued new guidance on PICT in health facilities as a means to significantly increase access to prevention, care

and treatment services. In India, however, a high level of routine HIV testing is also requested by private practitioners and

hospitals with referrals to laboratories where quality assurance is non-existent. This is a cause of concern, and NACO is planning

to establish regulatory measures to control non-priority testing.

According to available reports, 40% of those tested positive at the ICTC centers do not reach ART centers. NACO is addressing

this issue by strengthening the linkages between ICTCs and ART centers through establishment of a patient feedback system.

Coordination and Other Donor Support: The entire funding for CT programs in India comes from the Global Fund (Rounds 2, 3,

and 6). USG supports a national program officer on CT who assists the national program in curriculum development and

organizing trainings for ICTC counselors. Additionally, the technical support units in the USG priority states support the SACS in

conducting ICTC team training programs.

Current USG Support: USG is playing an important role in creating and expanding a variety of CT approaches tailored to different

populations. The USG provides direct support to 263 facilities delivering CT services in Tamil Nadu (TN), Maharashtra, Karnataka

and Andhra Pradesh (AP). This includes private sector services, services for MARPs and placement of nurses trained in HIV CT

in community-based primary health care centers (PHC).

The USG-supported APAC project, in collaboration with the Tamil Nadu State AIDS Control Society (TNSACS), is increasing

access to user-friendly CT services for MARPs. As part of this effort, the counselor and the lab technician from the government

ICTC visit the APAC intervention site once a week to provide CT services to MARPs. Mobile CT, first used to reach rural villages

in TN, has been adapted and scaled up by TNSACS and currently there are 20 mobile CT teams covering all 22 high prevalence

districts. Based on the successful experience of TN, mobile CT is now being adapted nationally to expand CT services to high-risk

rural populations. At the Government Hospital for Thoracic Medicine (GHTM) in TN and the Chest Hospital in Hyderabad in AP,

USG supports the Indian Network of Positive People to manage Family Counseling Centers at GHTM. This model contributed to

national recognition of the importance of post-test and follow-up counseling in positive prevention for PLHAs. PLHA involvement

has now been scaled up in the ART centers supported by the Global Fund in high prevalence states.

Other models work with the private sector, which overall has not been involved in the provision of CT services. USG has

partnered with 19 private medical hospitals in TN and 15 private medical colleges in AP to expand access to and strengthen the

quality of private sector CT services. The USG-supported Christian Health Association of India (CHAI) program has successfully

demonstrated the expansion of CT services through partnership with the PHC program in the high prevalence districts of AP. The

program strategy included placement of a nurse (initially funded by CHAI) and capacity building of the PHC team in providing user

friendly CT services to high-risk individuals. Ongoing supervision by CHAI is an important component of the model. NACO has

adopted this model in scaling-up CT services through integration with the NRHM program in the 24-hour PHCs.

A critical gap is low demand for services at the 4,567 ICTCs resulting in low service uptake. Hence, NACO recommended that the

Avert project in Maharashtra State develop a demonstration program on community mobilization to increase the uptake of ICTC

services in six districts and assist the state and national programs in scaling-up lessons learned through this effort. In FY08, USG

will support six programs that will utilize link workers to increase access to CT services. The link workers will work with community

-based structures such as Self Help Groups (SHGs), youth clubs and community leaders to mobilize high-risk individuals in

villages to test; motivate partners of PLHA, including positive pregnant women, to test; and facilitate access to user-friendly

services for MARPs.

USG FY09 Support: USG will provide technical support to SACS in USG-supported focus states in establishing systems to

achieve significant coverage of CT services down to the sub-district level. This will support NACO's plans to expand CT reach

through approaches that include: scaling up PICT services, reaching the high-risk rural population, strengthening linkages with

the TB program and prevention programs; and expanding CT services through PPPs. NACO also aims to ensure the quality of

HIV testing, including availability of quality test kits, and support demand generation for CT services.

1. USG will provide technical assistance (TA) to NACO and SACS to standardize the quality and consistency of counseling

services, develop and/or adapt technical standard operating procedures and a quality assurance/quality improvement framework,

and train CT staff.

(a) USG will provide TA to NACO to strengthen the national counseling curricula, including training in post-test counseling,

confidentiality, and family counseling.

(b) In Tamil Nadu (TN), USG is demonstrating a quality improvement model of the government ICTC program through onsite

capacity building and supportive supervision. NACO plans to learn from this model and scale it up nationally to improve the quality

and uptake of ICTC services. In Maharashtra, the USG-supported Technical Support Unit (TSU) will provide TA to the SACS in

planning and conducting training for 600 ICTC staff. In AP, based on the lessons learned from the primary health care CT

program, USG will assist the national program in scaling-up CT services through the 24 hour PHCs and integrating with the

NRHM including developing operational guidelines for implementation. In Karnataka, USG will establish six model CT centers

which will serve as learning sites for the 565 ICTCs supported by SACS.

(c) USG will provide TA to SACS in its focus states to develop plans for different approaches to increase coverage and quality of

CT services. This will include hiring experts to help SACS design PICT models; strengthening supply chain logistics; enhancing

systems to ensure quality counseling; and developing model CT centers as learning sites for the SACS. To increase uptake of CT

services by MARPS, in TN, TNSACS will conduct weekly clinics for MARPS for 30 USG-supported prevention programs. In

Maharashtra, the TSU will assist the SACS to develop referral linkages for MARPS with NGOs implementing prevention programs

to increase CT uptake.

2. USG will continue to develop and promote the expansion of private-sector models for quality CT. In the six states where USG

is supporting the TSU, TA will be provided to the SACS in expanding the PPP program to scale-up CT services. The TSUs will

support planning, selection of preferred private providers, capacity building and monitoring the quality of services. USG will also

strengthen the collaboration with 19 private medical hospitals in TN and 15 private medical colleges in AP to expand access to

and strengthen the quality of private sector CT services.

3. USG will expand community mobilization and targeted demand generation for CT services in the focus states and nationally. In

FY09, the Avert will provide TA to the SACS in Maharashtra and Goa to implement community mobilization programs to increase

CT uptake and will share best practices with NACO and USG partners.

4. USG will provide technical support to SACS on positive prevention and follow-up counseling: In FY09 USG will provide TA to

the SACS in the focus states in training counselors of ICTCs and ART centers on positive prevention strategies. The TN SACS

plans to train over 780 counselors across the state on use of the Prevention with Positives Follow up Counseling Tool Kit

(prepared by a USG partner). The toolkit has a standardized curriculum that covers advanced issues of living with HIV/AIDS,

including stigma and discrimination, disclosure, mental health safer sex, care and prevention. A complementary training is also

planned for health care providers.

5. USG will address gender concerns in CT: USG partners will develop and implement community outreach strategies to address

stigma and discrimination against women who test positive. This includes working with positive networks and SHGs to tackle

problems faced by positive women such as forced estrangement from their marital homes, physical and psychological abuse, loss

of property rights and custody of their child.

Table 3.3.14:

Funding for Testing: HIV Testing and Counseling (HVCT): $110,044

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

SUMMARY

National estimates indicate that less than 10% of people living with HIV know their status. Even among

MARPs the percentage reported having been counseled and tested is low. Only 38% of female sex

workers reported of ever having had an HIV test. Among MSMs, the proportion reporting of ever having

had an HIV test ranges from three to 69 percent among the different states.

Tamil Nadu has a good infrastructure for Counseling and Testing services. The State has 780 Integrated

and Counseling and Testing Centres (ICTC) (with the majority located in government hospitals), and more

than 2 million individuals are being tested annually. These include antenatal women and their spouse, TB

patients and STI patients.

In COP 09, only activities 3 & 5 in COP 08 will be continued.

ACTIVITY 1: Improving Access to CT Services for Most-at-Risk and Bridge Populations

This activity will not continued as NACO has suggested the project to utilize the government counseling and

testing centres. The project and the Tamil Nadu State AIDS Control Society have already worked out a

plan by which a team of ICTC staff (one counselor and lab technician) will visit the project supported MARP

intervention sites on a weekly basis (on a fixed day) for provision of CT services. This ensures sustainability

and greater utilization of the Govt. ICTCs. The experiences will be documented and shared with NACO and

other State AIDS Control Societies.

ACTIVITY 2: Improving Access to CT in Rural Areas in Selected High-Prevalence Districts

This activity is being dropped since TNSACS has adopted the concept of mobile CT services from APAC,

and plans to scale it for the entire state. APAC will provide technical assistance to TNSACS for effective roll

-out of the mobile CT services.

ACTIVITY 3: Capacity Building of Counselors and Lab Technicians

Will continue as in COP 08.

ACTIVITY 4: Facility Assessment of Public and Private Sector CT Centers

This activity will not be undertaken as this is not a recurring activity and is planned only twice in the next five

years.

The following change is planned for activity 5:

ACTIVITY 5: Technical Assistance to the State AIDS Control Societies

This activity will now have an expanded role. Based on a request from the Tamil Nadu State AIDS Control

Society (TNSACS) the project will support a consortium of agencies to provide technical assistance and

improve the quality of CT services in the state. These agencies will: a) provide onsite support to the

government ICTCs for quality assurance and adherence to national protocols; b) establish systems within

TNSACS for collation, analysis and timely feedback of monthly reports from ICTCs; c) strengthen cross

referral linkages between ICTCs and prevention, care, support and treatment partners in public and private

care settings; d) assess and grade ICTC; and e) document and disseminate best practices among ICTCs at

the state and national level.

FY 2008 NARRATIVE

SUMMARY

National estimates indicate that less than 10% of people living with HIV know their status. Most-at-risk-

populations (MARPs) and bridge populations do not access public sector counseling and testing centers

due to inconvenient timing, distance and lack of privacy. The AIDS Prevention and Control (APAC) project

will support activities to increase access to counseling and testing services for MARPs, bridge and other

selected sub-populations at risk through a network of NGO-based and private-hospital-based counseling

and testing (CT) centers. The project will increase access to CT services in rural areas of high-prevalence

districts through innovative approaches such as mobile CT. The project will encourage CT services in the

private sector and build the capacity of counselors and lab technicians to provide quality CT services in

accordance with the national guidelines. As the Technical Support Unit for the states of Tamil Nadu and

Kerala, APAC will also support an assessment of public sector CT centers to improve quality and client

friendly services, explore accreditation of private CT centers and strengthen systems for CT.

BACKGROUND

For the past twelve years, with USG support, Voluntary Health Services (VHS) has been implementing the

APAC project in the southern state of Tamil Nadu. APAC, which initially focused on targeted interventions

for MARPs, has expanded its efforts over the last few years to support a more comprehensive approach to

HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in controlling HIV prevalence

(prevalence among antenatal women has dropped from 1.13% in 2001 to 0.5% in 2005) and the APAC

project has significantly contributed to this success. The National AIDS Control Organization (NACO) has

recognized the expertise and contributions of the APAC project and has requested APAC to provide

technical support to the State AIDS Control Societies (SACS) of Tamil Nadu, Puducherry and Kerala by

setting up a Technical Support Unit at Tamil Nadu and Kerala, consisting of a core team of

consultants/experts co-located with the SACS, with a mandate to assist the SACS in scaling-up programs,

improving efficiency and quality. APAC also serves as the vice-chair on the national Technical Working

Group on Targeted Interventions.

Counseling and Testing (CT) is an integral part of the prevention, care and treatment initiatives of APAC. In

FY06, APAC supported NGOs to establish user-friendly CT centers that are easily accessible to MARPs

and bridge populations. APAC also supported district-level communication campaigns on the theme of

"Know your Status" and introduced mobile CT units to reach rural areas and inaccessible urban areas in

selected high-prevalence districts. The evaluation of the campaigns confirmed that the initiative increased

Activity Narrative: access to CT. Over 24,000 individuals were provided CT services over a period of two months. Based on a

request from the Tamil Nadu State AIDS Control Society (TNSACS), APAC conducted the first state-wide

assessment of public and private sector CT centers. The findings include: lack of adequate infrastructure,

the sub-optimal quality of counseling, issues of confidentiality, and weak referral linkages and follow-up. The

activities proposed by APAC in FY08 are based on this assessment and will continue to support the national

and state priority of increasing access to CT services for MARPs, bridge and other selected at-risk

populations.

In a recent development, National AIDS Control Organization (NACO) and Tamil Nadu State AIDS Control

Society (TANSACS) have taken a decision that the project should withdraw its support to 25 NGOs

implementing CT services in the targeted intervention programs as the CT services to the MARPs will now

be offered by the government run ICTCs in these districts. However, the project will continue to support the

19 private hospitals for the CT services.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Improving Access to CT Services for Most-at-Risk and Bridge Populations

In FY08, APAC will continue support to 16 NGO based CT centers in selected high- prevalence districts that

will primarily cater to MARPs and bridge populations. In addition, in these high prevalence districts APAC

will also support the establishment of CT centers at 19 private hospitals to enable MARPs, bridge

populations, pregnant women, TB patients, and the general public who choose to use private facilities for

health care, to access CT services. NGOs supported by APAC for prevention activities will promote these

services and create demand for CT through interpersonal communication and mid-media activities. The 19

private hospitals will also provide PMTCT, TB/HIV management and palliative care services including

ARVs. Linkages for palliative care will be established with care and treatment NGOs, networks of people

living with HIV/AIDS, and private and public sector hospitals. Through this initiative, APAC expects to

counsel and test 32,000 individuals. The HIV test kits for NGO-run CT centers will be leveraged from

TNSACS.

ACTIVITY 2: Improving Access to CT in Rural Areas in Selected High-Prevalence Districts

In selected high-prevalence districts, APAC will support mobile CT units to extend services to rural areas

which have limited access to CT services. The project will establish linkages with the Government Primary

Health Centers, Link Workers (two Link Workers to be appointed under NACP 3 for every village having

5000 population in High-Prevalence Districts) to promote access to CT services. This activity is based on

learning from APAC's previous experience of supporting mobile units and will be implemented in

coordination with other USG partners and TNSACS. APAC will also develop operational guidelines for the

mobile units and quality control mechanism will be an inherent part of the protocol. APAC will assess the

impact of the mobile CT units for addressing gaps, cost effectiveness, quality of services, follow-up, and,

linkages to care and treatment. Through this initiative, 4000 individuals will be counseled and tested. The

entire process will be documented and the findings disseminated to SACS, NACO and other agencies for

learning and replication.

ACTIVITY 3: Capacity Building of Counselors and Lab Technicians

APAC will support one state-of-art training institute to provide training to counselors on CT, consistent with

the national guidelines. This institute will also undertake field assessments to assess the quality of services

provided at NGO run centers, private hospital based centers and will also provide onsite training to

counselors. The counselors will go through periodic refresher trainings for improving quality of service

provision. Examples of the training components for counselors and lab technicians include: risk

assessment, pre/post test counseling, universal precautions and waste management. Apart from these

topics, the counselors will be trained to counsel on handling specific situations such as counseling

unmarried individuals who test positive, counseling discordant couples, antenatal women and their spouse,

MARPs, infected children, drug adherence, and positive prevention. The training institute will support the

development of reporting formats, counseling case sheets and other Quality control and Monitoring

documents.

A regional experience sharing workshop will be organized by the APAC project for the counselors

representing different agencies from all the southern states of India. The three-day program, with an

estimated presence of 250 Counselors, will provide an opportunity for the counselors to share their

experience, learnings and challenges. APAC will also support one training institute to train lab technicians

on CT services. The training curriculum will include testing procedures, confidentiality and ethics, universal

precautions, waste management, and Quality assurance. APAC will also explore the feasibility of

collaborating with the Directorate of Medical Education in Tamil Nadu to include a special training on

HIV/AIDS testing to the budding lab technicians passing out from public and private paramedical

institutions.

ACTIVITY 4:Facility Assessment of Public and Private Sector CT Centers

In FY 08, APAC will support another assessment of CT centers in public and private settings. This will

include areas such as facility assessment, quality of service provision, and follow up. The findings of the

assessment will be disseminated to stakeholders and policy makers.

ACTIVITY 5: Technical Assistance to the State AIDS Control Societies

The third phase of the National AIDS Control Program has planned for counseling and testing 21 million

individuals in the next five years. As part of its role as the TSU for the state of Tamil Nadu and Kerala, the

APAC project will provide Technical Assistance to the SACS to improve quality of counseling and demand

generation in line with the findings of the CT assessment study carried out by the project. The project will

assist the SACS in strengthening counseling protocols, possible accreditation of private CT centers and

linkages after testing. The project will work closely with the SACS to develop specific information materials

such as counseling aids for sero-discordant couples, positive children, and MARPs.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14159

Continued Associated Activity Information

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

System ID System ID

14159 6153.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $325,500

International Services

Development

10828 6153.07 U.S. Agency for Voluntary Health 5604 3949.07 $588,000

International Services

Development

6153 6153.06 U.S. Agency for Voluntary Health 3949 3949.06 $707,650

International Services

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

Health-related Wraparound Programs

* TB

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14:

Funding for Strategic Information (HVSI): $425,436

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

Except for Activity 2, all activities planned in COP 08 will be continued in COP 09. The reason for not

supporting Activity 2 is because BSS is planned once every alternate year and will not be undertaken in

COP 09.

In COP 09, the prime partner will also support the following new activity:

ACTIVITY 4: Establishment of the Strategic Information and Support Unit (SISU)

The Tamil Nadu State AIDS Control Society (TNSACS) has requested APAC to provide technical support

for: a) data mining of past records; b) introduction of data quality assurance at the reporting unit level; c)

collating data of different donors to ensure the Three Ones Principle; and d) build capacity of SACS officials

and in the District AIDS Prevention and Control Units (DAPCUs) on data analysis for evidence based

programming and influencing policy change. This is a recent development and APAC has already initiated

work on this area. The unit will also collect gender specific information (mostly sex disaggregated data),

private sector, linkages and offer strategic information support to TNSACS and other stakeholders in the

state.

FY 2008 NARRATIVE

SUMMARY

The National AIDS Control Organization (NACO) has emphasized the need for evidence-based

interventions. The AIDS Prevention and Control (APAC) project has extensive expertise in this area. In

FY08 APAC will continue to support initiatives to build the capacity of its NGO partners on Management

Information Systems (MIS) and strategic information, and will conduct behavioral and facility assessments.

As the Technical Support Unit (TSU) for the states of Tamil Nadu, Puducherry, and Kerala, APAC will

strengthen the MIS of the State AIDS Control Societies (SACS) and the District AIDS Prevention and

Control Units (DAPCUs) to collect, analyze and effectively use field data for program planning and

monitoring.

BACKGROUND

For the past twelve years, with USG support, Voluntary Health Services (VHS) has been implementing the

APAC project in the southern state of Tamil Nadu. APAC, which initially focused on targeted interventions

for most-at-risk-populations (MARPs), has expanded its efforts over the last few years to support a more

comprehensive approach to HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in

controlling HIV (prevalence among antenatal women has dropped from 1.13% in 2001 to 0.5% in 2005) and

the APAC project has significantly contributed to this success. The National AIDS Control Organization

(NACO) has recognized the expertise and contributions of the APAC project and has requested APAC to

provide technical support to the SACS of Tamil Nadu, Puducherry and Kerala by setting up a Technical

Support Unit in Tamil Nadu and Kerala, consisting of a core team of consultants/experts co-located with the

SACS, with a mandate to assist the SACS in scaling-up programs, improving efficiency and quality. APAC

also serves as the vice-chair of the national Technical Working Group on Targeted Interventions.

APAC has extensive experience in establishing systems and conducting assessments that provide strategic

information that helps to guide evidence-based planning for the state of Tamil Nadu and the APAC project.

In its twelve years of experience, APAC has conducted a large number of assessments and studies,

examples of which include: a) eleven rounds of behavioral surveillance surveys (BSS); b) two rounds of STI

prevalence studies; c) two rounds of health care provider assessments; d) condom quality assessments; e)

assessment of public and private sector VCT centers; and f) mapping of MARPs. Most of these

assessments have been used by SACS and NACO for program planning and decision making. APAC

supports the SACS in implementing the UNAIDS "Three Ones Principle" of a unified monitoring and

evaluation (M&E) framework and has played a significant role in the implementation of one M&E system in

Tamil Nadu. APAC has trained SACS officials from other states on strategic information and many of its

systems and procedures have been adopted by SACS and NACO.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Capacity Building of NGOs on Data Quality Assurance

In FY08, the APAC project will continue to support efforts to build the capacity of sub-partners on MIS,

develop data quality assurance protocols and checklists, and share/disseminate project information to

SACS and other stakeholders as part of its commitment to the "Three Ones Principle". The project will

continue to adopt existing approaches such as participatory site visits, experience-sharing meetings, and

cluster-level meetings to get more detailed information on field activities and to enhance the quality of

information and interventions. Training on data analysis and data use will be provided to NGO staff.

APAC will also continue to support the state's Geographic Information System (GIS), which was developed

using F06 funds, to collect and update information pertaining to health and more specifically HIV/AIDS. The

GIS will help APAC and other policy makers in the state to make better decisions based on evidence.

ACTIVITY 2: Behavioral Surveillance and Other Assessments

APAC will support another round of state level BSS to understand the behavior of MARPs and other

selected populations in the states of Tamil Nadu and Puducherry. In addition, the project will support

assessments such as mapping MARPs, district health facility resource mapping and other assessments that

will provide data to support the project and the state in planning evidence-based interventions.

ACTIVITY 3: Technical Assistance to the State on Strategic Information

APAC will build the SACS' capacity to carry out data quality assurance at the field level and strengthen

institutions that are involved in training NGOs and other agencies on MIS. As a TSU, APAC will strengthen

the MIS of the SACS and DAPCUs for greater coordination of data collation, analysis and use. The project

will strengthen the Strategic Information and Management Unit located within SACS to be able to analyze

Activity Narrative: data more effectively and make program-related decisions. Need-based assessments that help with state-

level planning by assessing the impact of interventions will also be supported. APAC will share examples of

best practices (such as multi-faceted monitoring strategies) in Strategic Information (SI) and monitoring and

evaluation (M&E) with the SACS. APAC also will play a critical role in promoting the implementation of

"Three Ones" Principles by all partners in the states, through establishing donor coordination committees for

SI/M&E.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14161

Continued Associated Activity Information

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

System ID System ID

14161 6156.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $396,000

International Services

Development

10831 6156.07 U.S. Agency for Voluntary Health 5604 3949.07 $392,000

International Services

Development

6156 6156.06 U.S. Agency for Voluntary Health 3949 3949.06 $794,000

International Services

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 18 - OHSS Health Systems Strengthening

Total Planned Funding for Program Budget Code: $6,835,866

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Overview: The ambitious roll-out of the third phase of the National AIDS Control Program (NACP-III) launched in early July 2007,

has increased the demand for USG assistance in India in several technical and cross-cutting areas including health systems

strengthening (HSS). The USG team makes important contributions to strengthening health systems in India by placing advisors

at the national and state level in key technical areas and participating with other donors in program development.

One of the goals of NACP-III is to decentralize HIV/AIDS management and control to the district level. This will be done through

the establishment of District AIDS Control Units (DAPCUs) that will provide managerial and financial oversight of the HIV/AIDS

programs. The State AIDS Control Societies (SACS) will continue to lead the planning, coordination and monitoring of activities in

the states but the DAPCUs will be the nodal agencies for coordinating activities. The goal of NACP-III is that the DAPCUs will, by

2012, be absorbed into the National Rural Health Mission (NRHM), established in 2007 with similar goals to decentralize and

integrate all health programs at the district level. Strengthening the DAPCUs will therefore contribute to stronger overall health

systems at the district level.

The National AIDS Control Organization (NACO) is overhauling its management and financial systems and has appointed a Joint

Secretary and Finance Director to oversee administration and fiduciary management. It has also developed and released

procurement and financial guidelines on its website and will soon be hiring a fulltime procurement specialist. USG is supporting

NACO in strengthening management and financial systems at the state and district level. However, responding to ad hoc

requests from NACO for support has been challenging. What is needed is a clear needs assessment and implementation plan for

future USG support.

Coordination and Other Donor Activities: The World Bank, DFID, USG and other donors reviewed and endorsed NACP-III in

2006. The World Bank and DFID also take the lead in the annual Joint Implementation Reviews of NACP-III, in which USG

participates. UNICEF continues to support PMTCT policy development, and provides advice to the Ministry of Education for in-

school HIV/AIDS programs and to the Department of Women and Child Development for OVC policies and programs. UNDP is

the lead agency for mainstreaming programs, with USG emerging as its key partner for mainstreaming HIV/AIDS with the private

sector. UNIFEM is the nodal agency to mainstream gender across various sectors and the World Food Program (WFP) provides

policy level support for nutrition and HIV/AIDS.

USG is a member of the India Country Coordinating Mechanism (CCM) of the Global Fund, several national Technical Working

Groups, the Technical Panel for the Bill and Melinda Gates Foundation, and the Technical Panel for the Clinton Foundation's

training program for private sector providers and public sector nurses. USG is a key member of the NACO-led Steering

Committee of donor partners, a forum for multilateral and bilateral partners, as well as of the State Project Steering Committees in

the four priority USG states. USG represents the bilateral donors on the India-CCM of the Global Fund and, in partnership with

GTZ, the European Commission and other bilateral donors such as DFID, supports the functioning and capacity-building of the

India CCM Secretariat, specifically including technical assistance for staffing, proposal development, and meetings for the private

sector.

Current USG Support: Technical Support Units (TSU) are a new entity under NACP-III established to give technical support to the

SACS. The TSUs provide technical assistance (TA) to the SACS for managing grants to non-governmental (NGO) and

community-based organizations (CBOs) to implement programs. TA is given in critical areas such as program management,

targeted interventions, capacity building, mainstreaming and public-private partnerships. USG was asked to establish TSUs in

Tamil Nadu, Maharashtra, Goa, Kerala, Puducherry, Uttar Pradesh and Uttarakhand, where USG has a history of program

support. This is the highest number of TSUs supported by any donor. In Andhra Pradesh and Karnataka, USG contributes by

providing assistance for district action plans, policies and guidelines.

USG continues to play an active role in the roll-out of NACP-III in its capacity as a member of the Donor Steering Committee as

well as through various national-level Technical Working Groups. Examples from FY08 include USG membership in the national

committees that facilitated the award of a nation-wide franchise to expand STI services, and the implementation and monitoring

across 13 states of the link-worker scheme piloted by USG. Additionally, USG's work in piloting task shifting through the nurse-

practitioner model at Primary Health Centers in Andhra Pradesh (AP) has facilitated the scale up of Integrated Counseling and

Testing Centers (ICTCs) in the State. USG has also supported the development of state and district-level plans in select states

and districts as part of the decentralization process. In AP, USG supports District Program Managers (DPMs) in 10 districts; these

positions will be absorbed into the future DAPCUs.

Policy and advocacy activities include development of a national policy guiding the role of private sector in HIV/AIDS services

under NACP-III. USG was also responsible for the country's first group insurance scheme from the private sector for positive

persons, which was launched by the Director-General of NACO, and is now being considered for adoption by various state

governments and at the national level. USG continues to advocate for a stronger focus on OVC in national and state programs,

enhanced support for the Greater Involvement of People with AIDS (GIPA), strengthening monitoring and evaluation (M&E) and

data systems, and ensuring that the special needs of women and vulnerable populations are adequately addressed.

USG also provides TA for the implementation of protocols and operational guidelines. USG worked in close association with

UNICEF to mainstream HIV/AIDS activities for infected and affected OVC into activities of the Ministry of Women and Child

Development (MWCD). This was informed by the Policy on Children and HIV/AIDS released jointly by NACO, MWCD and

UNICEF in May 2007, for which USG provided substantial technical support. Additionally, in close association with UNDP, USG

facilitated the compilation of an assessment of public-private-partnerships in HIV/AIDS for NACO. The assessment will help in

determining the current scope and depth of private sector engagement in HIV/AIDS prevention, care and treatment services,

including workplace programs.

At the technical level, USG supports NACP-III by funding 40 key personnel at NACO in the following areas: CT, PMTCT, ART,

care and support services, surveillance and M&E. In addition, the USG provides funding for staff (epidemiologists and M&E

officers) in several states to strengthen the national strategic information system. USG also supports technical specialists at state

level in such areas as workplace interventions, TB-HIV coordination, ART, and behavior change communication. Additional TA

support to NACO in technical areas included designing the methodology for mapping high-risk groups. Other contributions

include development of the state communication strategy for the Karnataka State AIDS Control Society and design of the

communication plan for the nation-wide Red Ribbon Express project, a 12-compartment train that has been traversing India over

the past 10 months.

USG FY09 Focus: In response to NACP-III's emphasis on repositioning donor support for systems strengthening, in FY09 USG

will speed up a transition from direct support for field-level implementation to providing more technical and management

assistance at higher levels to NACO and the SACS. At the India PEPFAR Program Review debrief, the Government of India

articulated the need for a USG role in key areas such as health systems strengthening, management of STI franchising, supply

chain management and human capacity development. There will be a focus on the following:

1. Systems strengthening and building human and technical capacity

i) At national level: USG plans to support the national Technical Support Unit, a new entity intended to build capacity and

strengthen systems of NACO's $2.5 billion NACP-III. USG will support the Team Leader and three key personnel in Human

Capacity Development, M&E and Strategic Program Management. The USG program will also continue to participate in

Technical Working Groups, taking the lead in several areas, including working with the private sector. USG will continue

collaboration with the Lawyers Collective to facilitate the inclusion in the Draft HIV/AIDS Legislative Bill of the recommendations of

the policy guidance on children and HIV/AIDS. USG will continue to provide leadership for in-service human capacity

development programs for professionals including government and NGO personnel through the USG-supported field leadership

training program.

ii) At state level: USG will continue to support the TSUs in Tamil Nadu, Maharashtra, Goa, Kerala, Uttar Pradesh and

Uttarakhand, which will focus on TA for human capacity development and district level integration activities. USG will also provide

technical assistance to SACS in the four USG priority states, particularly in prevention interventions with MARPs, counseling and

testing, Strategic Information (SI), OVC and health systems strengthening.

iii) Building capacity at sub-state level to strengthen a decentralized response: USG will provide technical support to build the

management and technical capacity of DAPCUs with a focus on program management, coordination and SI.

iv) NGO and civil society level: USG will continue to build the institutional capacity of local NGOs and CBOs, including faith-based

organizations, in program and financial management as well as in establishing M&E systems, including routine Data Quality

Assessment. USG will also support the TSUs to build capacity of the SACS' implementing partners to deliver high-quality

prevention and care programs.

2. Mainstreaming programs: USG will continue to support mainstreaming activities through partnerships with government

ministries such as the Ministries of Women and Child Development, Human Resource Development, Rural Development, Youth

and Sports, Social Justice and Welfare, and the National Rural Health Mission to integrate HIV/AIDS issues in their systems at the

national and state level. These activities will complement the support from the lead donor agencies in those areas. As part of the

Mainstreaming Taskforce, USG will assist efforts to mainstream GIPA as well as gender in priority ministries under NACP-III.

3. Strengthening PLHA networks: USG will continue to strengthen PLHA networks and support implementation of the GIPA Plan

(developed in 2007 with USG support). The plan proposes to increase the role of positive persons at the state and district level in

strategic planning, implementation and monitoring, including advocacy to address stigma and discrimination. USG will support TA

to SACS in the USG priority states to incorporate GIPA in state plans, appoint State GIPA Advisors, develop a toolkit for positive

prevention and support national and state level trainings for GIPA. Following the recommendation of the PEPFAR program

review, USG support to the Indian Network of Positive People (INP+) will be reviewed to align with PEPFAR priorities as well as

with those of NACP-III in terms of strategic institutional capacity building.

4. CCM Secretariat: Enhancing the effectiveness of the India Global Fund CCM Secretariat, which has limited resources and

staffing, will continue to be a priority. USG is ready to support strengthened M&E capability for the Secretariat (such as an M&E

officer and/or TA) to consolidate the M&E frameworks of all Global Fund Rounds currently underway, however final agreement on

the specific components of USG support is still under discussion with NACO. In addition, USG will continue to support the human

capacity development of CCM members from civil society. USG will also assist in the development of future high quality proposals

for TB and HIV/AIDS to the Global Fund.

5. Strengthening private sector systems: As a lead donor for mainstreaming activities in the private sector, USG will facilitate and

support NACO in the implementation of the national PPP policy and guidelines. USG provided TA in developing the policy

guidance and in developing operational guidelines for a PPP Trust that will manage all PPP activities under NACP-III. The Trust

will have a menu of options for private sector engagement in key areas of care, support and treatment. USG will also continue to

support models of private sector partnerships that provide cost-effective prevention and treatment services for workers in the

organized and unorganized sectors, linked to government services and through the private medical colleges that offer these

services. USG will also facilitate scaling-up the first group insurance scheme in the private sector for HIV-positive persons. In

FY09, USG will also provide technical assistance for the strategic scale-up of female condoms across India.

Specific Benchmarks/Outcomes:

1. National TSU supported at NACO

2. Development of district action plans in selected districts from USG priority states.

3. Staff specialists provided to support Global Fund CCM.

4. Development of National Policy and Operational plan to mainstream private sector engagement through PPP under NACP-3

5. Communication strategic plan developed for KN SACS.

6. Operational plan for Indian Network of Positive People (INP+) to implement GIPA strategy in USG priority states.

7. National symposium with public and private insurance sector for long-term engagement of sustainable health insurance for

positive people.

Annex: PPP document

Table 3.3.18:

Funding for Health Systems Strengthening (OHSS): $908,600

ACTIVITY UNCHANGED FROM FY 2008

FY 2008 NARRATIVE

SUMMARY

The third phase of the National AIDS Control Program (NACP-3) has underscored the need for system

strengthening and developing appropriate policies/guidelines to facilitate the scale up of high quality

HIV/AIDS activities. Several new polices and systems have been developed, such as the policy for orphans

and vulnerable children (OVC), the ART policy, and policies related to decentralized program management.

Other operational guidelines such as guidelines for NGOs on targeted interventions, guidelines for TSUs

are in the process of being finalized with USG playing an important role. National implementation of NACP-

3 is a major challenge for the GOI and will require extensive strengthening of infrastructure, management

systems and staff skills at all levels. In FY08, the AIDS Prevention and Control (APAC) project will support

system strengthening and policy change initiatives, primarily at the State level, but also at the national level

through technical assistance and demonstrating best practices. As the Technical Support Unit (TSU) for the

states of Tamil Nadu and Kerala, APAC will play a critical role in strengthening state systems at various

levels in the public and private sector. In the public sector, the project will support the State AIDS Control

Societies (SACS) and District AIDS Prevention and Control Units (DAPCUs) to strengthen existing program

management systems and develop new systems as required. APAC will support specific initiatives with faith

-based organizations, the Lawyers' Collective, PLHA networks and political leadership to influence policy

change. APAC will also work with a number of associations in the private sector to develop/strengthen their

systems to integrate HIV/AIDS activities into their ongoing programs.

With the establishment of Technical Support Unit under the project, the reach will increase for institutional

capacity building and community mobilization in the three states - Tamil Nadu, Puducherry and Kerala.

BACKGROUND

For the past twelve years, with USG support, Voluntary Health Services (VHS) has been implementing the

APAC project in the southern state of Tamil Nadu. APAC, which initially focused on targeted interventions

for most-at-risk-populations (MARPs), has expanded its efforts over the last few years to support a more

comprehensive approach to HIV/AIDS prevention, care and treatment. Tamil Nadu has been successful in

controlling HIV (prevalence among antenatal women has dropped from 1.13% in 2001 to 0.5% in 2005) and

the APAC project has significantly contributed to this success. The National AIDS Control Organization

(NACO) has recognized the expertise and contributions of the APAC project and has requested APAC to

provide technical support to the State AIDS Control Societies (SACS) of Tamil Nadu, Puducherry and

Kerala by setting up a Technical Support Unit in Tamil Nadu and Kerala, consisting of a core team of

consultants/experts co-located with the SACS, with a mandate to assist the SACS in scaling-up programs,

improving efficiency and quality. APAC also serves as the vice-chair of the national Technical Working

Group on Targeted Interventions.

APAC in its twelve years of experience has played a significant role in influencing decision- makers to

support policy change. It has worked with the state government, the Confederation of Indian Industries (CII),

faith-based organizations and physicians' associations to bring about policy change and strengthen the

organizational systems of these institutions. In FY08, APAC will continue to support these initiatives and

expand to work with newer groups on system strengthening, mainstreaming and promoting policy change.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Systems Strengthening of State-Level Public and Private Sector Agencies

The APAC project has been identified by NACO as the TSU for the SACS of Tamil Nadu, Puducherry and

Kerala. The primary objective of the TSU is to strengthen State systems to manage HIV/AID and build the

capacity of SACS in various areas. As the TSU, APAC will support a unit of 6-8 consultants/advisors, co-

located with the SACS in Tamil Nadu and Kerala. The team will assist the SACS in identifying and

organizing the technical expertise available in the state to strengthen the State's to respond to a well

designed, evidence-based technical assistance (TA) plan. Areas for TA from the TSU include strategic

planning, project management (including the selection, management and monitoring of NGOs), monitoring

and evaluation, capacity building, training, human resource planning and management, increased private

sector engagement, and mainstreaming. The TSU will also assist the SACS in developing systems to

support planning and implementation of HIV/AIDS activities implemented by the new DAPCUs., who will

play a critical role in coordinating and monitoring district-level HIV/AIDS activities.

The TSU will also assist in system development and building the capacity of other agencies such as

industry associations, associations of trucking companies, and physicians' associations to develop and

implement workplace policies and increase their engagement in HIV/AIDS activities.

ACTIVITY 2: Supporting Faith-Based Organizations to Develop and Implement HIV/AIDS Policies

APAC has initiated advocacy programs among the 17 dioceses of the Tamil Nadu Bishops' Council (TNBC)

and provided training for bishops and religious sisters in implementing the HIV/AIDS policy developed by

Catholic Bishops' Conference of India (with USG assistance). In FY08, the project will continue its support

to TNBC to strengthen the implementation of their HIV/AIDS policy in their educational, health and religious

institutions. In FY08, APAC will support Hindu and Muslim religious institutions to develop and implement

HIV/AIDS policies that support HIV/AIDS programs. In high-prevalence districts, committed religious leaders

will be identified and their capacity built to promote HIV/AIDS prevention messages and support for

individuals infected and affected by HIV/AIDS. APAC will also support one regional experience-sharing

workshop for showcasing and cross-learning about faith/spiritual initiatives.

ACTIVITY 3: Promoting the Rights of Women PLHA through Capacity Building and Systems Strengthening

of Legal Support Institutions

Women are more vulnerable to HIV/AIDS, exploitation, and in many cases their legal rights have been

compromised. Instances of women PLHA being denied property and basic rights have been reported across

the country. In the high-prevalence districts of Tamil Nadu, the APAC project will support a women's

Activity Narrative: lawyers' collective to advocate for and support the rights of women (particularly of marginalized, infected

and affected women). In these districts, through the lawyers collective, a panel of women lawyers will be

trained and supported to take up issues related to the rights of women PLHA. Linkages between NGOs,

CBOs, PLHA networks, and the women's lawyers' collective will also be established.

ACTIVITY 4: Systems Strengthening of District PLHA Networks

In FY06, APAC supported the Indian Network of Positive People (INP+) to build the systems and capacity of

district PLHA networks. SACS and other agencies have also supported PLHA networks to strengthen their

governance and management and technical capacity. In FY08, APAC will support an initiative to assess the

existing gaps in the capacity of PLHA networks. Based on the findings, the project will support one strong

PLHA network to build the systems and capacity of other district networks in areas such as project

management, monitoring and evaluation, human resource planning, and financial management. The

project will also support the PLHA network to advocate with government and other stakeholders to develop

PLHA-friendly policies.

ACTIVITY 5: Training and Advocacy with Legislative Assembly Members

In FY08, APAC will support a public sector institution to work with Legislative Assembly members to

educate them on HIV/AIDS issues and on the need to develop/amend policies that will facilitate the

implementation of robust, evidence-based HIV/AIDS programs and the protection of PLHA rights.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14162

Continued Associated Activity Information

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

System ID System ID

14162 6157.08 U.S. Agency for Voluntary Health 6720 3949.08 APAC $481,900

International Services

Development

10832 6157.07 U.S. Agency for Voluntary Health 5604 3949.07 $245,000

International Services

Development

6157 6157.06 U.S. Agency for Voluntary Health 3949 3949.06 $260,700

International Services

Development

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Malaria (PMI)

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $128,047

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.18:

Subpartners Total: $1,864,948
Bethesda Hospital: $30,333
Bharatiya Adim Jati Seval Sangh: Pondicherry: $45,000
Christian Medical College: $43,322
Community Health Education Society: $33,333
Geofiny Technology Private Limited: $4,762
Mahatma Gandhi Elaignar Narpani Mandram: $30,333
People's Association for Community Health Education Trust: $45,000
Sahodaran: $56,905
Society For Development, Research And Training: $45,000
Village Beneficiaries Education And Development Society: $45,000
Perundurai Medical College: $66,234
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: $45,000
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
Anbalayam: $45,000
Association For Rural Mass India: $75,333
Centre for Human Resource and Rural Development Program: $45,000
Centre For Social Reconstruction: $56,905
Chennai Micro Print Ltd: $61,143
Community Action For Social Transformation: $45,000
Empower: $45,000
Flame Advertising Company: $61,143
Gramium: $75,333
Indian Community Welfare Organisation: $30,333
Kancheepuram District Network of Positive People: $30,333
League for Education and Development: $30,333
Madras Social Development Society: $45,000
Media Vision: $61,143
Net Access India Private Limited: $4,762
People's Development Initiative: $42,238
Rakshashi Cemantics, Chennai: $61,143
Rural Education And Development Society: $45,000
Solidarity and Action Against The HIV Infection in India: $194,262
Sakshi Automation: $23,810
Indian Network for People Living with HIV/AIDS: $35,714
Scientific Educational Development For Community Organisation: $45,000
South Indian AIDS Action Programme: $34,322
Social Welfare Association For Men: $45,000
Society for Education, Village Action, and Improvement: $45,000
Shreshta Communications: $61,143
Carmelite Sisters of St. Theresa: $30,333
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
To Be Determined: NA
Cross Cutting Budget Categories and Known Amounts Total: $604,217
Human Resources for Health $96,548
Human Resources for Health $283,020
Human Resources for Health $96,602
Human Resources for Health $128,047