Attachment_3_CAR_PEPFAR_5-Yr_Strategy_3-15-12_FINAL_DP_Approved.pdf

Central Asia Region PEPFAR Strategy

March 15, 2012

FINAL DRAFT

The Central Asia USG PEPFAR Team

Peace Corps

Centers for Disease Control and Prevention

United States Agency for International Development

This document describes the 2011-2015 Central Asia regional approach to HIV prevention and control, and care and support of those infected with HIV. It is supplemented with strategies for individual countries.

Table of Contents

1. Guiding Principles

2. Epidemiology and Response

3. Sustainability and Country Ownership

4. Integration across the USG

5. Coordination with Other Donors and the Private Sector

6. Gender-Centered Approaches

7. Strategic Overview, Goals, Objectives and Policies

Objective #1: Improve access in public and private sectors to quality HIV prevention, care and treatment services to reduce the transmission and impact of the HIV epidemic in Central Asia

Objective #2: Strengthen the capacity of the health system to deliver improved, expanded, equitable and sustainable HIV/AIDS services for MARPS, PLHIV and their families, and other affected populations

Objective #3: Strengthen the capacity of public and private sectors to collect, analyze, manage and utilize data for evidence-based planning and policymaking at all levels

8. Consultation process for country strategies with Key CAR Stakeholders

9. Policy Environment

10. Monitoring and Evaluation

List of Acronyms

AIDS Acquired Immune Deficiency Syndrome

ART Antiretroviral Therapy

ARV Antiretroviral

CAAP Central Asian AIDS Control Project

CAR Central Asian Republics

CCM Country Coordinating Mechanism

CDC Centers for Disease Control and Prevention

CSO Civil Society Organization

EQA/PT External Quality Assurance/Proficiency Testing

GFATM Global Fund for AIDS, TB and Malaria

GHI Global Health Initiative

HIV Human Immunodeficiency Virus

HRH Human Resources for Health

HTC HIV Testing and Counseling

IDU Injecting Drug User

IPC Infection, Prevention and Control

MARP Most-at-Risk Population

MAT Medication-Assisted Therapy

MDR-TB Multi-Drug Resistant Tuberculosis

MOH Ministry of Health

MSM Men Who Have Sex with Men

NGO Nongovernmental Organization

NHA National Health Accounts

NSP Needle and Syringe Exchange Program

OB/GYN Obstetrician/Gynecologists

PEPFAR President‟s Emergency Plan for AIDS Relief

PHC Primary Health Care

PLHIV People Living with HIV

PPP Public Private Partnership

PwP Prevention with Positives

STI Sexually-Transmitted Infection

SW Sex Worker

SWAP Sector-Wide Approach

TB Tuberculosis

TWG Technical Working Group

UN United Nations

UNAIDS Joint United Nations Program on HIV/AIDS

UNODC United Nations Office on Drugs and Crime

USAID United States Agency for International Development

USG United States Government

WHO World Health Organization

1. Guiding Principles

The President‟s Emergency Plan for AIDS Relief/Central Asian Republics (PEPFAR/CAR)

Strategy supports and is in accordance with the PEPFAR II strategic priorities and the Global

Health Initiative‟s (GHI) guiding principles. The vision described in the PEPFAR/CAR

Strategy, as well as the management of its implementation, will promote and follow these guiding principles:

A country‟s response to its epidemic should be country-led and country-owned and financed to the maximum extent possible;

Government coordination bodies should be strengthened to serve as effective, transparent and inclusive entities for national planning, monitoring and reporting;

All PEPFAR activities, as well as actions by other partners and donors, should be fully integrated and supported by one national plan that is regularly monitored, with full involvement of all parties;

A country‟s response should be inclusive of public, private, civil society, non-governmental actors and international partners, with each contributing relative to each party‟s potential and comparative advantage;

Policies shall be designed based on full participation and on evidence-based interventions, and then implemented, to provide quality health services based on need, equitable access to services and for the protection of the rights of vulnerable populations;

Improvements in quality, efficiency and access will be sought through greater integration of or coordination between services in order to provide more comprehensive care for beneficiaries. A single, streamlined case management system should be used to monitor the range of services provided to HIV clients;

Sustainability of national Human Immunodeficiency Virus HIV programs is a high priority, and choices between alternative courses of action must consider maximum potential for sustainability and country ownership y. PEPFAR will conduct its activities in such a way as to build capacity and strengthen the systems of national programs that will allow these to continue their efforts over time, with lessening financial and technical assistance from the

United States Government (USG);

The foremost priority of this Strategy is the prevention of new infections and to provide continuum of care service to those infected with HIV/AIDS. PEPFAR will seek to focus its financial and technical resources toward evidence-based interventions that most contribute to reductions in transmission and prevention of new cases. Given the level of non-USG funding already in the region, PEPFAR will focus its efforts on providing technical assistance and capacity building to strengthen programs and achieve maximum impact and return on

PEPFAR investments.

Expand HIV and Tuberculosis (TB) service integration or coordination to ensure that

PLHIV are screened and treated for TB and that TB patients are tested, counseled and referred for appropriate HIV services;

Gender issues that increase the risk of HIV/AIDS or reduce access to services will also be addressed as needed;

PEPFAR will support both government and non-governmental entities and seek to clarify the relationship and strengthen the collaboration between them;

Promote a “Whole of Government” approach to ensure that PEPFAR agencies promote one

USG approach in the region, including integration and coordination of PEPFAR with other non-PEPFAR USG interventions;

Engage and coordinate with other multilateral partners, particularly the Global Fund for

AIDS, TB and Malaria (GFATM), the Joint United Nations Program on HIV/AIDS

(UNAIDS), World Health Organization (WHO), The United Nations Office on Drugs and

Crime (UNODC), United Nations Development Programme (UNDP) and the World Bank;

2. Epidemiology and Response

The HIV epidemic in Central Asia is concentrated among most-at-risk populations (MARPs), however, based on UNAIDS data, it is one of the fastest growing epidemics in the world.

Reported HIV prevalence among the general population is estimated at a high of 0.3 percent in

Tajikistan to virtually 0 percent in Turkmenistan.1 Of the total 61.3 million people in the region, 95,8892 individuals are estimated to be infected with HIV, and 40,106 cumulative HIV/AIDS cases have been officially registered to date.3 The government of Turkmenistan does not report any HIV infections.4

Injection drug use. Drug trafficking is a principal concern for Central Asia, given its link to opiate use, injecting drug use, HIV/AIDS, drug-related crime, and other health determinants.

There are several major trafficking routes through the region making use of the improved road and rail links. However, traffickers also move off the main roadways and make use of the maze of trails through the mountains and across “green borders” to avoid detection. UNODC estimates indicate the scope of opiate trafficking in the region is significantly higher than the volume seized.5

The HIV/AIDS pandemic in Central Asia is mainly fueled by injecting drug use (IDUs) concentrated in urban centers and along drug transport corridors from Afghanistan. UNODC estimates that up to 1 percent of adults are heroin users and sentinel surveillance data indicate

70-80 percent of all drug users in the region are IDUs. HIV prevalence rates of IDUs range from

4.2 percent in Kazakhstan to 17.6 percent in Tajikistan.6 Sentinel surveillance data of IDUs found HIV prevalence as high as 34 percent in parts of Uzbekistan.7 As of 2008, between 60 and 75 percent of all HIV infections were due to injection drug use.8

Sexual transmission. While injecting drug use remains the predominate driver of the epidemic, sexual transmission is playing an increasingly important role, with as much as 41.8 percent of

HIV infections attributed to sexual transmission in Kazakhstan in 2010.9 Unsafe sex by IDUs

1 UNGASS Reports, 2010 and respective Republican AIDS Centers.

Epi Profiles developed by the SUPPORT Program /Columbia University

3 CAR respective country Republican AIDS Centers. 2010.

4 Reports of actual HIV seropositivity in Turkmenistan have decreased from 16 cases in 1996 to two cases in 2002 to zero cases reported from 2006 to 2008. This has created the false appearance of 100% success in preventing HIV for much of the past decade despite high levels of HIV risk behavior, notably injecting drug use.

5 UNODC, Illicit Drug Trends in Central Asia. April 2008.

CAR respective country Republican AIDS Centers. 2010.

7 Republican AIDS Center, Uzbekistan. 2009.

8 2010 UNGASS Reports.

9 Republican AIDS Center, Kazakhstan.

and their sexual contacts, including sex workers (SWs), constitute a key bridge to the general population.

Men who have Sex with Men. Men who have sex with men (MSM) comprise a relatively small proportion of total HIV cases in the region in comparison to Western European and North

American nations. Unprotected male-to-male sex accounted for less than 1 percent of newly registered cases in Kyrgyzstan in 2006, where the route of transmission was known.10

Nevertheless, MSM remain an important risk group to conduct epidemiological studies on. In an unpublished report, MSMs had very low level of knowledge about transmission of HIV/AIDS and other and HIV prevention services.

Prisoners. Prisoners are at high risk of having HIV because of preexisting injection drug use and transmission within prisons through high-risk behavior, which includes shared needles and possibly unprotected sex. All Central Asian countries have voiced understanding vis-à-vis the risk of HIV among their respective prison populations. However, quite varied steps have been taken to address risk, including use of needle and syringe exchange programs (NSP) (see NSP, below), condom distribution, HIV testing and counseling, or medication-assisted therapy (MAT) within prisons.

Medical settings. A unique feature of the HIV epidemic in Central Asia is the recognized contribution of nosocomial-acquired infection to overall HIV incidence. Multiple outbreaks of

HIV and blood-borne infections via unsafe health care practices have been investigated and unsafe health care practices pertinent to HIV transmission are currently being systematically assessed. The CAR team will work closely with local Ministries of Health and other key stakeholders such as WHO to promote safe injection practices through an integrated approach of providing standard operating protocols and IEC materials. Interventions will also focus on the safe disposal of medical waste.

Coverage of Prevention Services. There is a large unmet need for critical prevention services to the highest-risk groups, although better determination of coverage and coverage gaps for all services is needed to guide further prevention efforts. Of the estimated 304,100 IDUs in the region, only 721 are currently receiving MAT. Expert opinion estimates that at least 20-40 percent of IDUs must be reached with MAT to meaningfully disrupt HIV transmission within this group and prevent propagation to the general population. This will require reaching at least

60,700 IDUs with MAT. Coverage of IDUs with NSP is higher,11 but the estimated number of

IDUs in need of needle exchange and at least a minimal package of services are 211,000. NSP within prisons varies by country with, for example, all Kyrgyz prisons have NSP while

Kazakhstan does not provide any.

In some countries, lack of confidence in Trust Points and other government services by IDUs hinders the ability of government sites to effectively deliver prevention services to the extent needed. Utilization figures for services to SWs and other risk groups are not reliable, but thought to be low. Inexact and outdated estimates of the numbers of individuals within MARPs hamper

10 UNAIDS, AIDS epidemic update - Regional Summary, 2008.

61% in Kyrgyzstan, 34% in Uzbekistan. 2010 respective UNGASS Reports.

“The overriding goal of PEPFAR in Central Asia is to reduce new infections and to provide adequate treatment and care services to those infected with HIV.”

determination of coverage. In addition, stigma against MSMs and IDUs hinders delivery of prevention services to these groups.

3. Sustainability and Country Ownership

A major priority of this joint five-year strategy is to promote a sustainable response to the HIV/AIDS epidemic in the region in close partnership with host governments and other partners. The relative wealth of resources found in Central Asia allows PEPFAR to focus on assisting governments to develop more comprehensive, effective and sustainable approaches to the epidemics facing their countries, rather than fulfilling immediate humanitarian needs.

Governments in the region demonstrate varying degrees of financial ownership and control of health programs within their borders. PEPFAR will work with these governments primarily to increase the quality of healthcare services, promote effective governance and greater transparency, and increase non-governmental participation in planning and service delivery.

PEPFAR will work with governments to promote effective governance, greater transparency and inclusion of non-government partners.

To achieve these ends, USG programs will build the policies, systems and competencies needed to engender more capable institutions, organizations and individuals that are better able to plan, implement and monitor national HIV/AIDS programs which address the epidemic and achieve planned outcomes. PEPFAR CAR recognizes that efforts to strengthen country capacity to steer and sustain an effective national HIV/AIDS response, will need to be designed, implemented and monitored in close collaboration with local partners and allow for the progressive transition of leadership during the years of the strategy. Accordingly, PEPFAR will undertake systematic efforts to enable countries to increasingly assume leadership, accountability, and policy and financial sponsorship of targeted national HIV/AIDS programs.

Political Ownership and Sustainability - A primary focus of USG assistance will be to enhance leadership on and governance of national HIV/AIDS programs. Each government in Central Asia has adopted a National HIV Strategy in which they prioritize prevention and all recognize the importance of targeting MARPs.12 Ministries of Health (MOHs) are the main government institutions for HIV prevention and control efforts in Central Asia. The PEPFAR team will work to mainstream attention to MARPs into national prevention, treatment and care systems that are more inclusive, accessible, effective, comprehensive, and meet quality standards. The USG has an extensive history of strengthening basic government systems and program management capacity in the region, including initiatives to replace the old Soviet hierarchical command-style of management with that of transparent, evidence-based decision-making. An example of this is

PEPFAR‟s work in the area of health system strengthening and in providing expert technical assistance to the five CAR‟s TB control programs. The PEPFAR program will continue this close relationship with MOHs and other government units as a support and technical assistance

A more detailed discussion of each country‟s strategic plan can be found in the Country Strategy section of each country-specific annex.

partner alongside national systems and leadership. The PEPFAR program may provide direct funding agreements with health ministries as one component to build service delivery capacity and increase coverage.

The PEPFAR program will strengthen the operations, management and oversight effectiveness of national level Country Coordination Mechanisms (CCMs) as multisectoral governing bodies on HIV/AIDS. assistance will seek build competencies of CCM members in core CCM functions, strengthen mechanisms for internal and cross-sectoral coordination and communication, and enhance the role of CCM structures in advocating for and shaping policies that support the national HIV/AIDS response. PEPFAR resources will also build the planning, coordination, management and advocacy capacities of selected subnational governance structures such as regional coordinating committees. Assistance will aim to enable local governance bodies to support local HIV/AIDS efforts in areas such as: monitoring the implementation and effectiveness of HIV/AIDS activities; tracking progress against local HIV/AIDS targets and indicators; managing the collection of sound data; engaging in HIV/AIDS policy advocacy efforts; and, as appropriate, supporting the development of regional HIV/AIDS strategies or plans.

PEPFAR will also support a strategic approach to policy development which will strengthen the capacity of national and local policy makers and stakeholders to analyze and address key policy barriers; improve collaboration between NGO, private and public stakeholders to plan and advocate for needed policy and legislative reforms; and build the systems needed to ensure transparent and participatory development and implementation of policies. Concentrating on fostering policies that enhance access by MARPs to more comprehensive quality care, the

PEPFAR team will work with key HIV/AIDS stakeholders to jointly undertake a rapid desk review of policy assessments conducted during the past few years, prioritize policy needs;

develop a strategic policy agenda; establish the mechanisms and processes for inclusive development and formulation of evidence-based policies, and advocate to a broad range of policymakers, including parliamentary leadership, to support policy reform. Where appropriate, the PEPFAR team will leverage programs that support Parliamentary development both to educate HIV/AIDS stakeholders on the complex policy process and engage Parliamentary Health

Committees as key participants to this process. The PEPFAR team expects to see greater progress in policy change in KG, which has a more progressive policy environment.

Institutional ownership - At the organizational level, PEPFAR activities will systematically enhance the management, organizational, programmatic and technical capabilities of public sector facilities and NGOs. Prioritizing NGOs providing services through GFATM grants, PEPFAR assistance will assist these organizations to better plan and provide services for MARPs and strengthen approaches to increase MARP access to quality services. Systematic capacity development efforts will be structured to progressively assist HIV/AIDS NGOs to become stronger and more mature organizations better able to network, collaborate and contribute to national HIV/AIDS efforts. USG assistance will improve the financial viability and sustainability of NGOs by assisting NGOs to diversify funding through approaches such as social contracting with governments, corporate support, and community contributions. Targeted technical assistance will also strengthen the soundness and transparency of NGO financial management systems.

PEPFAR will focus on building the leadership and capacities of organizations working with

IDUs, MSM, SW and other MARPs, as well as MARP coordinating bodies, to enable them to function as advocates for MARPs and to participate more effectively in HIV/AIDS program development, implementation and management. Assistance to strengthen the core competencies of these organizations will enable them to function as advocates for MARPs and participate more effectively in HIV/AIDS policy advocacy and program development, implementation and management. PEPFAR will help enhance government partnerships with NGOs as mechanisms through which to reach MARPs. PEPFAR CAR will also assist central and local government bodies to develop the policies and financial systems needed to contract with, or provide direct funding to, nongovernmental organizations for MARP service delivery.

Capabilities - Strengthened capacity of public sector facilities and NGOs providing HIV/AIDS services for MARPs will help improve the quality and effectiveness of services. The USG will build on training and mentoring efforts supported to date to undertake a more strategic, systematic and coherent approach to capacity development which fosters national and subnational ownership of HIV/AIDS programs. PEPFAR CAR recognizes that capacity building efforts will need to be designed, implemented and monitored in close collaboration with local partners and allow for the progressive transition of leadership on capacity building efforts to local partners during the next couple of years. Accordingly, CAR will use FY12 funds to partner with country level stakeholders from Ministries of Heath, National HIV/AIDS Programs, Global

Fund, UN and other donor partners, and NGO and MARP representatives to conduct rapid, structured diagnoses of key institutional and organizational cohorts including national and subnational HIV/AIDS Country Coordinating Mechanisms and local governance structures such as regional coordinating committees; and organizations including Republican AIDS Centers and

NGOs implementing Global Fund HIV/AIDS grants. PEPFAR will also support rapid assessments of training needs for service providers, outreach workers and NGO technical and management staff. Data from these assessments will guide the collaborative development of capacity building strategies that will contribute to strengthened national HIV/AIDS program performance.

The overriding goal of PEPFAR in Central Asia is to reduce new infections and to provide adequate treatment and care services to those infected with HIV. A guiding principle of this goal is to not to duplicate activities with other major donors or host governments. Instead, PEPFAR will focus on those interventions that capitalize on PEPFAR‟s comparative advantage and technical strengths to improve results and extend the reach of services in the region. The CAR

PEPFAR program will strategically target its relatively modest resources to promote best practices, policies and improved service quality to the populations most at risk of transmitting

HIV, and those most marginalized in society. These activities will be based on evidence-based interventions and country-specific needs. These interventions will include improving the quality of and capacity of outreach workers for key MARP groups (IDUs, SWs, MSMs, prisoners and migrants) and improving the quality of service providers for these groups through training and providing updated technical approaches to service providers in order to work more effectively with these marginalized populations, especially to reduce stigma and discrimination.

In addition to supporting MOHs, a key PEPFAR focus will also be to strengthen the capacity of non-governmental organizations (NGOs) and promote more active partnerships of NGOs with

The USG PEPFAR/CAR Team

Peace Corps

U.S. Agency for International Development

Centers for Disease Control and Prevention government services. An example of such strengthening will be to increase the capacity of the

NGO sector to target key affected groups with HIV prevention services, including information on risk reduction and linkages to HIV testing and counseling (HTC), treatment and care services.

Additionally, the PEPFAR program intends to encourage dialogue and linkages between government and civil society organizations, recognizing that civil society plays an important role in areas such as advocacy where government traditionally may not or cannot play the leading role. With the governments and Country Coordinating Mechanisms (CCMs), PEPFAR plans to provide technical assistance as requested in the development of their five year national HIV programs and strategies.

Accountability - In continued efforts to enhance national program accountability PEPFAR will support approaches to strengthen monitoring and evaluation systems. PEPFAR will continue to provide training in monitoring and evaluation to MOH staff, NGOs, Ministries of Labor, Youth, Education, Interior and international organizations, as well as support ongoing training on new generation indicators to MOH country staff. PEPFAR will also continue to strengthen the capacities of MOH staff across countries to undertake behavioral assessments and analyze data to inform program development. This is done by training MOH staff and providing technical assistance. PEPFAR will also strengthen utilization of a USG-provided electronic HIV case-based surveillance management system by providing on-site training to continue to improve data quality, consistency, and system functionality. Most important, PEPFAR will intensify support for the elaboration and collaborative rollout of a unified „one monitoring and reporting system‟ that can be utilized by both government and NGO partners to the national HIV/AIDS program.

4. Integration across the USG

CDC and USAID implementers may operate in different geographic areas and social environments to develop effective service delivery models. The PEPFAR team will collaborate closely with other donors and the MOH in monitoring and information sharing, with regular reviews of ongoing activities to ensure lessons learned are applied to the program. In some cases, CDC and USAID implementers may operate jointly in the same geographic area, each contributing to a specific service delivery component, social networking, policy assessment, capacity development and other areas. Micro-planning around a specific facility, network or activity will ensure critical elements of the program are adequately covered and avoid duplication of efforts.

The PEPFAR Coordinator‟s Office works under the leadership of the five U.S. Ambassadors to

Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenis tan, and Uzbekistan, and under the day-to-day oversight of the U.S. Ambassador to Kazakhstan, or his or her designate, as part of the USG

PEPFAR Team in Central Asia. Each U.S. Embassy in Central Asia is encouraged to participate in PEPFAR planning, management and oversight of the program in their respective country. A primary responsibility of the Regional PEPFAR Coordinator is to ensure inter-agency collaboration and integration across the USG.

USAID and CDC are the two main agencies working on technical and policy interventions under

PEPFAR in Central Asia. Peace Corps contributes significantly through community and peer education and engagement with MARP networks. At an operational level, USG agencies and

PEPFAR implementers will meet as one PEPFAR team at least quarterly to assess progress toward expected results, discuss lessons learned and further program collaboration. At a strategic level, the PEPFAR team will collaborate closely with other donors and the MOH in developing, planning, implementing and monitoring PEPFAR activities, will promote dissemination of information and continuing dialogue on program progress, and will facilitate regular Ministry of

Health-led joint reviews of PEPFAR programs to reinforce country ownership and accountability for results. PEPFAR USG agencies will work with each country to ensure that the joint program reviews are not duplicative of other existing structures and will work with each MOH to integrate annual planning to their annual planning cycle. The program will also work closely with the MOH and other stakeholders in developing country-specific annual work plans and will integrate these into the regular monitoring plan of the MOH to enhance local ownership. In addition, this integration will ensure PEPFAR contributions to the national HIV program are complementary to other resources and help highlight program gaps or opportunities for further collaboration.

In addition, the PEPFAR team and key stakeholders plan to participate in technical working groups (TWGs) on key topics such as SWs and MARPs. The TWGs will meet frequently to share and analyze information from across each country, the region and outside Central Asia to inform program decisions. USG staff in the region will also meet frequently to share observations on current issues, opportunities and challenges.

5. Coordination with Other Donors and the Private Sector

All five Central Asian countries have National HIV/AIDS Programs or National Health Plans that includes HIV/AIDS in their respective countries. Funding share of national HIV/AIDS program varies from 41 percent in Kazakhstan to eight percent in the Kyrgyz Republic. The deficit is partially covered by donor organizations, most notably the GFATM, which provides

$125 million in HIV-specific programs throughout the region.

Global Fund. PEPFAR will coordinate closely on all activities with the GFATM, the largest

HIV donor in the region and a central focus of attention under PEPFAR. Where possible, PEPFAR intends to provide expertise to help GFATM-funded programs function more effectively and assist recipient countries to remain eligible to receive GFATM grants. The

PEPFAR CAR program will continue to partner with GFATM and other donors to scale up best practices and key services, improve quality of existing services and enhance management of HIV programs.

The GFATM‟s operating concept of a CCM chaired by a CCM President who is free of any conflict of interest, inclusive of civil society and non-governmental voting members, and that oversees the operations of grants provided to agencies of the United Nations (UN), government ministries and non-governmental organizations, has little historical basis in Central Asia.

Consequently, helping CCMs function and oversee GFATM grants in the region presents particular challenges. The PEPFAR Team will enlist the help of senior USG officials, including ambassadors, as appropriate, to engage CCM members and host government leadership to encourage adherence to GFATM operating principles. PEPFAR also plans to provide specific technical assistance to CCMs in assisting structural or other reforms to maintain eligibility for

Global Fund resources. As these are sensitive areas in CAR, PEPFAR can only provide this assistance when requested by country programs. Ultimately, improved GFATM performance will improve the success of the PEPFAR investments in the region.

As a means to foster collaboration with the GFATM, PEPFAR has hired a full-time senior management and technical advisor to work with the CCMs and broker an active capacity building partnership with GFATM/Geneva and GFATM grant programs in the region. This advisor, acting in the capacity of Regional Global Fund Liaison, is developing coordinated approaches to addressing HIV/AIDS and facilitates joint or collaborative planning and greater

„unity of effort‟ between PEPFAR and GFATM-funded entities in Central Asian countries.

UNAIDS. The PEPFAR team will work with UNAIDS in its coordinating and policy role. It is expected that UNAIDS specialists will participate in the national TWGs as well as play a role on coordination of workplans among the varied stakeholders in each country, where appropriate.

WHO. PEPFAR will partner and collaborate closely with WHO in its efforts to promote policies for treatment and prevention that are evidence-based and consistent with international guidelines.

UNODC. PEPFAR will work closely with UNODC in all five countries in efforts to address

IDU. The USG intends to provide financial support to UNODC to work in areas that are deemed particularly sensitive, including MAT policy and prisons. PEPFAR also plans to work with

UNODC to promote evidence-based practices and policies concerning drug use and services to

IDUs.

Other bilateral donors. PEPFAR will partner with other donors and technical agencies as appropriate. It will develop concrete and transparent planning and monitoring tools to share with existing donor coordination bodies, such as the sector-wide approach (SWAP), and will work to improve coordination among key actors within national HIV programs.

Private sector. As feasible across the region, PEPFAR will actively seek out opportunities to engage and partner with the private sector. In FY12, PEPFAR will support an ongoing partnership with Chevron Nebitgaz in Turkmenistan to open a drop-in center for drug addicts and sex workers.

6. Gender-Centered Approaches

The HIV pandemic in Central Asia is concentrated in the MARP population, in which women and girls comprise a minority. IDUs account for the largest number of new HIV infections;

however, because most of the injection drug users are predominately male, they expose their sexual partners, primarily women, to HIV/AIDS and other infections. Thus, it is necessary to not only reach out to IDUs, but to also involve their sex partners and potential sex partners. As the epidemic in Central Asia evolves from a concentrated to a more mixed epidemic, sexual partners of IDUs could be an important bridge population. In an effort to increase gender equity in

HIV/AIDS activities and services as well as collect data for more targeted program planning, the team will conduct a survey on the non-injecting sexual partners of people who inject drugs

(PWID). PEPFAR will also implement targeted interventions to increase outreach and services specifically tailored for female injecting drug users. For example, PEPFAR will implement and encourage other development partners and governments to expand outreach for female PWIDs, include female PWIDs on outreach teams, disaggregate PWID data by gender, and offer referrals to additional health services such as STI and ob-gyn services.

Sex workers are a growing source of HIV infection throughout the region and also an avenue for

HIV to spread more broadly into the general population. PEPFAR intends to focus on women and girls involved in both sex work and injecting drug use. It is not known what percentage of

MSM may also have female sexual partners; however, PEPFAR approach in Central Asia will also try to address this issue when working with MSMs.

Women and men have different needs and challenges in the context of the regional HIV pandemic. Understanding these differences and responding to them appropriately is a key guiding principle of PEPFAR‟s approaches to HIV/AIDS in Central Asia. The recent USAID

Gender Assessment for Central Asia highlights how women suffered additional challenges due to the fast deterioration of the social safety net after the fall of the Soviet Union. Economic hardships and the growth of migrant labor put an increasingly difficult stress on women‟s roles in the family and have turned some to commercial sex work.

Human trafficking plays an under-recognized role in HIV transmission within Central Asia. The region is a source, transit and destination point of human trafficking, fueled by economic desperation and the inferiority of women‟s social status. The vulnerable and marginalized of society constitute most of the victims of human trafficking (both women and men).

Economically vulnerable women have a higher risk of turning to drug use and commercial sex out.

Additionally, migrant labor has a significant impact on Central Asian communities. Two million of Tajikistan‟s able-bodied men regularly leave their country in search of seasonal jobs, leaving whole communities with few men. As a result, women are left vulnerable and may be at greater risk of HIV and other sexually-transmitted infections (STI), whether through their own sexual behavior or by their partners returning home with STIs.

Finally, competing socio-political models of “womanhood” characterize women‟s struggles in

Central Asian society. The Soviet legacy, the reemerging influence of Islam and the redefinition of a historically-based national identity all offer unique challenges to women‟s struggle to retain previously-achieved progress toward equality. An approach to addressing HIV/AIDS must take into account the local context of the roles of women and girls in society. Outreach activities, policy advocacy and training methods of care-givers will be designed with these realities in mind.

7. Strategic Overview, Goals, Objectives and Policies

PEPFAR has specific goals and objectives in providing HIV programming assistance generally to the regional program.

The overarching goal for the Regional Initiative is to prevent new HIV infections and provide high quality HIV services for affected populations through a strengthened and sustainable health system in the five Central Asian Republics (please see Appendix VI, PEPFAR Central Asia Region Strategy Framework).

With HIV highly concentrated among relatively small high-risk groups, there exists a unique opportunity to stem the growing spread of the epidemic to the general population. To do so, governments and their partners must act quickly and decisively with interventions focused on stopping transmission among and from key most at risk and highly vulnerable groups. PEPFAR will aggressively target prevention among IDUs and SWs as the primary drivers of the Central

Asian HIV pandemic and toward MSM and prisoners as important secondary drivers, as well as in medical settings to prevent nosocomial transmission of HIV.

The USG plans to invest a relatively small amount of PEPFAR resources in Central Asia, compared to the GFATM, World Bank and other donors. Overall USG development assistance funds for health in the region are modest in comparison to available state-owned resources of the oil-producing countries in the region, with the notable exception of Tajikistan. Even so, USG health programs have historically provided key technical contributions to these other programs and have had a significant positive influence on health policy and service delivery.

In the case of Tajikistan and its relatively more resource-constrained environment, PEPFAR intends to invest comparably more resources to support service delivery scale-up more directly.

The PEPFAR team will adjust its approach to this country based on the availability of continued

Global Fund resources for HIV.

Objective #1: Improve access in public and private sectors to quality HIV prevention, care and treatment services to reduce the transmission and impact of the HIV epidemic in Central Asia

1.1 Equitable Access: Improve the

comprehensiveness, quality and coverage of evidence-based HIV/AIDS prevention, care and treatment services for most at risk populations

(MARPs) and people living with HIV (PLHIV) and their families.

1.2 Enabling environment: Support the

development, adoption and implementation of laws, policies, strategies and/or regulations that facilitate effective, equitable, and stigma-free HIV/AIDS prevention, care and treatment efforts.

Each of the five Central Asian Governments has prioritized prevention in their National HIV

Strategies. Moreover, a focus on preventing the spread of HIV among MARPs is a defining feature for all. In line with respective government priorities, PEPFAR will focus on preventing the spread of HIV among MARPs, including persons who inject drugs, sex partners of drug

Country-specific goals can be found in each respective country‟s annex.

users, sex workers, men who have sex with men, and prisoners. The USG plans to provide a combination of technical assistance and direct support to scale-up evidence-based interventions.

Starting in countries where the policy environment will facilitate success, PEPFAR will support effective evidence-based programs targeting IDU, SW, MSM and prisoners (and migrants in some specific countries) as well as to prevent nosocomial transmission.

PEPFAR anticipates providing technical assistance to government ministries and civil society to improve the quality and efficiency of MARP outreach activities including behavior change communication and education about preventing HIV and other STIs. Behavior change interventions will also be closely linked to improvements in counseling and testing services and referrals. The USG plans to support government and civil society to improve the quality of counseling and testing services and to help ensure that such services are safe places for MARPs and actively encourage marginalized populations to use these services.

The PEPFAR CAR Team will focus on promoting uptake of best practices and creating an enabling environment for expanded care and support services, including mobilization of non-

USG funds for these programs. PEPFAR will support a narrow range of interventions, including promoting implementation of national guidelines, outreach, and peer education to ensure that people living with HIV (PLHIV) have access to social support, referral and follow-up to care and treatment services. PEPFAR plans to improve access to quality counseling and testing services and linking newly identified HIV-positive people in coping with their status through Prevention with Positives (PwP) programs.

HIV testing remains limited and focused in medical settings. USG will work to improve access to counseling and testing for HIV infection to MARPs (including same-day results), and increase the knowledge of sero-status among MARPs. PEPFAR will work with outreach and laboratory services to improve high-quality HIV counseling and testing services.

Through technical assistance and mentoring, PEPFAR will improve and extend the reach of non-

ARV care services to PLHIV. This will include training caregivers in counseling and inter-personal skills. It will also include strengthening referral linkages and systems and working with governments to make clinical service provision more accessible and “client-friendly” to MARPs.

Assistance to governments for care and treatment of HIV-infected patients, other than providing

ARVs via the GFATM, has not been a priority for any donor. PEPFAR will focus on identifying and providing a minimum standard of care to HIV-infected MARPs as a critical means of reducing the spread of HIV. PEPFAR will work with non-government partners to refer PLHIV to appropriate service providers and to provide ongoing case management support via a network of well-trained and sensitive outreach workers and PLHIV associations.

PEPFAR will strengthen and promote the effective linkages to service providers of PLHIV associations. These associations are crucial to advocacy activities to promote effective and appropriate care and support services benefiting all PLHIV.

Given the modest amount of PEPFAR funds available to Central Asia and significant USG and non-PEPFAR TB funds already mobilized in the region, no PEPFAR resources will support TB interventions under this Strategy. However, PEPFAR is working with key partners to address

TB and Multi-Drug Resistant Tuberculosis (MDR-TB) with additional funds outside of

PEPFAR.

PEPFAR/CAR does not presently nor does it plan to provide direct ART services to PLHIV.

PEPFAR will work closely with its U.N. partners and the GFATM to update ART protocols and supervision based on WHO standards. PEPFAR will advise on updating training curricula so that physicians and nurses are adequately prepared to apply appropriate protocols.

The primary strategic focus of PEPFAR/CAR with regards to care and treatment of PLHIV is on the quality of services provided and particularly on the linkages and the points of entry for both

MARPs and PLHIV that promote both equitable access and adherence to treatment, once commenced. PEPFAR CAR Team believes that the non-government sector has a critical and complementary role to play to ensure that persons in need of treatment can access it as well as in patient referral, support and follow-up.

Objective #2: Strengthen the capacity of the health system to deliver improved, expanded, equitable and sustainable HIV/AIDS services for MARPS, PLHIV and their families, and other affected populations

2.1 Capacity Building to Improve Public Health

Technical Expertise and Program Management:

Increase capacity of government, civil society and the private sector to plan, design, implement and monitor quality HIV/AIDS services.

2.3 Governance: Increase transparency and

ensure inclusiveness of relevant stakeholders in the oversight and management of the HIV/AIDS response.

2.2 Integration, collaboration and sustainability:

Increase integration of HIV/AIDS with other health services and sectors, and promote collaboration among ministries and other key stakeholders to gain efficiencies and maximize local resources to increase financial responsibility and sustainability of HIV services in host countries.

2.4 Laboratory Infrastructure: Support functional

and appropriate laboratory infrastructure to support timely, high-quality HIV and other HIV-related diagnostics and test results.

PEPFAR is committed to the enhancement, management and coordination of HIV/AIDS services in the region. Health systems in Central Asia are based on the former Soviet Union‟s approach to highly specialized, illness-specific vertical programs. For instance, to receive a complete set of services, a HIV/TB co-infected IDU on MAT with an STI would receive services from four separate and unlinked service delivery systems. While PEPFAR will seek out opportunities to promote the greater integration of currently disparate systems over the course of this Strategy, its intermediary approach will be to improve the quality of services provided and to ensure the linkages between systems exist and function in a way that facilitates MARP and PLHIV access to services and adherence to treatment.

Government leadership and ownership are well established in the region. This is largely due to the fact that no country in the region was an original PEPFAR “focus” country. The governance and coordination issues that the Strategy must and will address relate more to issues of transparency and participation of non-government parties in the management of public sector activities. The GFATM is the largest source of funds for HIV in Central Asia and a high priority partner to PEPFAR. Several GFATM CCMs and technical programs are not performing as effectively as they should, and some countries have had funds frozen or have been declared ineligible for further funding by GFATM/Geneva. Poor performance or oversight of the

GFATM programs directly affects PEPFAR activities and will likely reduce the results the USG would expect to achieve in the region. As discussed earlier in the Strategy, PEPFAR partners will provide technical assistance, training and mentoring to the Global Fund CCM and

Secretariat to strengthen their management, oversight and leadership functions.

Since the HIV interventions in the Strategy will be tightly targeted at MARP services, the USG will ensure that non-PEPFAR funded health and other activities are coordinated and oriented to strengthen the operating systems which support those services, and create an enabling policy environment for scale-up of sensitive activities. Where appropriate, PEPFAR activities will be linked to wrap-around programs in nutrition and food security, economic opportunities for vulnerable groups, human trafficking and migration, local governance and other USG initiatives.

PEPFAR will assist governments and NGOs to effectively plan for and manage their Human

Resources for Health (HRH) in order to provide effective services. This will include strengthening of management capacity, improved supervision approaches and possible introduction or increased priority to new types of staff where appropriate. This assistance shall also include addressing human resource financing problems for sustainable programming.

Much of PEPFAR‟s work to strengthen HRH in the region will concentrate on the in-service training of key service providers, the supervision and motivation of service providers and the full inclusion of private and non-government providers of care, treatment and prevention services within national policies, plans and budgets. The PEPFAR team will strengthen local capacity to update curricula and manage training programs, as well as support direct (targeted) in-service training for laboratory technicians, epidemiologists, persons providing HIV testing and counseling, primary health care services and providers working for NGOs.

At present, the human resources that could be made available by and through NGOs are not fully utilized nor recognized in the current system that places an emphasis on highly specialized services at the tertiary level. PEPFAR will work to promote task shifting and greater inclusion of non-government workers within the national response.

PEPFAR will focus on strategic planning within the laboratory infrastructure to assist governments in planning, deploying and managing lab resources effectively and efficiently.

Traditionally and largely still today, the central financing of health care services throughout

Central Asia was based on their supply rather than demand or quality. This orientation creates incentives to build infrastructure rather than considering first the needs at the patient or

“consumer” level and determining how best to meet those needs. PEPFAR will work to assess the laboratory needs of MARPs and PLHIV and determine with respective MOHs how to supply services more effectively and economically, without additional infrastructure. At the Republican and oblast level, PEPFAR/CAR‟s strategic focus to support a fully functional laboratory system will be on strategic planning, accreditation and creation of quality assurance. Training in these areas, as well as technical training for performance of quality-assured testing down to the primary health care level, will occur. Emphasis will be placed on point-of-care testing, when appropriate.

PEPFAR/CAR believes that laboratory is an area of HIV/AIDS services where there is a potential for the development of Private Public Partnerships…