New/Continuing Activity: Continuing Activity

Continuing Activity: 19453

Continued Associated Activity Information

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

System ID System ID

19453 19453.08 U.S. Agency for United Nations 7739 3955.08 FBO Palliative $300,000

International Development Care and

Development Programme Prevention

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $60,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

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

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Biomedical Prevention: Intravenous and non-Intravenous Drug Use

The HIV/AIDS epidemic in Russia continues to evolve. Approximately 44,000 new cases of HIV were registered in 2007, a rate of

~10-12% per year since 2004. While an increased percentage of newly detected cases of HIV in Russia are attributed to

heterosexual transmission (34% in 2007), available data from routine and surveillance data supports continued concentration of

the HIV epidemic in Russia among injecting drug users (IDUs), mostly male, and their sex partners. A majority of the newly

detected cases (65% in 2007) are attributed to injecting drug use. Men account for ~70% of all IDUs in Russia and they accounted

for 57% of newly detected cases of HIV in 2007. Among the cases of HIV among women (44% of all cases), 2/3 of these were

attributed to heterosexual contact; however, there is evidence that this is also linked with IDU. A study of HIV-infected women in 5

cities in 2006 found high rates of personal injecting drug use (15%-50%) and sexual contact with known IDUs (25%-61%).

Similarly, a case-control study found strong risk factors for HIV among women were having regular partners who were HIV-

positive or IDUs. In addition, HIV prevalence among non-IDU commercial sex workers (CSWs) who were hepatitis C-negative was

less than 5% in a two city survey in 2007, suggesting that even among individuals with high numbers of partners, heterosexual

HIV transmission remains limited. In light of these findings, the USG support will prioritize prevention among IDUs and their sex

partners. A smaller portion of the prevention program will target sexual prevention activities (see Sexual Prevention).

The estimated IDU population in Russia is between 1.5-3 mln (2-4% of adults 15-49 years of age). HIV prevalence among

surveyed IDUs varies widely between regions from 0-64% in 2005-2007. Due to high rates of IDU, HIV is now established in

marginalized groups including CSWs, prisoners, street youth, and to a lesser extent men having sex with men (MSM). Among

CSWs, HIV infection is tightly linked to IDU risk. Among 1,016 CSW surveyed in 10 cities in 2006, IDU-CSWs had an HIV rate of

11.2% versus 0.6% among non-IDUs. Among prisoners, 4% are HIV-positive and IDU is the overwhelming risk factor. Among

street youth in St. Petersburg, more than 90% of HIV infections were in the half of street youth that admitted IDU. Among MSM,

rates of HIV in available surveys are low (0-9%); where evaluated, the majority of these HIV infections are not linked to IDU,

however IDU dramatically increases the risk of being HIV positive.

In 2008, the Government of Russia (GOR) demonstrated a growing commitment to HIV prevention by doubling the prevention

budget under the National Priority Project from approximately $8M in 2006 to $17M in 2008 and 2009. However, this represents

less than six percent of the total GOR spending on HIV and only 25% of this figure was targeted directly for interventions among

most at-risk populations (MARPS). This prevention estimate includes a few, relatively small federal tenders for prevention

programs through the NGO community such as last year's three year, $2M award to a local NGO consortium for prevention

among MARPS programs. Although it is often difficult for Russian NGOs to access GOR grants, there are a number of NGOs that

have been able to secure support from either the municipal, regional or federal government. For example, the partially USG-

supported Center for Drug Addiction in St. Petersburg is now receiving funds from the municipal government to provide case

management for patients who have completed substance abuse treatment and need support to reintegrate into society. The NGO

has also been able to secure funds to conduct training of other NGOs in Global Fund (GF)-supported regions. USG will explore

ways to replicate this approach and promote successful NGO practices at federal and regional levels.

However, even with a doubling of GOR resources, international partners such as GF and USG remain the primary resource for

prevention among MARPs. Prevention among MARPs is largely carried out by NGOs which effectively provide outreach,

information and referrals to health and social services for these marginalized groups. In regions where GOR National Priority

Project "Health", GF and PEPFAR programs for MARPs exist, coverage is estimated to reach only 24% of IDUs.

In addition to insufficient GOR funding on prevention, there are a number of other challenges to effective HIV prevention for IDUs.

Importantly, there is limited awareness of drug addiction and effective prevention, treatment and care interventions for substance

abuse among decision-makers, affected families and the public. Within Russian society, considerable stigma and discrimination

continues to be associated with HIV and drug abuse. Governmental health and social services lack trained specialists and

services tailored to the needs of IDUs. The legal status of prevention programs among IDUs, such as for risk reduction, are

ambiguous, and most medication assisted treatment (MAT) for opioid dependency is prohibited by law. IDUs have very limited

access to counseling, drug treatment, and rehabilitation. Effective outreach to IDUs remains challenging, and innovative case

management systems developed with USG support that facilitate access to services and encourage adherence are still new and

require further technical assistance and monitoring.

Continued USG leadership will be especially important in FY 2009 and beyond as prevention programs for IDUs through the GF

Rounds 3, 4 and 5 grants end in December 2009, 2010 and 2011 respectively. The USG program will continue working with the

government and civil society to advocate for effective prevention programs for IDUs that are integrated into regional and national

HIV programs.

In FY09, building on success in reaching a growing number of MARPS in PEPFAR target regions (almost 25,000 MARPs in FY

2008), the USG technical assistance will advance the work of NGOs working with HIV prevention among IDUs with the aim to

reduce the risk of HIV transmission through three approaches to address the complex medical, social support and psychological

assistance needs essential for sustained behavior change.

First, USG-supported partners will train local partners on effective monitoring and tracking of outreach to substance abusers and

their sexual partners with a tailored package of HIV prevention programs. This package, based on USG-supported best practices

the past few years will focus on IDUs and their sexual partners and include community-based and peer-to-peer outreach,

provision of risk reduction information and counseling, and the promotion of condoms to prevent sexual transmission of HIV to

IDUs' partners. In FY09 USG-supported partners will build on the successful case management approach that was developed

through the PSI program that trained local NGO partners in case management and established four case management hubs in

the two target PEPFAR regions where over 1,400 individuals received assistance. In FY09, USG assistance will include provision

of training and capacity building to local partners to continue to reach IDUs with case management that addresses HIV prevention

pioneered by USG partners, linking IDUs to necessary support services (e.g. to secure legal registration documents necessary to

access health services in Russia) and health care (e.g. for HIV counseling and testing, TB treatment and diagnosis, treatment of

sexually transmitted infections (STIs), and substance abuse treatment and rehabilitation.) Another example will include the work

through a Russian NGO to train female CSWs to deliver HIV prevention messages to other CSWs as peers, prioritizing those

CSWs with substance abuse issues.

Second, USG/Russia partners will provide technical advice and guidance to health professionals and NGOs to enhance

substance abuse programs as HIV prevention. USG's umbrella grant program with the UNDP will provide technical assistance

and training to NGOs and FBOs to develop more effective monitoring and measurement of drug-free rehabilitation programs and

the impact of support groups for substance abusers which currently reach over 200 clients in the target regions.

Supporting multiple entry points to substance abuse treatment and rehabilitation will be a priority. For example, USG partners will

train NGO and governmental substance abuse center staff in offering outpatient clinics for female drug addicts with children. This

will also include technical advice, training and support to governmental service providers for advancing the multi-disciplinary team

approach at substance abuse facilities to link clients to other needed services, including counseling and testing for HIV, STI

diagnosis and treatment and TB treatment. These programs give special attention to reaching sexual partners of IDUs and to

addressing the needs of female and pregnant IDUs and ensuring their referral to appropriate services. Substance abuse among

youth is another area of focus for the USG program. To address IDU and non-injection drug abuse (NIDU) among youth, the USG

will continue to support initiatives that address experimental injection and NIDU among youth through peer outreach, training of

parents and educators, family therapy, and referrals to relevant medical or social services.

In FY09, USG partners will promote the exchange of international best practices for HIV and drug abuse prevention in order to

address the outdated, poor quality, highly priced and limited availability of substance abuse treatment and care services. This

includes supporting an exchange of information, current research and experience with successful models of prevention between

international experts and Russian policy makers and professionals in the areas of HIV, substance abuse, health, and social

welfare. A series of "master classes" will be convened at regional and federal levels on a range of HIV and substance abuse

treatment and rehabilitation interventions, such as drug free rehabilitation, cognitive therapy, therapeutic communities, a

multidisciplinary approach to rehabilitation, 12-step programs, group therapy, and individual and family counseling. Special

attention will be given to strengthening the collaboration between governmental and non-governmental service providers;

integrating HIV prevention into existing health, substance abuse and social services for IDUs; and consolidating a system of

referrals to ensure access to a broad package of HIV prevention interventions. For example, a USG partner will work with local

NGO and governmental drug treatment facilities to provide training for peer counselors to conduct risk reduction counseling and

link HIV-positive clients to AIDS Centers for treatment and care.

As part of the USG support for substance abuse programs as HIV prevention, particular attention will also be paid to opportunities

for further consideration of MAT in Russia. Despite the aversion of some Russian officials to the use of methadone, which remains

illegal in Russia, the USG program will pursue a strategic pathway to the adoption of greater treatment options and the expansion

of MAT. The only drug approved in Russia for heroin addiction treatment is naltrexone. While studies in both the US and Russia

on the effectiveness of naltrexone, especially long-acting formulations, are recent and limited, they provide a platform for further

consideration of MAT as a tool for HIV prevention among drug abusers and for improving adherence to anti-retroviral treatment

(ART) among HIV-positive drug abusers. In light of domestic production of naltrexone, its approved use for substance abuse

treatment and recent interest in its use for outpatient treatment and rehabilitation of heroin addiction, the USG will continue to

explore ways, such as exchanges between Russian and foreign health professionals, to further the dialogue and promote wider

consideration of MAT as an important intervention in Russia's response to HIV/AIDS.

Third, USG partners will continue to address the policy barriers to effective HIV prevention among IDUs, including restrictive and

prohibitive legislation, an outdated approach to substance abuse treatment and rehabilitation, and highly vertical systems for the

separate delivery of HIV and substance abuse services. The USG/Russia PEPFAR program will intensify policy dialogue efforts at

national and regional levels on issues relating to IDUs and MARPs access to information and services for HIV prevention (see

health systems strengthening). For example, wider application of Russia's "preventive registration" for IDUs that agree to seek

drug abuse treatment and care instead of being prosecuted under the law may facilitate IDUs accessing other HIV prevention

services such as HIV counseling and testing, and treatment of sexually transmitted infections.

With FY09 funding, USG assistance will launch a process to bring together Russian decision-makers, providers, NGOs and

people living with HIV/AIDS to prioritize effective interventions for IDUs that can be transferred to and disseminated more widely

by Russian governmental, NGO and faith-based partners. The process will build on the inventory of best practices in USG- and

GF-supported regions and regions participating in MARPs prevention under the GOR National Priority Health project. This

inventory, expected this year (with FY08 USG funds) will inform the work of USG partners in the coming year and will provide a

means for sharing best practices and strengthening partnerships between NGOs and GOR, including exploring options to

formalize relationships best suited to reach the MARPs. This effort may include links with national NGO networks working on

HIV/AIDS to facilitate their participation with the GOR in the development of a joint platform for action. It will also include work with

NGOs currently providing services to build their capacity and develop sustainability plans for their eventual transition from USG

support, building on the success of a growing number of NGOs who are accessing government support. Additionally, continued

technical advice, training and support will enable new and existing partners to provide needed high quality services for IDU.

Products/Outputs:

•Increased awareness of the complexity of drug addiction and of effective HIV prevention for IDUs among policy makers, program

managers and service providers

•Strengthened collaboration between NGOs and Government in HIV prevention

•Increased potential for greater GOR focus on support to NGOs

•USG-supported HIV prevention interventions for IDU summarized and shared with governmental and civil society partners for

dissemination

•HIV prevention interventions provided to female IDUs, sexual partners of IDUs, and IDU's family members

•Increased number of IDUs receiving HIV prevention services

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

Total Planned Funding for Program Budget Code: $0

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

Total Planned Funding for Program Budget Code: $3,000,000

Total Planned Funding for Program Budget Code: $0

Table 3.3.06:

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $120,000

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: $2,580,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Program Area: Adult Care and Treatment

The provision of anti-retroviral treatment (ART) to over 35,000 people living with HIV/AIDS (PLWHA) in 2007, largely by the

Government of Russia (GOR), is the greatest success to date in a growing national response to HIV/AIDS. With Russia's

epidemic maturing, many of the large number of HIV-positive individuals infected between 1998 and 2001 are now reaching

advanced stages of immunodeficiency, and the number of people needing ART and care will dramatically increase in the next few

years. To address these needs, the GOR has committed to the universal access targets of providing ART services to at least

80% of PLWHA in need by 2010. The GOR has allocated $197 million in 2007 compared to $68 million in 2006. The Global Fund

(GF)-supported cohort analysis showed that 78% of people living with HIV/AIDS (PLWHA) known to be on anti-retroviral

treatment (ART) 12 months after initiation of antiretroviral therapy indicating improving quality of ART. The GOR's continued

success in treatment will be predicated on the decentralization of ART and care services from specialized AIDS centers to primary

care facilities; a successful model that was initiated with USG support in St. Petersburg and will be finalized by September 2009.

Building on the GOR's commitment to 80% ART coverage for their universal access goals and the development and anticipated

dissemination of an effective decentralized model of ART service provision in PEPFAR sites, no additional PEPFAR funding will

be provided in the Adult Treatment category. Instead the USG funds will target care and support for adults as described below.

With increased provision of ART, the needs for care and support services for people PLWHA are more and more apparent.

Opportunistic infections are especially pronounced in HIV-positive patients with marginalized status, and more than 80% of

PLWHA in Russia are or were substance abusers, commercial sex workers (CSWs), vulnerable youth, prisoners or a combination

of these. There are significant challenges to linking these marginalized populations with care services and keeping them on

treatment. It has been found that those in care are more likely to adhere to treatment, so getting people into care is critical. In the

case of injecting drug users (IDUs), there are particular challenges to accessing care and treatment; for example the poor quality

of many drug treatment and rehabilitation services and the limited availability of rehabilitation options. There are also legal

barriers, including an opposition to medication assisted treatment (MAT) for opiate dependence. Methadone remains illegal.

More generally, the lack of policies at the regional and municipal levels and the lack of mechanisms for their implementation are

obstacles to achieving national goals for HIV/AIDS care.

Continued USG assistance for care is a key priority under the USG/Russia PEPFAR program. Influenced by international donors

and the Global Fund (GF), the GOR has recognized the need for enhanced care services for PLWHA. The GOR has committed to

meeting universal access goals of providing treatment of opportunistic infections and monitoring for at least 70% of those in need,

and psychological support and palliative care for at least 80% of those in need by 2010. Yet the implementation of such policies

remains a challenge.

Previous USG assistance helped regional governments in PEPFAR sites to introduce a system for treatment and care that

provides a platform for coordination of governmental and NGO interventions that are based on a patient-centered approach to

service provision. Decentralization of services from AIDS centers to municipal level health and social facilities is strongly

emphasized. Through training and technical expertise, this networking system integrates HIV/AIDS services with primary care,

substance abuse prevention and treatment, social support services and other health care for PLWHA, and successfully targets the

most at-risk populations (MARPs) to get them into needed treatment and care programs. The emphasis is on the role of primary

care clinics including medical follow up of HIV-positive patients; referrals to substance abuse treatment; multidisciplinary

adherence teams at the AIDS centers; psychosocial support services; treatment of opportunistic infections (OIs) provided by

infectious disease specialists; and integration of counseling and testing services into the scope of general health care

practitioners.

The USG supported the development of a framework that clearly identifies the roles and responsibilities of a regional/municipal

network of health, social agencies and NGOs in provision of clinical, psychological, spiritual, social and prevention services from

the time of diagnosis throughout the continuum of illness. In FY09, USG partners will explore best methods for dissemination to

the GOR of this framework. The framework will include a description of algorithms and referral mechanisms between services,

recording forms, models of district plans, and guidance on the formation and functioning of coordination councils/committees.

Part of this effort will include development of enabling policies, laws, and guidelines at the regional and municipal levels. This

assistance will be provided by USG implementing partners who will work with government and NGO partners to inform regional

and local governments on the impact of policy changes. These efforts will strengthen the ability and commitment of the regional

governments and NGOs to implement this patient-centered, integrated system of quality care for MARPS.

Further limited USG assistance to the Russian post-graduate medical continuing education program for health professionals will

help ensure a critical mass of treatment and care providers trained in HIV-related treatment and care best practices.

In FY09, in terms of targeting priority populations, USG assistance will include training and capacity building for NGOs and

governmental providers working in various areas of the care continuum. First, building on the successes of USG-supported

community-based program for HIV-positive street youth in St. Petersburg (37% of street youth were HIV+ in 2006), USG will

support measures and technical assistance to institutionalize this program with longer-term financial support from the St.

Petersburg Social Services Administration. With USG technical assistance and training, the integrated approach coordinates

governmental agencies and NGOs providing street outreach, drop-in-centers, overnight shelters, halfway houses, HIV prevention,

risk-reduction, and behavior change communication. By September 2010, over 100 NGO and state service providers will be well

positioned to work as a network and serve as a resource center for wider dissemination of the approach in Russia. This will be

especially important for local administrations grappling with street youth populations in other urban centers across Russia.

Second, the USG program will support faith-based organizations (FBOs) providing care, building on resource centers established

to provide training for FBOs on three topics: home-based and terminal care, psychological assistance to PLWHA at the parishes,

and HIV prevention and drug-free rehabilitation for IDUs (see biomedical prevention). With FY09 funds, FBOs will be supported

both to engage with the GOR to influence HIV policies and programming for PLWHA care and support, and to disseminate their

models of palliative care and spiritual support throughout the faith-based community.

Third, the USG will continue to support and build the capacity of Russian NGOs to provide care and support activities for HIV-

positive people. Over the last ten years, some 200 NGOs have been increasingly engaged in the fight against HIV/AIDS. A

growing number of these NGOs have recently begun providing care services to PLWHA. In PEPFAR focus regions in 2008, half of

all NGO clients were HIV-positive, and NGOs provided needed care and support for these PLWHA, including behavioral

counseling, case management, peer support groups, and counseling and testing of family members. Like the FBOs, NGOs will be

supported to engage with the GOR in policy dialogue and program planning and coordination as well as to disseminate their

successful care interventions more widely. Particular focus will be given to strengthening the formal relationships between the

GOR and civil society, with a view to consolidating strong partnerships and eventually establishing contracting mechanisms that

can sustain civil society's involvement in HIV care programming.

Fourth, complementary to USG assistance for care for PLWHA in the FBO or NGO setting, HIV-positive detainees are equally in

need of care and treatment. It is widely recognized that substance abuse correlates with criminal behavior and, and many HIV-

positive IDUs are in regular contact with the police and spend time in detention facilities and prisons. Building on the success of

reaching more than 5,000 PLWHA in the penal system with HIV/AIDS care in PEPFAR-supported regions in 2008, the USG-

supported model of care and support for detainees will be finalized and shared with the relevant GOR authorities for adoption and

dissemination. The USG-supported efforts for HIV-positive prisoners provides for case management, medical services, drug

abuse treatment and rehabilitation, psychological and legal support, employment training and counseling, self-help groups, peer

support, and social services.

USG-supported strategic information activities are an integral part of the care program and will continue to provide data for

decision making. For example, activities will include training in the use of CARE Ware HMIS software, how to conduct clinical

chart audits, and how to use the PMTCT database to monitor treatment and care. Access to evidence-based practices will be

provided to policy makers and care providers through the established resource centers, web-sites, distance learning and internet-

based clinical consultations.

Since the driving force behind the HIV/AIDS epidemic across the Russian Federation has been, and continues to be, injecting

drug use, USG efforts will also specifically target the weak link in the Russian HIV/AIDS treatment and care system - namely the

outdated, poor quality, and limited availability of substance abuse treatment and care services. (see biomedical prevention).

USG implementing partners will promote an increased awareness of international best practices for care and treatment of HIV-

positive IDUs. Building on previous success, a series of "master classes" on the continuum of HIV and substance abuse

treatment and rehabilitation interventions will be convened at regional and federal levels; these will include information on effective

methods to monitor and evaluate services for HIV-positive IDUs.

Additionally, particular attention will be paid to opportunities for further consideration of medication assisted treatment (MAT) in

Russia. Despite the aversion of some Russian officials to the use of methadone, which remains illegal in Russia, the USG

program will pursue a strategic pathway to the adoption of greater treatment options and the introduction of a form of MAT. The

only drug approved in Russia for heroin addiction treatment is naltrexone. While studies in both the US and Russia on the

effectiveness of naltrexone, especially long-acting formulations, are recent and limited, they provide a platform for further

consideration of MAT as a tool for HIV prevention among drug abusers and for improving adherence to ART among HIV-positive

drug users. In light of domestic production of naltrexone, its approved use for substance abuse treatment and recent interest in its

use for outpatient treatment and rehabilitation of heroin addiction, the USG will continue to explore ways, such as exchanges

between Russian and foreign health professionals, to further the dialogue and promote wider consideration of MAT as an

important intervention in Russia's response to HIV/AIDS.

In response to the increasing number of HIV-positive women who are either IDUs or sexual partners of IDUs, the USG will

intensify assistance to care providers and policy makers to identify and share best practices and effective models to address the

specific needs of these women and their families. A package of organizational guidelines for the delivery of care and social

support services for HIV-affected families will be finalized by the Government of St. Petersburg and provided to federal and

regional authorities for dissemination. These guidelines will further strengthen case management and treatment referral systems

to ensure client-focused care and the provision of needed health care, social support and prevention.

Specialized training curricula on HIV/AIDS and related subjects will be disseminated to postgraduate medical training institutions

to ensure the Russian ownership and sustainability of medical education on HIV/AIDS in high prevalence regions. To strengthen

service provision, the role of nurses in ensuring universal access to HIV treatment and care will be emphasized. Technical

assistance will be provided on early detection and clinical management of HIV related opportunistic infections to health care

providers in primary care facilities. Limited TA will be provided to officials at federal and local levels to implement enhanced care

models, including greater involvement of nurses. Experienced nurses will provide mentoring and other U.S. expertise will be

drawn upon as appropriate. Expansion of specialized training curricula on HIV/AIDS and related subjects to postgraduate medical

training institutions will continue through 2009.

The dissemination approaches will be proposed by USG and discussed with the GOR. The two critical conditions to success will

be the GOR's political commitment and buy-in at the federal and regional levels.

Products/Outputs:

•Integrated approach to HIV prevention, treatment and care for MARPs, particularly IDUs, fully implemented in PEPFAR sites and

disseminated to other regions.

•Strategy for the dissemination of a system of improved HIV treatment and care with a focus on MARPs approved and launched at

the federal level.

•Number of GOR, NGO and FBO service outlets providing HIV-related care increased.

•900 community-based, health care, educational, psychosocial workers of GOR, NGOs and FBOs trained in care, thereby

expanding the range of service providers able to provide palliative care.

Table 3.3.08:

New/Continuing Activity: Continuing Activity

Continuing Activity: 19455

Continued Associated Activity Information

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

System ID System ID

19455 19455.08 U.S. Agency for United Nations 7739 3955.08 FBO Palliative $120,000

International Development Care and

Development Programme Prevention

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $210,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.08: