PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2010
The Avert project is a bilateral program implementing HIV prevention, care and treatment activities in five high-prevalence districts of Maharashtra State. The population of these five districts is 20 million and the HIV prevalence ranges from 0.5 % to 1.75 %. Overall, prevalence among pregnant women attending antenatal clinics (ANC) in the state is above the average for India at 0.67%, though this is a decline from 1.5% in 2003. There are a number of factors that contribute to Maharashtra's vulnerability to the HIV epidemic. It is bordered by other states that have well-established and growing HIV epidemics (Karnataka and Andhra Pradesh). There is extensive migration to and from these states, and there are major transportation routes connecting Maharashtra to them. Maharashtra is a major destination hub for migrants from various states of India. Additionally, Mumbai and several other districts have well recognized places where sex workers operate. The total estimated number of HIV positive persons is over 460,000 which accounts for 20% of the total estimated HIV infected persons in the country and second highest after Andhra Pradesh with 485,000 HIV positive persons.
The Avert project supports the National AIDS Control Program (NACP III) and works in collaboration with Maharashtra State AIDS Control Society (MSACS). MSACS is implementing a comprehensive HIV prevention, care and treatment program throughout the entire state of Maharashtra that is supported by the Mumbai District AIDS Control Society (MDACS). The Avert project and the Bill and Melinda Gates Foundation (BMGF) are the two other major programs that complement the efforts of MSACS in scaling up HIV prevention, care and treatment programs. BMGF's primary focus is supporting prevention programs among most-at-risk-populations (MARPs) in 13 high prevalence districts in Maharashtra. UNICEF provides technical assistance (TA) on prevention of mother to child transmission (PMTCT). The Clinton Foundation is supporting pediatric antiretroviral therapy (ART) services. The state also receives funds from the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM) for scaling-up integrated counseling and testing (ICTC) and care and treatment programs. In addition, USG supports Johns Hopkins University (JHU) and the Hindustan Latex Family Planning Promotion Trust (HLFPPT) to assist MSACS in designing behavior change communication (BCC) and condom social marketing programs for most at risk populations (MARPs).
The overarching goal of Avert project is to complement the efforts of Maharashtra State in reducing the prevalence of HIV from 1% to less than 0.5%; and in improving access to care and treatment services in five high-prevalence districts. In addition, Avert project through the technical support unit (TSU) is playing a critical role in building the capacity of the MSACS which is spearheading the HIV prevention efforts to halt and reverse the epidemic in the state.
The Avert project focuses on saturating coverage of MARPs such as female sex workers (FSWs), men who have sex with men (MSM), and migrants, implementing community mobilization activities to increase the uptake of counseling and testing, PMTCT, and care and treatment services in the five high-prevalence districts. Additionally, the Avert project is mandated to implement workplace interventions in the entire state.
In June 2011, the Avert project will enter the third phase of programming. It is expected that Avert project will then begin transitioning its direct implementation activities to MSACS and focus on providing TA to build the capacity of the MSACS and local organizations.
Key Ongoing Activities:
Support and strengthen the capacity of over 70 nongovernmental organizations (NGOs) and community-based organizations (CBOs) to saturate the coverage of MARPs to promote behavior change such as consistent condom use, and seeking STI treatment and counseling and testing (CT).
Implement link worker (LW) programs to mobilize the MARPs in rural areas to utilize prevention, CT, PMTCT, care and support and ART services.
Support eight drop-in centers to implement home-based care and provide HIV/AIDS services to 2,250 orphans and vulnerable children infected and affected by HIV/AIDS.
Scale-up and strengthen workplace intervention programs with organized and unorganized industrial sectors vulnerable to HIV/AIDS in five districts in Maharashtra.
Create models of HIV prevention programs among short-stay migrants and support replication of the model in the state and national level.
Conduct activities to ensure a strong evidence-base for planning and implementing HIV programs, including mapping studies and studies of access to and quality of services, and needs assessments to support demand generation. An Integrated Biological and Behavioral Assessment (IBBA) in the Avert districts have been approved by the Research Group at NACO and will be submitted for ethical clearance.
Support the TSU, to build the capacity of MSACS, MDACS and Goa State AIDS Control Society (GoaSACS) in grants management, monitoring, institutional capacity building, mainstreaming and public-private-partnership programs. This TA is expected to be phased out by 2012.
The Avert project is collaborating with Christian Medical College (CMC), Vellore to strengthen the strategic information system (SIS) at the state level. TA has been provided to carry out co-relational analyses of ANC surveillance, CT and ART services.
Avert project is also seeking TA from CMC, Vellore in strengthening the human capacity building initiatives in Maharashtra State. As part of this effort, it plans to build the capacity of institutions and individuals, adopting a systems approach to curriculum development and training in order to improve the quality and sustainability of training. Most importantly, this will be a model for replication in other states and for guiding national policies on human capacity building.
Program Achievements and Innovations:
The Avert project has established robust project management systems such as NGO selection, monitoring, capacity building and evidence-based programming. This has resulted in establishment of a network of over 70 NGOs implementing prevention programs, care and support programs for MARPs in the five Avert priority districts including improving the quality of interventions.
Developed models of workplace interventions for public and private sector industries, business associations and the unorganized sector and developed methodologies to segment targeting in workplace interventions to ensure that the most-at-risk industrial sectors are reached. Based on these models, workplace interventions are being scaled-up and targeted to those industries and informal workers most vulnerable to HIV/AIDS.
Over 3,000 peer educators trained to carry out behavior change activities among MARPs.
The Avert TSU has played a significant role in assisting the SACS to scale-up and strengthen 84 targeted intervention programs in Maharashtra and 19 in Goa; and 60 public-private-partnerships on integrated counseling and testing centers (ICTC) and 1,260 STI franchising clinics in Maharashtra. The TSU has assisted MSACS in mainstreaming HIV/AIDS into the National Rural Health Mission (NRHM), women and child development and Panchayat Raj departments.
Consistent condom usage among sex workers has increased significantly from 70% in 2004 to 90% in 2008.
The Avert project will develop strategies to mitigate gender concerns in HIV/AIDS programs for MARPs and other vulnerable populations. Specifically, it will train NGOs to address the double stigma and discrimination MARPs face in community and health care settings. The prevention program for FSWs includes a strategy to access legal services to address violence and coercion by police and clients. Programs such as training of women PLHIV on vocation skills and linkages to banks are designed to improve access to income and productive resources.
The Avert project is demonstrating an integrated care program for adults and orphans and vulnerable children (OVC) through a family centric approach in four Avert priorities and five of the districts where the Maharashtra State AIDS Control Society (MSACS) is implementing HIV/AIDS activities. Family is the key for the health of people living with HIV/AIDS (PLHIV) - but families need skills in caring for the sick and dealing with pain and counseling skills. The Technical Support Unit (TSU) will support Avert project in transitioning the NGOs to MSACS including building their capacity to manage the activities.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: Integrated Adult care and OVC Programs:
The Avert project has learned from experience that separate adult care and OVC programs are not feasible and cost-effective in the context of India's concentrated epidemic. Hence, the project has initiated a demonstration program on integrated family-centered adult care and OVC in FY08. Currently, the Avert project is supporting nine PLHIV networks to implement integrated adult care and OVC programs. The OVC component is added to adult care program with addition of two staff (Life Skills Education Teacher and a Nurse). In addition, the adult care providers are also trained on OVC activities such as counseling, medical care, referral support and documentation. The integration has saved the cost of supporting a separate NGO for staffing, rent and other infrastructure support. These programs are reaching 13,775 adult PLHIV and 1,500 OVC. In FY09, the Avert project will reach an additional 5,400 adult PLHIV and 3,000 OVC. The activities for adult PLHIV include psychosocial support including counseling, medical care, referral to ART services, legal aid and linkages to socioeconomic programs The OVC package of services includes psychosocial support, medical care, nutritional support based on assessment, life skills education, formal and non-formal schooling and accompanied referrals to pediatric testing and ART services. In FY09, the Avert project will decentralize the program by forming sub-district level PLHIV networks and building their capacity to provide care services closer to the community. The sub-district level PLHIV networks will form a crisis committee to address stigma, violence, harassment, and other forms of physical and emotional abuse. A district-level forum will be constituted with representatives from the sub-district level networks to undertake advocacy at places of work and in health care settings. The PLHIVs will be trained as speakers to encourage disclosure, normalize HIV/AIDS and create a non-threatening environment for PLHIV. The Avert project will also develop referral systems (between most-at-risk-population (MARP) nongovernmental organizations (NGOs) and Care program and strategies to provide user-friendly services to MARPs. In addition, the Avert project is forming a network of HIV-positive MARPs who will play a critical role in improving access to care and treatment services for MARPs.
In FY10, the Avert project will conduct an evaluation and transition the nine integrated adult care and OVC programs to MSACS. The TSU will assist MSACS in establishing systems to absorb the nine care programs. The best practices of the demonstration program will be documented and disseminated at national and international levels.
ACTIVITY 2: PLHIV Insurance Program
In collaboration with the Population Services International (PSI) Connect project, a PLHIV insurance program will be initiated through the nine integrated care programs. With technical assistance (TA) from PSI-Connect Project, a feasibility study will be conducted to design the insurance scheme for the PLHIVs in Maharashtra State. The findings will be shared with the insurance companies and a partnership will be formed with the company who comes forward to take up the initiative.
ACTIVITY 3: Program on Prevention with Positives
The national program has accorded low priority to prevention for HIV-positive people. The Center for Disease Control (CDC) program in India has developed the Prevention-with-Positives Follow-up Counseling Tool Kit. 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. In FY10, Avert project will provide technical support to MSACS on positive prevention and follow-up counseling. Avert project will support the MSACS to train counselors of integrated counseling and testing (ICTC) and ART centers in positive prevention strategies including skills to use the Prevention-with-Positives Follow-up Counseling Tool Kit.
One of the important objectives of the care and support strategy of the Avert project is to ensure the well-being and protection of orphans and vulnerable children (OVC) and families to reduce the burden of HIV/AIDS. Based on lessons learned, the Avert project has integrated the OVC component in the adult care program.
Activities and Expected Results
ACTIVITY 1: Integrating OVC Components into the Adult Care Programs
The Avert project is supporting nine nongovernmental organizations (NGOs) (four in Avert priority districts and five in MSACS districts) that have integrated OVC into adult care services. The purpose of implementing OVC activities in Maharashtra State AIDS Control Society (MSACS) districts is to build the capacity of the technical officers in the MSACS through joint monitoring and on-site mentoring.
Based on the experience of implementing separate OVC programs, Avert project found out that it was not cost-effective to support an NGO for only OVC activities as the number of OVC children on an average was 50 to 75 per district. Moreover, Avert project found that in a community-based family-centered approach, both the adult care and the OVC NGOs were reaching the same families in providing the care services. Hence, the OVC component was added to adult care program with addition of two staff (life skills education teacher and a nurse). In addition, the adult care providers were also trained on OVC activities such as counseling, medical care, referral support and documentation. The integration has saved $330,000 that would have been paid for staffing, rent and infrastructure if we had funded separately nine OVC NGOs.
As part of the OVC program, weekly medical clinic is organized at the NGO office. At the clinic, the medical doctor screens and provides treatment for opportunistic infections; conducts nutritional assessment and OVC children with <18 body mass index (BMI) is provided therapeutic supplementation until normalcy; and also refers to ART center for higher level care. Cooking demonstration using locally available foods is conducted for the family members of OVC. A life skills training is carried out for OVC children using the Family Health International (FHI) life skills tool kit. The NGO also advocates with the schools to enroll OVC children and provides follow-up support such as assistance in learning and provision of free study materials.
Currently, the Avert project is providing services to 1,500 OVC and plans to reach another 3,000 OVC in FY09. In FY09, a mapping of OVC will be conducted with technical support from the national OVC technical resource group. Accordingly, the program will be scaled-up to reach the new number. The Avert project will train the NGO staff in OVC strategies to provide a minimum standard of care for OVC children. In addition, Avert project will train 30 care givers from the families of OVC children.
Avert project will also provide outreach services and travel support to assist HIV-infected children in accessing ART services. Linkages will be established with educational institutions, child survival programs, orphanages, nutritional programs and other social support programs to leverage the various services.
In FY10, Avert project will conduct an evaluation and transition nine integrated adult care and OVC programs to MSACS. The Technical Support Unit will assist MSACS in establishing systems to absorb the nine care programs.
Under the National AIDS Control Program Phase III (NACP III), HIV counseling and testing (CT) services have been rapidly scaled-up through out the country. In Maharashtra State, 604 integrated counseling and testing centers (ICTC) have been established in high prevalence districts expanding to all community health centers (CHCs). In addition, ICTC services have been initiated in 152 twenty four-hour primary health centers (PHCs) and 56 ICTC centers were established in the private sector to improve accessibility to most-at-risk-populations (MARPs). Based on request from the National AIDS Control Organization (NACO), the Avert project is demonstrating the link workers program to increase the uptake of ICTC services by mobilizing the MARPs and vulnerable populations using a variety of approaches. The Link Worker Scheme is an outreach strategy in the NACP-III aimed at generating a cadre of trained local personnel ("link workers") to work with MARPs and vulnerable populations, in the rural areas of high burden A and B categorized districts. The Technical Support Unit (TSU) of the Avert project provides technical assistance to the Maharashtra State AIDS Control Society (MSACS) in planning, implementing and monitoring the private sector ICTC services.
Migrants have difficulty accessing the existing health services. There are several factors such as culture, language and being an outsider and not having local identity, that act as barriers to access the ICTC services. NACO aims to test and counsel 80% of migrants reached through prevention programs. Hence, NACO recommended that Avert project pilots a mobile ICTC program for migrant populations, document the lessons learned and assist the national program in designing policies and plans for CT services for migrants country-wide. The mobile ICTC clinics will be scheduled at timings and at sites convenient to the migrant populations.
ACTIVITIES AND EXPECTED RESULTS
ACTIVITY 1: Community Mobilization to Improve Access to CT Services
In FY08, the Avert project with USG funds initiated a Link Worker Program in five high prevalence districts to improve access to prevention, testing care and treatment services for MARPs and vulnerable populations in rural areas. In addition, NACO has selected Avert project to implement the Link Worker Program in 21 high prevalence districts with funding from Global Fund Round Seven. The Avert project will select 21 nongovernmental organizations (NGOs) and build their capacity to manage the Link Worker Program. As a first step, the Avert project will conduct a needs assessment of the district including mapping, to identify 100 high-risk villages based on selected criteria (such as number of positive people, number of MARPs etc.) in line with the link workers guidelines. The aim is to demonstrate the best practices in implementing the Link Worker Program. One of the key strategies of the Link Worker Program is to mobilize MARPs including vulnerable populations to access ICTC services, and to link those who test positive with care and treatment services. The Link Worker Program will network with prevention NGOs for MARPs for linkages to ICTC services. In FY 09 and continuing in FY10, Avert project will strengthen the link workers activities. The link workers will be trained using the standard curriculum developed by NACO. The Link Worker Program will be evaluated and the best practices will be documented and disseminated nationally and internationally including publications in peer reviewed journals.
ACTIVITY 2: Strengthening the CT Services through Mobile ICTCs for Migrants.
The Avert project is piloting six mobile ICTCs in the high prevalence districts of Thane, Aurangabad, Sholapur, Nagpur and Jalna. The district of Thane has the largest concentration of migrants with over 600,000 working in the textile industries. A Technical Resource Group formed for migrant interventions will provide ongoing technical assistance (TA) to strengthen the quality of the ICTC services. The activities of the mobile ICTCs include counseling and testing, STI treatment, TB screening and distribution of information education and communication (IEC) materials. Rapid tests are carried out using the NACO protocol. The testing kits for the mobile ICTC program are leveraged from the MSACS. The mobile ICTC team comprises of two part-time medical officers, two nurses cum counselors and one lab technician. A monitoring system is put in place to track the progress including quality of services. To ensure quality of HIV testing the mobile ICTCs will be linked to the External Quality Assessment Scheme (EQAS) implemented in Maharashtra State. Migrants testing positive will be linked to care and treatment services in the districts. Generally, the migrants stay for a period of three to six months depending upon the nature of occupation. In this context, it is a challenge to provide care and support services when they go back to their villages. The Avert project will take efforts to link the HIV positive migrants to positive networks in their respective states. In FY 10, Avert project will evaluate the effectiveness of the mobile ICTC services, document the best practices and challenges and disseminate at the national and international level including publications in peer reviewed journals. A transition plan will be drawn to transfer the mobile ICTCs to the MSACS.
As FY10 will be the last year of the current Avert project, the project will support evaluation of various programs including prevention programs for most-at-risk-populations (MARPs), workplace interventions and community mobilization programs. In addition, the Avert project will support Maharashtra State AIDS Control Society (MSACS) in conducting data triangulation, correlation and trend analyses of state-level data and collation and analyses of district-level programs. The findings of the evaluation and various state level analyses will feed into the design process of any follow-on assistance provided by USG. The Avert project will also support MSACS in conducting evidence-based planning for the state and disseminating the results at state and national levels.
ACTIVITY 1: Evaluation of Prevention Programs for MARPs
USG will conduct a final evaluation of the prevention programs for the MARPs. The evaluation will address the following questions:
1. Have the prevention programs saturated coverage of MARPs? Have they led to the reduction of HIV prevalence in the districts?
2. How effectively were the prevention strategies for MARPs implemented, including the systems established to monitor the quality of the programs?
3. What were the lessons learned and challenges in implementing the prevention programs among MARPs?
USG will hire a team comprising of international and local experts to conduct the evaluation. The findings of the evaluation will be disseminated at state and national level. In addition, scientific articles on the evaluation findings will be submitted for publication.
ACTIVITY 2: Evaluation of Link Workers Program in Mobilizing Community to Access HIV Services
The Link Worker Program implemented by the Avert project in 25 districts of Maharashtra State will be evaluated - to assess the effectiveness of the various community mobilization strategies to increase the uptake of HIV services. These include prevention, counseling and testing, care and support and ART; the cost-effectiveness of this program and the feasibility of integrating these services into general health services of Maharashtra Government. USG will hire a team comprising of international and local experts to conduct the evaluation. The findings of the evaluation will be disseminated at state and national level. In addition, scientific articles on the evaluation findings will be submitted for publication.
ACTIVITY 3: Evaluation of Integrated Adult Care and Support and HIV Care for Orphan and Vulnerable Children
In FY08, the Avert project initiated the integrated adult care and OVC program in five high prevalence districts. This was based on the lesson learned that, in a concentrated epidemic, it is not cost-effective to implement separate care and support programs for adults and OVC. USG will hire a team comprising of international and local experts to conduct the evaluation. The findings of the evaluation will be disseminated at state and national level. In addition, scientific articles on the evaluation findings will be submitted for publication.
ACTIVITY 4: Evaluation of the Technical Support Unit (TSU) Program
In FY10, the USG funded TSU will complete three years of supporting MSACS in establishing systems to scale-up and to strengthen the quality of prevention programs including public-private-partnerships in counseling and testing and STI services. The USG will hire a team of experts to evaluate the effectiveness of the TSU. The key evaluation questions are:
1. Has the TSU established systems and built the capacity of MSACS in grants management, monitoring and evaluation and training of NGOs?
2. How effective is the role of the TSU in strengthening the District AIDS Prevention Control Units (DAPCUs) to integrate HIV/AIDS programs in the general health services of Maharashtra Government?
3. Has the TSU transferred the skills to MSACS for designing and managing public-private-partnerships in HIV/AIDS?
ACTIVITY 5: Behavioral Surveillance Survey (BSS) Round Six
In FY10, the BSS Round Six (rural and urban) will be undertaken by the Avert project based on the request from State AIDS Control Society (SACS) and covering a large number of groups MARP, bridge population and general population (male/female, youth/adults). The BSS captures the behavioral trends among the MARPs and migrant populations on specific indicators such as consistent condom usage, STI treatment seeking behavior, reduction in multiple partners and HIV testing. The aim of the survey is to assess the impact of prevention programs through the targeted intervention approach for MARPs in urban areas and prevention programs through Link Workers reaching the high-risk populations in the rural areas. The BSS findings will also feed into the evaluation program planned for MARPs. The survey will be undertaken by an external research agency and will be monitored by the technical advisory group of the Avert project.
ACTIVITY 6: Data Triangulation and Analyses
In FY08 and continuing in FY09, the Avert project in collaboration with the Biostatistics Department of the Christian Medical College, Vellore is supporting the state in conducting the triangulation of data to assess the impact of programs, identify programmatic gaps and strengthen policies and programs. In FY10, the focus of data triangulation will be at district-level to better understand the local HIV epidemic and conduct micro-planning to sharpen the focus of the programs. The sources of data will be BSS, data from HIV services (CT, PMTCT, ART) and NGO programs. An overarching approach in conducting the data triangulation is to engage biostatisticians and program officers from the state (MSACS and DAPCU) and build their capacity through hands-on experience. The findings from triangulation and other analysis will be disseminated and sent for publications in peer reviewed journals.
ACTIVITY 7: A Study to Explore Issues of Family Members as Care Givers for PLHIV
NACP III has identified the need to have a community and family-based response in care and support to PLHIV, and hence proposes a shift from provider-centered to family-centered care. The study aims to understand the profile of family care providers, the dynamics within families due to HIV and their needs with regard to providing care and support to PLHIV. The Avert project will hire qualitative experts to conduct the study and the findings will be disseminated at state and national level. The findings will be utilized to design family care-centered strategies, including developing training modules for family care providers.
ACTIVITY 8: Impact Assessment of District Communication Plan
In FY08 and continuing in FY09, the Avert project with technical support from Johns Hopkins University (JHU) had developed district communication plans in the five high prevalence districts. The key strategy of the district communication plan includes the engagement of the entire district health system in implementing of the communication plan. A baseline survey will be conducted prior to implementation of the plan, and an evaluation is planned in FY10 to assess the effectiveness of the district communication approach.
The Avert project plays a critical role in strengthening the health systems activities of the State AIDS Control Societies (SACS) of Maharashtra and Goa States. As requested by the National AIDS Control Organization (NACO), the Avert project established the Technical Support Unit (TSU) in April 2008. The TSU plays a significant role in assisting the SACS to scale-up and improve the quality of HIV/AIDS programs in the two states. NACO has requested the USG to strengthen the District AIDS Prevention Control Unit (DAPCU) in its focus states. While the SACS continue to lead the planning, coordination and monitoring of activities in the states, the DAPCUs are being established to serve as the nodal agencies at the district level to coordinate the HIV/AIDS activities as well as to promote integration with National Rural Health Mission (NRHM). The TSU is tasked to develop a strategic plan in consultations with the SACS to strengthen the DAPCU to achieve the long-term vision of the NACO to integrate with the NRHM by 2012. The Government of India established the NRHM in 2005 with the aim of providing effective health care to rural populations in 18 backward states which have weak public health indicators and weak infrastructure.
ACTIVITY 1: Capacity Building of SACS through TSU
By FY10, the TSU aims to strengthen the systems within the SACS for supporting a sustained response in HIV prevention services. While the SACS is responsible for making grants to non-governmental (NGO) and community-based organizations (CBOs) to implement programs, the TSUs provide strategic and technical assistance and oversight, and lead technical assistance (TA) on critical thematic areas of strategic program management, targeted interventions, capacity building of NGOs/CBOs, mainstreaming and public-private partnerships.
The Avert TSU has played a significant role in assisting the SACS to scale-up and strengthen 84 targeted intervention programs in Maharashtra and 19 in Goa; 60 public-private-partnerships in integrated counseling and testing services; and 1260 sexually transmitted infections (STI) franchising clinics in Maharashtra. One of the key STI strategies of NACO is to partner with preferred private health care providers to provide STI services to MARPS through a franchising approach at district and sub-district levels.
TSUs are assisting the SACS in conducting task analyses, identifying training needs, developing curricula, planning training logistics and implementation, and monitoring and evaluating the quality of training programs. The TSUs have assisted the SACS in developing training plans and conducting training programs for the newly identified targeted intervention NGOs working on prevention for MARPs. For example, the TSU has assisted the SACS in conducting training for NGOs on proposal development, induction training for new NGO staff, and training doctors in STI management, training various cadres of government health workers in order to integrate HIV services in NRHM. In FY08, 1,054 NGO staff in Maharashtra and 150 NGO staff in Goa were trained with TA provided by the TSU. In FY10, Avert project will conduct an evaluation of the effectiveness of TSU (See 17-HVSI Strategic Information for details).
ACTIVITY 2: Technical Support to Strengthen DAPCU
Based on NACO's recommendation, the TSU has developed a plan in consultation with MSACS to strengthen the capacity of the DAPCU in 33 high prevalence districts. Specifically, DAPCU's capacity will be strengthened to coordinate HIV/AIDS programs of the district-level and to integrate HIV services such as STI treatment, counseling and testing and PMTCT into the general health services of Maharashtra Government. The DAPCU team comprises of a District Program Officer, Monitoring & Evaluation officer and Accountant. The TSU will provide technical support to build management and technical capacity of DAPCUs with a focus on program management, coordination and strategic information. To implement this initiative, the TSU has developed a resource pool of 150 consultants to provide ongoing support to the DAPCUs in implementing coordination and integration activities.
ACTIVITY 3: Building State Capacity to Implement a Systems Approach to Curriculum Development and Training
In line with the national agenda, MSACS with support from the TSU has intensified training efforts by identifying a pool of training institutions across the state to deliver technical (prevention, care and treatment) and management training programs to various cadres of NGO and public and private sector staff providing HIV/AIDS services.
A major concern in human capacity building is the lack of competency among training personnel to conduct trainings using scientific approaches including adult learning principles. The TSUs have been mandated to fill this void and support the capacity building efforts of the SACS following a systems approach to curriculum development and training. The TSU in collaboration with the RUHSA (Rural Unit for Health and Social Affairs) Department of Christian Medical College, Vellore, conducted a training of trainers (TOT) training on a Systems Approach to Curriculum Development and Participatory Training Methods. The TSU with technical support from RUHSA will develop a strategic plan to build the capacity of health care and development institutions; capacity-building managers in government and private health institutions, and a large pool of resource persons at state, district and sub-district level. The vision is to develop a culture of adopting a systems approach to curriculum development and training in the state. The best practices of this initiative will be documented and replicated at the national level.
ACTIVITY 4: Provision of In-Service Training
As part of the in-service training program, in FY10, Avert project will conduct a range of the training programs for the outreach team of the NGOs based on the needs identified through task-analysis methods. Avert project will collaborate with the training institutions to train 117 peer educators, 73 project coordinators, 110 counselors, 292 outreach workers, 73 accountants, 30 care providers and 160 link workers. The training programs will be based on the modules developed in consultation with Avert project following systems approach to curriculum development and in-line with the NACO guidelines. The topics include peer development, basic facts in STI/HIV/AIDS, counseling, management information system, care & support and accounts.
The Avert project is implementing prevention activities among most-at-risk populations (MARPs) in five high prevalence districts (Aurangabad, Jalna, Nagpur, Sholapur and Thane) of Maharashtra State. By 2011, Avert project aims to bring down the prevalence from 1% (average of five districts) to less than 0.5% by saturating the coverage and improving the quality of services among MARPs. An epidemiological analysis carried out using Behavioral Surveillance Survey (BSS) and HIV prevalence data showed that a 10% increase in consistent condom usage among female sex workers (FSW) and men who have sex with men (MSM) will lead to a reduction of 0.1% HIV in prevalence among general population.
The Avert project has reached 80% of the estimated 15,000 FSW and 65% of the 17,500 MSM populations with prevention services. The HIV prevalence among FSW in Maharashtra is 17.9% and among MSM 11.9% (Sentinel Surveillance, 2007). Based on the evidence from migrant studies in India, the National AIDS Control Organization (NACO) has identified migrants as an important driver of the HIV/AIDS epidemic. To date, there are no well developed models for migrant interventions in India. To support national efforts in designing migrant strategies, the Avert project has initiated demonstration programs among certain migrant groups who are at greater risk of HIV/AIDS, e.g. those working in textile, construction and sugarcane industries. The Johns Hopkins University (JHU) is supporting the Avert project in designing demand generation campaigns tailored to MARPs. Similarly, Hindustan Latex Family Planning Promotion Trust (HLFPPT) is providing technical support to integrate the condom social marketing program into the MARP interventions. To design and strengthen workplace intervention programs, Avert project is seeking technical assistance (TA) from the International Labor Organization (ILO).
Previously, Avert project supported a large number of nongovernmental organizations (NGOs) to implement prevention activities with MARPs. In line with PEPFAR India vision, the USG HIV/AIDS program, starting from FY09 and continuing in FY10 the Avert project will transition from a direct implementation to a TA program.
In FY 10, Avert prevention activities will focus on the following six key areas; (a) developing learning sites for FSW and MSM interventions; (b) demonstrating models for prevention for migrant populations; (c) demonstrating models for workplace interventions; (d) addressing gender concerns in prevention activities for MARPs; (e) transferring Avert-funded NGOs to Maharashtra State AIDS Control Society (MSACS); and (f) documentation and dissemination.
ACTIVITES AND KEY RESULTS
ACTIVITY 1: Developing learning sites (LS) for FSW and MSM interventions
In FY10, the Avert project will develop two FSW LSs -one brothel-based and one non-brothel based- and one MSM learning site. These LSs are intended to demonstrate best practices in prevention for replication in Maharashtra and Goa States. The brothel and non-brothel based FSW have different community structures. The Nagpur District has a large brothel of over 4,000 FSWs and Aurangabad District has over 4,000 non-brothel based FSWs. Based on lessons learned, the prevention strategies have been revised to suit the context and the needs of these two types of FSWs. Similarly, the Avert project is supporting a well established CBO reaching over 10,000 MSMs in Thane District, and the program in this district will be developed as a MSM learning site. A multi-disciplinary team comprising of a behavioral scientist, bio-statistician and a management expert will be put in place to guide the development of the learning site. In addition, the staffing of the NGOs and the Avert project will be augmented to develop and manage the learning sites for MARPs.
An overarching strategy of the prevention programs adopted by the Avert project is to develop partnerships with the existing community groups and engage them in planning and monitoring the interventions. In line with the national strategy, Avert project has adopted a comprehensive prevention approach such as behavior change interventions; sexual transmitted infection (STI) services tailored to MARPs (over 80% treated); structural interventions to address violence and coercion; legal aid and linkages to social development programs; and referral linkages to counseling and testing (CT) and care and treatment services.
The behavior change interventions are carried out by a strong network of peer educators who are trained on interpersonal communication skills, development of self esteem, STI identification; micro-planning and monitoring following nationally approved training curricula. The peer educator on an average conducts five to seven sessions per FSW with each session lasting one hour in a week. The peer educators are trained to conduct street plays, puppet shows and games related to MARPs. In addition, the peer educators promote condoms (male and female); provide accompanied referral services to FSW on STI, CT and care and treatment and document the activities. JHU has developed a set of innovative materials for outreach workers and the peer educators including street play scripts to conduct behavior change interventions with MARPs. The picture and color coded monitoring tools developed by Bill and Melinda Gates Foundation (BMGF) for peer educators to monitor and record activities are adopted by the Avert project.
HLFPPT provides condom social marketing support by establishing condom outlets that are easily accessible to MARPs and their clients. In addition, free condoms are distributed by the peer educators to FSWs and MSMs to ensure that condoms are available at all times to negotiate use with clients.
The Avert project has developed referral systems for CT and care and treatment services, to ensure that over 80% of MARPs are counseled and tested, and those tested positive have access to ART services. The Avert project will also develop a network of positive MARPs groups which will implement positive prevention programs including linkages to care and treatment services.
In FY09, the Avert project is planning to integrate research and evaluation into the MARP intervention to test the efficacy of the prevention strategies. The research will answer reasons of non-coverage of MARPs including accessibility to services. Avert project will also strengthen the monitoring and evaluation (M&E) system including data management system and enhance the capacity of the staff in conducting evaluation, analysis and dissemination.
ACTIVITY 2: Demonstrating Models on Migrant Interventions
Maharashtra is an industrial state that attracts a large number of migrant workers from different parts of the country. The majority of the migrants come from the states of Uttar Pradesh (27 percent), Karnataka (19 percent), Gujarat (10 percent), Madhya Pradesh (10 percent), and Andhra Pradesh (7 percent). It is estimated that there are over 6.2 million migrants (census report, 2001) and of these 1 million are vulnerable to HIV (estimate based on Pop Council Study) in the five Avert priority districts. The migrant types are linked to the nature of industries. For example, textile industries have predominantly single male migrants while the sugar cane and brick making industries have family migrants. In FY08, Avert project had initiated 24 interventions among migrants in the textile, brick making and small scale industries. From among these interventions, the Avert project is planning to develop three models on migrant interventions among textile, brick making and selected small scale industries that are at risk to HIV. The Avert project is establishing a technical resource group comprising experts in migrant research and programs to guide the design, implementation, M&E and research. The behavior change communication (BCC) approaches are tailored to the migrant subcultures and includes advocacy with management, peer-led group sessions and community media activities such as street play, puppet shows and games. The peer educators are trained in interpersonal communication skills, basic facts on HIV/AIDS, condom promotion and referral services using a standard curriculum. The peer educators conduct three group sessions of one hour each for their unit of workers in a week. The peer educators will monitor the activities using a simplified tool that are color and picture coded. Avert project is implementing a mobile STI and CT services for the migrant populations (details provided in 14 HVCT) and those testing positive will be supported with accompanied referrals to care and treatment services including motivating them to join the people living with HIV/AIDS (PLHIV) network. The adult care and support strategy envisages networking between MARP NGOs and the care and treatment programs to facilitate HIV care services to MARPs. Avert project will also conduct operational research studies in behavioral intervention models and improving access to HIV services. In FY10, Avert project will document the best practices, disseminate to NACO and provide technical support in developing policies and guidelines for national level scale-up.
ACTIVITY 3: Demonstrating Models on Workplace Interventions
In FY09, the Avert project with technical assistance (TA) from the International Labor Organization (ILO) will conduct a study to identify industrial sectors vulnerable to HIV in the five industrial zones located in Nagpur, Nasik, Thane, Mumbai and Pune (Pop Council, 2008). In addition, the Avert project will also conduct a study to assess the vulnerability of the workers in the sugarcane industry in the sugar cane belt comprising of Sangli, Satara and Kolhapur districts. Based on the findings of the two studies, Avert project will prioritize vulnerable sectors in the five districts and a baseline behavioral survey among workers will be conducted. Avert project will select lead NGOs in these districts to implement a comprehensive workplace intervention program with technical support from ILO. JHU will develop communication materials including workplace intervention campaigns tailored to the context and the vulnerability to HIV/AIDS of different sectors. The BCC approaches in workplace intervention includes advocacy with senior management, peer-led interpersonal communication activities and small media activities such as street plays and exhibitions. Motivated peer educators from the different units of an industry will be identified and trained using standard curricula. The Avert project will also advocate with the industries to develop HIV/AIDS workplace policies to support prevention, care and treatment services. The Avert project will adopt various strategies to provide CT services to most-at-risk workers including organizing mobile testing services and providing accompanied referrals to CT centers in public and private sectors. Networking between workplace intervention and care and support NGOs including PLHIV networks will be conducted to facilitate HIV care services to workers tested positive. A monitoring and evaluation system including a robust management information system (MIS) will be developed to assess progress and to identify gaps and strengthen the interventions. In FY10, the demonstration programs will be continued and an evaluation will be conducted to assess the outcomes of the workplace intervention program. Avert project with technical support from ILO will document the best practices and will disseminate them to a variety of stakeholders including National AIDS Control Organization (NACO), Ministry of Labor and Ministry of Industries. In addition, a national policy and operational guidelines will be developed for replication in other states.
ACTIVITY 4: Programs to Address Gender Concerns
The key strategy of Avert project is to mainstream gender activities in the prevention, care and support programs implemented by NGOs. In the FSW intervention, the strategies included formation of crisis groups to address violence and coercion by police and clients, legal aid and advocacy with the police. In the migrant intervention programs, gender strategies will focus on addressing sexual exploitation of women by labor contractors. The technical capacity of the Avert project to carry out gender programming is not strong. Hence, Avert project will seek technical assistance from the USG PEPFAR Gender Technical Working Group (TWG) at headquarters who will collaborate with local gender experts for strengthening the gender activities including developing guidelines, training modules and monitoring tools. In FY10, an evaluation of HIV/AIDS gender programming will be conducted through gender audit, the best practices will be documented and dissemination will be carried out nationally. Avert project will support USG in providing technical assistance (TA) to NACO in developing policies and guidelines to address gender concerns for MARPs.
ACTIVITY 5: Transfer of NGOs to MSACS
The second phase of the Avert project will end in June 2011. In anticipation of the project ending, the Avert project is gradually transitioning from direct implementation to a TA mode. An evaluation of the Avert project will be conducted in 2011 (details in HSS budget code narrative). As part of these transition efforts, the Avert project will plan with MSACS and NACO to transfer 25% of grants (20) in FY09 and 75% of grants (40) in FY10 to government funding. The Technical Support Unit (TSU) will support the Avert project in transferring the grants including strengthening the systems at the MSACS and district AIDS prevention control units (DAPCU) to manage the additional burden.
ACTIVITY 6: Documentation and Dissemination:
Avert project will hire experts to document the best practices of the demonstration programs on migrants and workplace interventions. In addition, articles will be written and sent to peer-reviewed journals for publication.