Attachment_10_CAPACITY_Final_Report_2009.pdf

Submitted 24 December by

JSI Research & Training

Institute, Inc. (JSI)

CAPACITY PROJECT

FINAL REPORT

30 September 2004 29 September 2009–

CAPACITY was a 5-year program funded by the United States Agency for

International Development (USAID) and implemented in Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. The purpose of

CAPACITY was to provide technical support and assistance to the countries of Central Asia in their efforts to launch large-scale and urgent responses to the HIV/AIDS epidemic in vulnerable populations.

CAPACITY was implemented by JSI Research & Training Institute, Inc., with partners Abt Associates, Boston University, Howard University, the

International HIV/AIDS Alliance, and Population Services International.

We would like to express our gratitude to the United States Agency for

International Development (USAID) for its generous financial support of our project (cooperative agreement #176-A-00-04-00014-00). We would also like to express our appreciation to the Ministries of Health of the five countries of Central Asia, National AIDS Centers and all the other local and international partners that have worked closely with us to make this project successful. And, of course, this project could not have been implemented without the highly professional and dedicated team that worked on the project.

This document was made possible through support provided by

US Agency for International Development, under the terms of

Cooperative Agreement No. 176-A-00-04-00014-00.The opinions expressed and conclusions drawn in this report are those of the authors, and may not be those of the

US government or of the Governments of the Republics of Central Asia.

ACKNOWLEDGMENT

www.capacityproject.info

LIST OF ACRONYMS

AFB acid fast bacilli

AFEW AIDS Foundation East-West

AIDS Acquired Immunodeficiency Syndrome

ART antiretroviral therapy

ASO AIDS service organization

CAAP Central Asian AIDS Control Project

CAPACITY Central Asian Program on AIDS Control and Intervention Targeting Youth and

High-risk Groups

CMS community mobilization strategy

DDRP drug demand reduction program

DoH Department of Health

DOTS directly-observed treatment, short-course (for TB control)

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria

HIV Human Immunodeficiency Virus

IDU injecting drug user

IEC information, education, communication

IHMS Institute of Health and Medical Statistic

IPC interpersonal communication

IPT isoniazide preventive treatment

JSI JSI Research & Training Institute, Inc.

MARP most-at-risk populations

M&E monitoring and evaluation

MoH Ministry of Health

MoJ Ministry of Justice

NACM national HIV/AIDS coordinating mechanism

NGO nongovernmental organization

OAM opportunity, ability and motivation

PERForM Performance Framework for Social Marketing

PIU Principle Implementation Unit (of Global Fund Grant)

PLHIV people living with HIV

PSI Population Services International

RAC Republican AIDS Center

RFM Republican Fund Mahalla

STI sexually transmitted infection

SWELL sites where at-risk youth have sex, work, entertain, live, and learn

TA technical assistance

TB tuberculosis

ToT training-of-trainers

TRaC Tracking Results Continuous Survey

TWG technical working group

UIC unique identifier code

UN United Nations

UNAIDS United Nations Program on HIV/AIDS

UNDP United Nations Development Program

UNGASS United Nations General Assembly Special Session (on HIV and AIDS)

UNODC United Nations Office on Drugs and Crime

USAID US Agency for International Development

VCT voluntary counseling and testing (for HIV)

WHO World Health Organization

YC youth center

YPC youth power center

TABLE OF CONTENTS

Introduction 1

Chapter 1: Strengthening Stewardship of National AIDS Programs through secondment of specialists

Chapter 2: The TUMAR Project: Achieving high coverage of injecting drug users and sex workers with a comprehensive package of HIV prevention services

Chapter 3: Youth Power Centers: HIV Prevention among At-Risk Youth 24

Chapter 4: Targeted Capacity Building of AIDS-Service Organizations and

Community Mobilization for Increased Coverage of Most-at-Risk Populations

Chapter 5: Engaging communities in HIV prevention activities in Uzbekistan 38

Chapter 6: Improving the Management of Patients with Dual HIV and TB

Infections in Central Asia

Chapter 7: Development of the model of voluntary counseling and testing for

HIV in the Kyrgyz Republic

Chapter 8: Integration of anti-retroviral therapy and HIV prevention within the primary health care system

The CAPACITY Project, USAID s premier HIV and

AIDS project for Central Asia, was awarded in

September 2004 and was implemented for the five year period ending in September 2009.

CAPACITY covered the five former Soviet Central

Asian

1. Improving Stewarship of the National HIV and

AIDS Programs in Central Asia

2. Educating and Empowering Vulnerable

Populations

3. Improving Quality of HIV and AIDS Services

4. Improving Resource-Use through the

Integration of HIV and AIDS Services

In order for countries to succeed in their response to the HIV epidemics, it is necessary for them to have sufficient capacity, tools, and coordination. Three main areas were identified for strengthening early during the CAPACITY

Project. These were monitoring and evaluation, communication, and inclusion of NGOs and civil society into the national decision-making and coordinating bodies. CAPACITY s major effort for strengthing stewardship was through the secondment of specialists in these three areas to the national AIDS coordinating mechanisms

(NACM). Chapter 1 of this final report describes the process used for seconding staff to the

NACMs and the results of doing so.

The HIV epidemics in Central Asia are concentrated primarily among injection drug users (IDU) and sex workers. To some degree, young people who tend to generally be risk takers and may be influenced by their exposure to injection drug use, may also be at risk for HIV.

Republics Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan, and included four strategic directions. These were:

Improving Stewarship of the National HIV and

AIDS Programs in Central Asia

Educating and Empowering Vulnerable

Populations

INTRODUCTION

The CAPACITY Project focused its prevention efforts on these three vulnerable populations.

Chapter 2 describes the TUMAR Project, which was an HIV prevention project nested within

CAPACITY, to provide high coverage with comprehensive HIV prevention services to IDUs and sex workers in seven sites in four countries of Central Asia. This chapter discusses the package of services that were provided by local

AIDS service organizations (ASO), and the significant results that they achieved with technical support from CAPACITY. Chapter 3 explains CAPACITY s implementation and support for Youth Power Centers in Kazakhstan, Kyrgyzstan, and Turkmenistan, designed to provide HIV prevention education services for at-risk youth.

To improve overall coverage of these vulnerable populations with HIV prevention services, CAPACITY also worked with local governmental

ASOs rograms and prepare funding proposals to international grant-makers.

They also improved skills in various aspects of organizational management and how to provide essential, comprehensive services to the most-at-risk populations. In Uzbekistan, traditional community organizations called

There are increasing numbers of people in

Central Asia who are in need of HIV diagnosis and treatment.

and non-governmental to build their organizational, institutional, and techincal capacity. Chapter 4 tells how CAPACITY implemented the community mobilization strategy to engage increasing numbers of organizations in the national responses to HIV.

ASOs learned how to plan p play an important role in community development.

Chapter 5 of this final report describes how the

CAPACITY Project engaged and built capacity among the leaders of the to provide

HIV education to the general population in several oblasts of Uzbekistan.

mahallas mahallas

Improving Quality of HIV and AIDS Services

Vertical medical services that exist in Central

Asia sometimes make treatment of AIDS, often a complex set of medical problems, difficult to manage effectively. The CAPACITY Project worked closely with counterparts in four Central

Asian countries to implement pilot projects for improving the interaction of TB and HIV services for better management of patients with dual HIV and TB infections. Chapter 6 explains how

CAPACITY implemented those pilots and the results that were achieved. Chapter 7 describes a pilot project CAPACITY implemented in

Kyrgyzstan to improve access to and quality of voluntary counseling and testing (VCT) for HIV diagnosis for most-at-risk populations.

As the number of people who need AIDS treatment services increases in some geographic areas of Central Asia, the existing vertical AIDS treatment facilities are becoming overwhelmed.

Chapter 8, the final chapter of this report, describes the pilot project

While there were many other activities implemented over the course of the five year project, the eight chapters in this report represent the most important efforts and the most impressive results of the CAPACITY Project.

Much progress was made over the past five years in the region s response to the HIV epidemics. It is hoped that the results of the

CAPACITY Project will be scaled up over the next years in order to help slow the rate of HIV transmission within the concentrated most-at-risk populations, as well as to the general population. Only with coordinated, focused, and targeted efforts by all stakeholders will each country s HIV response be successful.

Improving Resource-Use through the Integration of HIV and AIDS Services

CAPACITY

implemented in one such location in Kazakhstan, where antiretroviral therapy (ART) was integrated into the primary health clinic.

Photo: Alternative activities at the Ashgabat Youth Center

Photo: TB/HIV training in Uzbekistan

Photo: Outreach work in Osh, Kyrgyzstan

CHAPTER 1: Strengthening Stewardship of National AIDS

Programs through Secondment of Specialists

Background

Program methods

Central Asian countries, including Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan, are experiencing a rapidly expanding HIV epidemic, affecting injecting drug users, commercial sex workers, inmates and seasonal labor migrants.

The response to the epidemic involved all sectors of the society and was supported by the international donor community. To ensure effective coordination and leadership of the national HIV and AIDS efforts, the countries adopted internationally recognized Three Ones

Principles epublican AIDS Centers (RAC). Following a transition period, the coordinating and monitoring functions were shifted from the RAC to the NACM.

The assumption of the stewardship role by

NACMs has not been smooth. HIV and AIDS was a relatively new phenomenon for the region, and countries lacked the human resources and expertise required to effectively address the epidemic. The needs assessment conducted at the beginning of CAPACITY revealed that NACMs needed technical assistance in communication, monitoring and evaluation, and collaboration with civil society. To address these needs, CAPACITY agreed to second up to three specialists to the NACMs in each country: a communication specialist, an M&E specialist, and NGO (or community, as in the case of

Uzbekistan) liaison specialist.

Secondment of the specialists was included into

; one of the key elements of these principles calls for the establishment of a single, multi-sectoral, national HIV and AIDS coordinating mechanism (NACM). HIV-related interventions had previously been under the purview of the Ministries of Health and the

R

Regulatory framework of the secondment process the Memorandums of Understanding (MoU) signed between CAPACITY and its national counterparts (MoHs in Kazakhstan, Tajikistan, Turkmenistan, and Uzbekistan and the Vice-

Prime Minister in Kyrgyzstan) MoUs specified which organization within the NACMs would host the specialists (AIDS Coordination Unit

(ACU) in Kyrgyzstan and RACs in other countries).

Based on the MoUs, detailed secondment plans were developed, agreed upon, and signed tion of the secondment, and ways to ensure sustainability of the specialists ions, and the financial and in-kind contributions of each party.

Job descriptions for the secondment specialists were widely advertised in the national media. It was agreed that current hosting organization staff members would not be considered for the secondment positions, since doing so would not add any value to the hosting organizations takeholders. Selection of the

NGO Liaison Specialist was somewhat different.

In order to ensure involvement of the civil society sector in the process, the short-list candidates were nominated by representatives of AIDS-service NGOs after preliminary and

; the respective hosting organizations described all steps and nuances of the process, including recruitment of specialists, mechanisms of supervision of the seconded staff, job descriptions, performance evaluation procedures, financial contributions, dura

' functions.

Further, as implementation of the secondment plans revealed some gaps in the regulatory frameworks, the plans were supplemented by operational agreements between CAPACITY and the hosting organization with detailed description of rights, obligat teams. Preliminary screening of the applicants'

CVs and cover letters was conducted jointly with

NACM representatives. CAPACITY staff tested pre-finalists for professional skills, and short-listed candidates were interviewed by a joint panel, including representatives of CAPACITY, the

NACM, and other s

Selection and recruitment of specialists

CAPACITY arranged discussion, a one-day roundtable meeting. The selection panel included one representative from the civil society sector who was also nominated during the roundtable meeting.

All selected specialists signed work agreements with CAPACITY and became CAPACITY employees. The Secondment Plans stated that seconded specialists ent-level salaries, so this issue was renegotiated with the

NACMs.

Since seconded specialists had to report both to the NACM and CAPACITY, the key challenge was to ensure smooth coordination of the specialists alists

Enabling effective collaboration between the seconded specialists and NACM staff was an important part of the secondment process, so

' salaries should not be larger than those of current hosting organization staff in order to mitigate jealousy and to increase the chances of sustainability. However, in some countries it was not possible to attract qualified candidates with the low governm work between the NACM and CAPACITY.

Accordingly, the secondment plans and operational agreements set forth the mechanisms of such coordination through a joint selection process, joint approval of the specialists' work plans, and joint appraisal of the specialists' performance by the hosting organization and by CAPACITY. The Secondment

Plan emphasized that the specialists would be supervised by a NACM representative (usually

RAC Director or Head of ACU), who retained the right to request discontinuation of the speci ' contract in case of unsatisfactory performance.

Management and supervision of the seconded specialists

Specialists' interaction with the NACM and

CAPACITY

certain measures were included in the secondment plans and operational agreement.

First of all, the orientation meetings took place with participation of the seconded specialists, NACM, and CAPACITY staff to clarify the purpose of the secondment and improve networking between the participants. The specialists regularly took part in the host organizations access to the internal host organization information

At the same time the specialists maintained close connections with CAPACITY. They received daily technical support and operational guidance from the regional and country offices, took part in the country and regional staff meetings, assisted in designing and implementing activities of CAPACITY relevant to their area of expertise, and had access to CAPACITY s internal information management database.

Over nearly four years, the seconded specialists provided significant assistance to NACMs, contributed to successful implementation of the

Three Ones Principles, and strengthened the role of the national AIDS stewards in Central

Asian countries. The success of the secondment prompted the Central Asian AIDS Project (CAAP) to replicate the model by seconding additional specialists to the NACMs. Specialists staff meetings, program events, and team-building activities; coordinated their work plans with other host organization personnel;

integrated their activities into the general host organization work plans; gained

; submitted monthly reports to their host organization supervisor; and held regular meetings with the latter to discuss progress of their activities.

' specific accomplishments are described on the next page.

Results

Monitoring and Evaluation

Communications

Liaison with civil society

Assisted in establishing national HIV and AIDS M&E frameworks (including development of manuals and guidelines)

Built capacity of national and oblast-level M&E specialists and working groups

Facilitated national M&E working groups

Prepared national M&E reports according to the United Nations General Assembly Special

Session (UNGASS) standards

Maintained national and regional management information systems (CRIS, CARISA) in cooperation with communication specialists

Conducted M&E of national and sub-national HIV and AIDS programs and projects

Assisted in conducting sentinel surveillance among vulnerable populations

Developed M&E systems for TB and HIV, antiretroviral therapy, and voluntary counseling and testing services

Institutionalized the best M&E practices (e.g. unique identifier code) at the national level

Linked partner organizations across the sectors in a single communication space under the

NACMs auspices

Developed and maintained NACMs eveloped and promoted NACM communications strategies nsured constant information exchange, including mass media, between NACMs and other stakeholders

Organized special events, such as World AIDS Day and NACM Partner Forums

Promoted and maintained the CARISA information system

Built communications capacity of local specialists

Provided technical assistance to improve civil society representation in NACMs by conducting national forums of AIDS-service NGOs and drafting the procedures and developing mechanisms for regulating the election of NGO representatives to the NACMs

Ensured effective communication and information exchange between the NACMs and AIDS-service NGOs

' communications tools (websites, monthly bulletins, events calendars, mailing lists)

D

E

Involved civil society organizations in discussions about and development of national regulatory and programmatic documents (e.g. National HIV and AIDS Programs, country applications to the Global Fund grants)

Developed regulatory documents related to civil society s involvement in the HIV response in countries (Law on AIDS of the Kyrgyz Republic

Promoted regional cooperation among AIDS-service NGOs in Central Asia

Mobilized civil society organizations to scale-up the HIV and AIDS response

Provided technical assistance to AIDS-service NGOs through trainings, workshops, and consultations

Maintained national databases of AIDS-service NGOs

; Statute and Regulation for the establishment of the Resource Center for AIDS-service NGOs in Kyrgyzstan)

Other technical assistance to NACMs

Sustainability

In addition to providing specific assistance within their technical area of expertise, the seconded specialists took an active part in other NACM activities, including establishing oblast-level AIDS coordinating bodies, developing country proposals to the Global Fund, drafting national

HIV/AIDS strategic plans, developing various manuals and protocols, conducting needs assessment and program evaluation exercises, organizing of NACM events, and many others.

NACM representatives were pleased with the specialists s activities and their positions became an important issue. NACMs in all five countries expressed interest in continuing the secondment process. However, the prospects of sustaining the secondment varied by country and by the activity area. Some secondment

Photo: Training for M&E specialists. Bishkek, Kyrgyzstan

' progress in building capacity of

NACM and increasing effectiveness of the

National AIDS Programs, so sustainability of the seconded staff' positions were sustained through transfer to another structure within the NACMs (e.g. NGO

Liaison Specialist positions within the GFATM

Project Implementation Unit (PIU) in Kazakhstan and Kyrgyzstan). In other cases the seconded positions were expanded; the GFTAM PIU established an entire M&E department in

Kazakhstan, a whole department for M&E. For those seconded positions that were discontinued at the end of CAPACITY, various structures within the NACMs and other partnering organizations have assumed t

National Coordinating Committee on AIDS, TB and Malaria (NCC),rather than the RAC, that should have hosted the seconded staff.

This controversy was addressed through a compromise when the seconded staff provided assistance both to RAC and to the

NCC Secr

' opinions were crucial for addressing the NACMs concerns and for resolving confusion regarding the secondment process.

As NACMs often lack their own resources to support the seconded positions, fundraising activities should be initiated early, taking into account the major donors' funding cycles.

he activities and initiatives implemented by the seconded staff.

In some countries, the secondment process revealed that selection of the hosting organization may not meet expectations of all stakeholders.

For instance, in Tajikistan some international partners argued that it was the newly established Secretariat of the etariat.

To be successful, the secondment process required constant communication and open discussion between the NACMs and CAPACITY. Flexibility, transparency of procedures, and openness to the national counterparts

It is important that both the seconding and hosting organizations emphasize to partner organizations that the specialists are an integral part of the NACMs, so the partners cooperate with them willingly and in a timely manner, as they would with the

NACM direct staff members.

Lessons learned and recommendations for future

Selection of the hosting organization should be agreed upon.

ication and open discussion is vital.

Be clear that specialists are part of NACMs.

Ensuring sustainability of the secondment process requires preparations well in advance of the project end.

Commun

Conclusion

Secondment of the specialists to NACMs proved to be an effective approach to building capacity of the national AIDS coordinating mechanisms.

Close collaboration between CAPACITY, NACMs, and other partners was an important precondition for the success of this initiative. As a result, NACMs received quality assistance in the technical areas where they previously lacked expertise. Secondment allowed NACMs to understand the importance of new approaches and activities initiated by the seconded specialists in implementing effective responses to HIV epidemics. At the same time, sustainability of the seconded positions remained the main challenge in some countries, though many activities are being continued by

NACMs and other partners.

; and

; and

1.

Advocacy activities, such as meetings and trainings, were planned with key community members—

— to overcome negative attitudes towards MARPs and PLHIV and to create a favorable political environment for HIV prevention activities.

2.

Through outreach and drop-in center-based activities, IEC materials were developed and volunteers were trained to provide information and materials about HIV prevention and risk reduction to MARPs.

3.

Through outreach and/or drop-in center-based activities, individual means of protection

4.

. Referral systems were set up among various medical institutions and medical consultants target groups

Decreased incidence of HIV infections.

Preparation stage

The main steps undertaken in preparation for model implementation included:

Developing the comprehensive package of services

Identifying pilot sites and a participatory needs assessment

Selecting of implementing partners

Signing agreements with site partners

Securing funds for project implementation.

The comprehensive package of services developed by CAPACITY was based on WHO, UNAIDS and other UN agencies and international organizations working on HIV prevention among MARPs. The package consisted of four key elements:

including police, mass media and religious leaders were made available and distributed to MARPs.

were contracted to provide free

Reduction of stigma and discrimination

Provision of HIV education and information.

Provision of individual means of protection against HIV infection .

Access to medical services related to risk practices

' ' refers to condoms and safe injection equipment. No US government funding was used to support any aspect of providing or distributing safe injection equipment to clients.

Individual means of protection

Introduction

Program methods

Injecting drug users (IDUs) and sex workers are the main drivers of the HIV epidemics in Central

Asia. Sentinel surveillance conducted in the region since 2005 have demonstrated a high prevalence of risky behaviors among injecting drug users (sharing of needles and syringes and unprotected sex) and sex workers (unprotected sex).

At the same time, HIV prevention interventions in

2005 covered a limited number of the most-at-risk populations (MARPs), reaching only 7-15% of the estimated IDU population in Central Asia. The lack of effective coordination between the stakeholders, low capacity and expertise of service providers, and the low priority of HIV prevention among MARPs by policy makers all contributed to the low coverage. Because of this situation, the CAPACITY project developed and implemented a model for achieving high coverage of MARPs with a comprehensive package of essential HIV prevention interventions.

The model pursued the following three objectives:

1. Develop mechanisms of coordination of stakeholders for the provision of prevention services to IDUs and sex workers in selected sites

2. Ensure increased coverage of IDUs and sex workers with a comprehensive package of essential HIV prevention services

3. Prove effectiveness of HIV prevention activities.

The following key outputs and outcomes were expected as a result of the model implementation:

Increased knowledge about modes of HIV transmission and methods of prevention

Decreased HIV-related risky behavior among

Model objectives and expected outcomes

; and

CHAPTER 2: Achieving high coverage of injecting drug users and sex workers with a comprehensive package of HIV prevention services medical services including detoxification treatment, STI diagnosis and treatment, VCT for

HIV, prevention of vertical transmission of HIV, and management of surgical complications of drug injecting

Local partners rs conducted a participatory needs assessment involving the model beneficiaries in

7 sites (see Table 1) from February through

March 2006 and developed the following recommendations for the model design:

Expand HIV prevention services package

Scale up coverage of IDUs and sex workers with prevention activities

Improve access to MARPs for provision of prevention services

Decrease stigma and discrimination of drug users and sex workers by law enforcement agencies

Increase the involvement of g vernment and non-government organizations and

— to MARPs.

— including Ministries of Health, Republican and Oblast AIDS Centers, AIDS-service organizations (ASO), oblast health departments and local multisectoral AIDS coordinating bodies— collaborated to identify pilot sites. Decisions were based on the HIV epidemiological situation, prevalence of HIV-related risky behaviors, and the existence of

ASOs to implement the comprehensive package of services. Together with CAPACITY, local partne o

; and health facilities in HIV prevention among

MARPs

Strengthen capacity and substantially involve NGOs in HIV prevention among IDUs and sex workers

Create new and support existing needle and syringes exchange points for IDUs

Create a community center for the organization and implementation of prevention activities, counseling, and organization of self and mutual assistance Improve knowledge and skills of health professionals on HIV prevention among MARPs

Improve level of awareness about HIV and

STIs among the general population

Improve coordination and communication among organizations working on HIV prevention;

Create unified client tracking and referral systems for all implementers of HIV prevention activities

Ensure anonymous and accessible services for STI prevention, diagnosis, and treatment among sex workers

Inform IDUs and sex workers about services available for them in government organizations

Increase the number of volunteers for HIV prevention outreach to MARPs

Develop monitoring and evaluation (M&E) systems for HIV prevention activities.

Country Model Site Location Target

Population

Population

Size

Main Implementing

Partner

Almaty City, Rabochi

Rosyelok IDUs 1,600 Almaty City AIDS Center

Kazakhstan Aksu Village, Pavlodar

Oblast IDUs 1,500 NGO Zhardem

Osh City Sex workers 2,000 NGO Podruga

Kyrgyzstan Karasuu City and

Kashgar Kishlak, Osh

Oblast

IDUs 1,500 NGO Parents Against

Drugs

Khujant City, Chkalovsk

Village Sex workers 950 Sogd Oblast AIDS Center

Tajikistan

Kurgan-Tube City IDUs 900 NGO Fidokor

Uzbekistan

Urgut City and 4 mahallas from Urgutski

Rayon, Samarkand

Oblast

IDUs 2,000 Samarkand Oblast AIDS

Center

Table 1.

Model sites, target populations, and main implementers.

Each implementing partner signed letters of agreement with other service-providing partners including Republican and Oblast AIDS

Centers, STI Dispensaries, Narcology Centers, Surgery and Obstetrics and Gynecology facilities, and AIDS service NGOs odel activities.

Based on either the existing data from the rapid situation assessments conducted in some sites as part of the sentinel surveillance surveys, or on the mapping and interviews with key informants, the participatory needs assessment also provided data to estimate the size of target populations at each site. Implementing partners for each site were identified based on the assessment results and negotiations with stakeholders (see Table 1 ).

Finally, CAPACITY supported the local implementing partners to prepare and submit a regional grant application to the World Bank and

DFID-funded Central Asia AIDS Control Project

(CAAP) in order to secure funding for implementation of the HIV prevention models.

The application was approved and funds were granted in July 2007, after which implementation started. During the regional start-up meeting, the implementing partners named the new model TUMAR

— in their the target area.

In addition, agreements were made with local

AIDS coordinating bodies, city and district authorities, health departments, law enforcement agencies, media outlets, and other partners, to ensure their support and approval of the m on the previous page

' ', the Central

Asian word for a traditional talisman worn to prevent evil and to promote good luck, and chose a new logo consisting of the AIDS red ribbon with seven stars signifying the seven model sites (see Figure 1).

Figure 1. Logo of TUMAR

Service provision

Outreach activities and behavior change communication

Drop-in centers.

. Outreach workers were recruited and trained to implement interpersonal communication interventions for behavior change and distribute personal means of protection. On average, one outreach worker served 45-50 clients. Outreach workers conducted informati

. During the outreach activities, workers also informed clients about the drop-in centers and their activities and provided referrals to different medical services for clients with medical needs.

Each model site drop-in centers provided MARPs with a safe and well-managed space, located, in most cases, outside governmental institutions. Various services were provided at the drop-in centers, including consultations by professionals such as onal and educational sessions on HIV, STIs, personal risk assessment, HIV testing, condom use, and reduction of risk from drug use. Sessions often also included the distribution of individual means of protection as well as several different types of printed IEC materials

Photo: Drop-in Center in Osh, Kyrgyzstan psycholo exception to the rule of placing the drop-in centers outside of government services was in

Urgut Rayon of Samarkand Oblast in Uzbekistan, where six previously-existing, government-run

' ' were supported to function in much the same way as the non-government drop-in centers.

During outreach contacts and visits to the drop-in centers, clients were offered referrals for STI diagnosis and treatment, detoxification and drug rehabilitation, medical services for treatment of post-injection complications, and VCT. Female IDUs and se gists, lawyers, substance abuse specialists, and STI specialists. Clients participated in group discussions on

HIV/AIDS/STIs in general, HIV prevention in particular, and risk reduction for drug users.

They received individual means of protection and IEC materials, and were referred to detoxification, rehabilitation, STI diagnosis and treatment, PMTCT, and other medical services as needed. In addition, drop-in centers provided services to meet everyday needs of clients

(shower, laundry, snacks, haircuts, etc.), andconstructive spare-time activities (board games, TV, books, music, rabbit-raising and wood-working) in a supportive social space away from their usual social environment that enabled or encouraged further risky behavior.

An

Trust Points x workers were referred to gynecological services, and pregnant, HIV-positive IDUs and sex workers were referred to the closest PMTCT service. In order increase the effectiveness of referrals and to help the clients get to services, volunteers escorted some of the referred clients to the service site and helped them enroll. Clients that declined an escort were provided with leaflets that gave directions to clinics and included instructions and guidelines for utilizing various medical services. Former IDU volunteered to help those IDUs who wanted to go enter detoxification and further rehabilitation services, which increased positive treatment results.

Clients needing legal assistance were referred to

Referral to services.

lawyers who were contracted to work with the models. Based

TUMAR

to discuss the progress, results, and future plans of the project. These meetings contributed to a favorable environment for working with MARPs. The project also organized special trainings about

HIV prevention and reduction of stigma and discrimination for law-enforcement agencies, religious leaders, and journalists.

In addition, a short video clip aimed at reducing stigma and discrimination was developed and shown at drop-in centers, medical clinics, and aired on a few television stations.health departments to discuss the progress, results, and future plans of the project. These meetings contributed to a favorable environment for working with MARPs. The project also organized special trainings about HIV prevention and reduction of stigma and discrimination for law-enforcement agencies, religious leaders, and on signed agreements, service providers were reimbursed for either medicines, services, or both. To ensure that all services were client-friendly, focus group discussions and exit interviews were held with clients.

staff conducted numerous meetings with local partners, including city administration, law enforcement agencies, and local education and health departments

Advocacy to decrease stigma and discrimination against MARPs and PLHIV.

Photo: Training for law enforcement workers in Kurgan

Tube, Tajikistan journalists. In addition, a short video clip aimed at reducing stigma and discrimination was developed and shown at drop-in centers, medical clinics, and aired on a few television stations.

printed brochures were developed for distribution during outreach work and at drop-in centers. All

IEC materials were made available in Russian and in national languages to increase their utility.

A key component of TUMAR was building the capacity of local implementers and medical consultants to provide HIV prevention services to

MARPs. Training activities focused on improving knowledge of HIV, STI, and drug demand reduction issues. Eight outreach worker field guidelines were developed in easy-to-understand language for volunteers to use on various topics relevant to their outreach work. Service providers received on-going consultations and onsite coaching by CAPACITY staff and consultants.

Another key component of TUMAR was proving high coverage of MARPs with HIV prevention services is both possible and an effective means for behavior change. CAPACITY supported the development of a monitoring and evaluation system to track information about clients d regularly into a single regional database for analysis and comparison across sites.

Development of IEC materials. Many different types of existing IEC materials developed by other partners in the region were used in the model sites. In topical areas where no or inadequate IEC materials existed, CAPACITY provided technical assistance to develop new materials. Seven contacts with each type of activity at each model site. Data management was implemented through day-to-day record keeping (contact reports) by outreach workers, medical consultants, and other implementing staff at each site. Data from each site was entere

In order to ensure confidentiality and prevent

Capacity building

Monitoring for quality and coverage double counting, each client was assigned a unique identification code that was used in place his/her name. The data was used as a continuous management tool, allowing TUMAR project managers to assess client coverage for all provided services and to make decisions about how to improve service provision.

An assessment of intermediate results, coverage, quality and integrity of the implementation, and performance evaluation of staff was conducted to inform decisions on adjustment of the model activities. Monitoring and evaluation activities were contracted ams, consisting of MedSocInform and CAPACITY staff, visited field sites and conducted small focus group and individual discussions with project staff and key partners to assess the quality and integrity of

TUMAR s services. To ensure that beneficiaries were included in the monitoring process, all assessments among providers were followed by quality checks with clients.

End-line evaluation of results

The evaluation of TUMAR measured whether or not IDUs and sex workers in the target areas had a reduced risk of HIV transmission. Separate evaluation survey instruments were designed for

IDUs and sex workers to measure knowledge about HIV and behavioral risk for HIV transmission.

Key behavioral indicators included needle and syringe sharing among IDUs, and condom use among IDUs and sex workers. Key knowledge indicators included knowledge about modes of HIV transmission and methods of prevention. Other indicators, such as STI diagnosis and treatment-seeking behavior among sex workers and HIV testing among IDUs and sex workers, were also included.

to an external agency, the NGO

MedSocInform, which completed regular monitoring visits and conducted process evaluations at each site. CAPACITY staff was also involved in periodic evaluation of project progress and implementation status. The evaluation te

The surveys were implemented in June, 2009, at five of the project sites and at five control sites.

Surveys were given to IDUs at three of the project and control sites to sex workers at two project and control sites. Samples in each of the survey sites were selected using respondent driven sampling (RDS) (Heckathorn, 1997) seeds nd the sample sizes from each are detailed in Table 2).

Incentives were provided in the form of food and hygiene packages to all who participated in the survey and to all who successfully referred others to the survey. Each respondent was asked to go through a verification procedure to ensure that s/he fit the requirements for survey participants. Once accepted, individuals were interviewed using a short questionnaire.

articipants had a chance to stop the interview at

. At each site, 12 respondents were selected as

' ' to begin sampling. Each seed respondent was asked to invite up to three additional respondents. This was repeated in up to four waves of respondents until the sample size at each survey site reached approximately 300 (the exact project and control sites a

, given sufficiently long becomes stable (i.e., reaches “ ”) and results in a probability sample of hard-to-reach populations.

RDS is a chain-referral procedure whereby samples are selected from social networks of the target population (in this case, IDU). RDS relies on the assumption that equilibrium referral chains (3-6 waves), the sample composition any point in time and skip questions they did not want to answer. All collected data has been kept confidential. Questionnaires were encoded with unique identification codes.

All completed questionnaires were directed to the CAPACITY Regional Office for further analysis. Data were double-entered in Excel

(Microsoft Corp) and EpiInfo (CDC, Atlanta, GA, USA). After comparison and correction, the data were analyzed using STATA 8.2 es were made between respondents from the project sites and those from the control sites. For other outcomes, non-clients from the project sites were compared with those from the control sites. For some outcomes, the comparison was made between project clients and non-clients (both those from the project sites and those from the control sites). The

Mantel Haenszel chi-square test was used and confidence intervals were computed to determine statistical significance. A statistically significant difference was determined at a -value of less than 0.05.

(StataCorp LP).

Descriptive statistics was used to explain the distribution of the demographic characteristics of the participants. Bivariate and multivariate analyses were performed to detect possible relationships and trends. Comparisons for some outcom p

Sex workers IDUs

Project sites � Osh

� Khujand

� Aksu

� Karasuu

� Kurgan-Tyube

Control sites � Karasuu (Kyrgyzstan)

� Gafurov (Tajikistan)

� Ekibastuz (Kazakhstan)

� Jalalabad (Kyrgyzstan)

� Vakhsh (Tajikistan)

Project site respondents, n 612 898

Control site respondents, n 465 751

Clients (project group), n 491 841

Non-clients (project group), n 121 57

Non-clients (control group), n 586 808

Table 2.

End-line study sites and respondents

Results

Client coverage

Knowledge and behavior change among IDUs

The estimated total number of MARPs in the

TUMAR project areas was 10,450. Among injection drug users, the estimated population size ranged from 900 in Kurgan Tube, Tajikistan, to 2,000 in Urgut, Uzbekistan and totaled 6,651.

Among sex workers, the estimated number ranged from 950 in Khujand, Tajikistan, to 2,000 in Osh, Kyrgyzstan and totaled 3,142. An additional 176 sex workers were also injection drug users.

During the 18-month implementation, a total of

10,161, or 97% of the estimated total number of

MARPs, were ever reached with services provided by TUMAR. 52% of the estimated total number of MARPs was reached five or more times during the life of TUMAR. This group of clients had regular contact and is considered to have been covered by TUMAR. 33% of ever-reached IDUs and 37% of ever-reached sex workers used the drop-in centers, while 74% of ever-reached IDUs and 80% of ever-reached sex workers were contacted through outreach. This indicates that outreach services were more popular, but drop-in centers still attracted a substantial number of MARPs. (Tables 5 and 6 at the end of this chapter show project coverage and volume of service usage).

Respondents in both the project and control groups were similar in age and length of time involved in injecting drugs. They differed somewhat in their choice of drugs. Project site respondents were most likely to inject heroin

(OR=21.2

Participation in project activities, gender, and the type of drug used had the most influence on

; 95% CI:15.4-29.1), while control site respondents were split between heroin and opium use.

the injecting behavior of IDUs. Thus, only 4% and

5% of respondents from the project site reported using needles and syringes that were previously used by someone else or passing his/her own needle and syringe to someone else during the last month and the last 6 months, respectively, compared to 37% and 39% among controls. Heroin users were more than two-and-a-half times less likely to report sharing needles and syringes during the last month and during the last 6 months (OR=2.6

Frequent clients of the project (five or more contacts) were almost five times more likely than less-frequent clients (1-4 contacts)

(OR=4.9

Among IDUs who were sexually active, 54% from the project sites reported always using condoms during the last 12 months, compared to 28%

; 95% confidence intervals [CI]:2-3.4). In both groups, women were nearly two-and-a-half times more likely than men (OR=2.5; 95% CI:1.5-4) to report safer injecting behaviors (never shared needles).

Controlling for gender and type of drug used, project clients were more than 18 times more likely than non-clients to report safe injecting behaviors (OR=18.4; 95% CI:12.3-27.7), when asked about injecting practices over the last month, and more than 13 times more likely

(OR=13.6; 95% CI:9.4-19.8) when asked about the last 6 months. Non-client respondents from the project groups were almost 5 times more likely to practice safer injecting behaviors during the last month (OR=4.8; 95% CI:1.7-13.2) and almost 3 times more likely during the last 6 months (OR=2.8; 95% CI:=1.3-6.2) than respondents (non-clients) from the control groups. When asked about sexual behaviors and knowledge of HIV transmission modes and prevention methods, no difference was found between the two groups of non-clients.

; 95% CI:1.5-16.7) to report safer injecting practices over the past 6 months. There was no difference in behaviors between those clients who were contacted once and those who had from 2-4 program contacts.

from control sites reporting same. Among respondents from the project sites, 60% reported using condoms during last sex, compared to 37% among controls. The odds of reporting regular condom use was almost 11 times greater (OR=10.9 during the last 6 months and always using condoms during the last 12 months, compared to 52% of project clients.

Nearly all IDUs from the project sites correctly identified either sex (98%), or injections (96%), as modes of HIV transmission, while only 64% from control sites identified sex and only 56% identified injections. 94% of project respondents

56% from control groups identified both injecting and sexual modes of HIV transmission nsmission of drug used, the odds of clients knowing two modes of HIV transmission

(sexual and via injections) increased to more than 18 times than that of non-clients (OR=18.4

Project clients were slightly better-informed about HIV infection (OR=1.9 infected person can look healthy, as compared to 57% of the control group.

; 95% CI:7.1- 16.6) among clients of the program who also reported never sharing needles and syringes during the last 6 months, as compared to non-clients. Less than

24% of control group respondents reported never sharing needles

89% from project and 52% from control groups could name two main modes of transmission and had no misconceptions about HIV transmission while only 36% of IDUs from project sites and 9% from control sites correctly identified all four main modes of HIV-tra * and had no misconceptions.

When analyzed independently, heroin users were more likely than opium users to name both unprotected sex and sharing needles and syringes during injection as modes of HIV transmission (OR=2.5; 95% CI:1.9- 3.1). After adjusting for kind

95% CI:12.9-26.1).

95% CI:1.6-2.4), with 72% correctly answering that an HIV– or

Sexual, during injections, blood transfusion and from

HIV-infected mother to her child during pregnancy, labor breastfeeding.

Less than 0.5% of project clients reported STI symptoms, while in the control group this figure reached 4%. However, logistical regression analysis showed no statistically significant interaction between being a client and reporting any STI symptoms.

IDUs from project sites were more than twice as likely as controls (OR=2.5 mong IDUs from the end-line survey).

When IDUs in both project and control sites were asked why they shared needles and syringes, 81% replied that it was because of a lack of money

Respondents at both the project and control sites were similar in age, length of time involved in sex work, number of clients seen in a month, ; 95% CI:2.1-2.8) to have ever had an HIV test, and more likely to have had recent (in the past 6 months) HIV tests

(OR 0.6: 95% CI:0.4-0.8) (58% vs. 44%). (See

Table 3 at the end of this chapter for detailed comparisons of behavior and knowledge results a

; 10% said they did not have access to clean needles and syringes;, and 12% reported it was because they trust their partner, because everybody does it, or because when they are high they do not really think about it.

Asked why they do not always use condoms, IDUs said it was because of lack of money (45%);

they do not like condoms (17%); they trust their partner (17%); they have a regular partner

(14%); they did not have condoms with them

(6%); and because their partner dislikes condoms (2%). Finally, asked why they have not undergone an HIV test, IDUs said they did not want to get tested (34%); they did not think about getting tested (32%); they were afraid

(22%); they did not think it was necessary (8%);

and the HIV testing location was too far away

(3%).

Why IDUs engage in HIV risk behaviors

Knowledge and behavior change among sex workers and the percent who also use injection drugs.

Participation in the project was the only factor that influenced…