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INDIA - CANADA COLLABORATIVE HIV/AIDS PROJECT
FINAL DRAFT PROJECT IMPLEMENTATION PLAN
Submitted to Government of India, April 2000
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Table of Contents
1.
INTRODUCTION AND BACKGROUND
1.1
1.2
1.3
1.4
2.
3.
..7
..7
..7
..8
..8
..9
..9
..9
10
10
10
11
12
13
14
DESIGN CRITERIA.
17
2.1
2.2
2.3
17
17
17
Project Goal and Purpose
Project Goal and Purpose
Expected Outcomes..........
18
DESIGN METHODOLOGY
3.1
3.2
4.
Developmental Context......................................................................
1.1.1 Development indices...................................................................
1.1.2 Economic situation......................................................................
1.1.3 Health Status...............................................................................
1.1.4 Poverty and Gender....................................................................
Project Rationale.................................................................................
1.2.1 HIV/AIDS in India........................................................................
1.2.2 Response by Canada..................................................................
Gender Analysis....................................................................................
1.3.1 Gender and HIV/AIDS Prevention and Care...............................
1.3.2 The Status of Men and Women in India.....................................
1.3.3 Gender and HIV in India..............................................................
1.3.4 Men and Women’s Experiences of HIV/AIDS.............................
1.3.5 Key Pertinent Issues...................................................................
Lessons Learned from Similar Activities and Previous Experience
7
Design Team Composition..................................
Design Process and Design Mission Activities
18
18
OVERALL DESIGN APPROACH
20
4.1
4.2
20
21
21
21
22
23
Design Rationale.....................................................................................
Cross-cutting Issues..............................................................................
4.2.1 Sustainability..................................................................................
4.2.2 Integration with Overall Development............................................
4.2.3 Addressing Gender Issues at Every Level....................................
4.2.4 Creating an Enabling Environment and Destigmatization.............
4.2.5 The Involvement of People Living With HIV/AIDS and Vulnerable
Groups in Programming................................................................
4.2.6 Evidence-based Grounding of Programs......................................
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23
24
5.
Introduction.........................................................................
Underlying Principles.........................................................
Gender Strategy..................................................................
5.3.1 Project Design.............................................................
5.3.2 Formative and Ongoing Research..............................
5.3.3 Capacity-building at National, State and Local Levels
5.3.4 Policy Development....................................................
5.3.5 Decision-Making/Management...................................
5.3.6 Program Implementation............................................
5.3.7 Monitoring and Evaluation..........................................
5.3.8 Budget........................................................................
26
26
27
27
27
27
28
28
28
29
29
LOGICAL FRAMEWORK ANALYSIS...............................................
30
KARNATAKA COMPONENT
35
5.1
5.2
5.3
6.
Situation and Needs Assessment...............................
7.1.1 Developmental and Socio-demographic Context
7.1.2 HIV Situation and Vulnerability...........................
Institutional Resources and Responses...................
7.2.1 Overview..............................................................
7.2.2 Opportunities for Capacity Building.....................
Karnataka Component Project Description.............
7.3.1 Overview..............................................................
7.3.2 Work Breakdown Structure.................................
7.3.3 Description of Outputs and Activities...................
35
35
36
37
37
38
39
39
40
42
RAJASTHAN COMPONENT......................................................
61
Situation and Needs Assessment...............................
8.1.1 Developmental and Socio-demographic Context
8.1.2 HIV Situation and Vulnerability...........................
Institutional Resources and Responses...................
8.2.1 Overview.............................................................
8.2.2 Opportunities for Capacity Building....................
Rajasthan Component Project Description............
8.3.1 Overview.............................................................
8.3.2 Work Breakdown Structure.................................
8.3.3 Description of Outputs and Activities..................
61
61
62
63
63
63
64
64
64
67
NATIONAL COMPONENT..........................................................
85
7.1
7.2
7.3
8.
8.1
8.2
8.3
9.
26
GENDER STRATEGY
9.1
9.2
Situation and Needs Assessment...............
9.1.1 National AIDS Control Organization ...
9.1.2 Technical Resource Groups...............
National Component Project Description
9.2.1 Overview.............................................
9.2.2 Work Breakdown Structure...............
9.2.3 Description of Outputs and Activities..
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85
85
85
88
88
88
90
10.
11.
12.
13.
MANAGEMENT COMPONENT
93
10.1
10.2
Work Breakdown Structure..............
Description of Activities and Outputs
93
95
STRATEGY FOR RESULTS-BASED MANAGEMENT.
101
11.1
11.2
11.3
11.4
11.5
11.6
101
102
102
102
103
103
RBM and Performance Monitoring Approach
Organizational Strategy.................................
Integration of Stakeholder Participation....
Logical Framework Analysis............................
Performance Measurement Framework........
Risk Management Framework...........................
PROJECT MANAGEMENT DETAILS
104
12.1
12.2
12.3
12.4
12.5
12.6
104
105
107
107
108
108
108
109
109
109
110
110
111
Project Management Strategy........................................
Project Organization Chart.............................................
Project Staffing.................................................................
Project Offices..................................................................
Financial Management.........................................................
Roles and Responsibilities.................................................
12.6.1 Government of India..................................................
12.6.2 Government of Canada (CMC, New Delhi)...............
12.6.3 Government of Canada (CIDA).................................
12.6.4 National AIDS Control Organization of India (NACO)
12.6.5 State AIDS Societies..................................................
12.6.6 Canadian Executing Agency.....................................
12.6.7 Project Steering Committee (PSC)............................
PROPOSED BUDGET
112
13.1
13.2
13.3
112
113
114
Budget by component.
Budget Notes.............
BUDGET BY ACTIVITY
14.
PROJECT IMPLEMENTATION SCHEDULE
116
15.
PROJECT REPORTING
125
15.1
15.2
15.3
15.4
15.5
15.6
General..........................................................................
Annual Workplan and Budget.....................................
Semi-Annual Progress and Financial Status Report
Annual Report...............................................................
End-of-Project Report...............................................
Other Reports ...............................................................
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125
125
126
126
127
127
16.
PROCUREMENT PLAN
128
17.
FIRST ANNUAL WORKPLAN
130
17.1
130
130
131
132
132
Planned First Year Achievements......
17.1.1 Karnataka Component...............
17.1.2 Rajasthan Component................
17.1.3 National Component...................
17.1.4 Project Management Component
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TABLE OF ABBREVIATIONS AND ACRONYMS
AIDS
AWP
CBO
CEA
CHC
CIDA
FSW
GOC
GOI
HIV
IAS
IDU
IEC
KSAPS
LFA
NACP-1, II
NACO
NGO
PIP
PMF
PLWHA
RBM
RMF
RSACS
SACS
SAPO
STD
STI
TRG
UNAIDS
WBS
WHO
Acquired immune deficiency syndrome
Annual workplan
Community-based organization
Canadian executing agency
Canadian High Commission
Canadian International Development Agency
Female sex worker
Government of Canada
Government of India
Human immunodeficiency virus
Indian Administrative Service
Injection drug user
Information, education and communication.
Karnataka State AIDS Prevention Society
Logical framework analysis
National AIDS Control Programme (Phase I and II) of India
National AIDS Control Organization (of India)
Non-governmental organization
Project Implementation Plan
Performance Measurement Framework
Person living with HIV or AIDS
Results-based management
Risk Management Framework
Rajasthan State AIDS Control Society
State AIDS Control Society
State AIDS Program Officer
Sexually transmitted disease
Sexually transmitted infection
Technical Resource Group
Joint United Nations Programme on AIDS
Work breakdown structure
World Health Organization
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1.
INTRODUCTION AND BACKGROUND
1.1
Developmental Context
Development indices
India, with the second largest population in the world (estimated at 966.2 million in 1997), ranks
132nd out of 174 countries on the Human Development Index (HDI), placing it at the lower end
of the medium category on this scale1. The HDI is constructed from life expectancy at birth,
adult literacy rate, combined gross school enrolment ratio and real gross domestic product (GDP)
per capita. Life expectancy at birth in India has risen from 49.1 years in 1970 to 62.6 years in
1997, with 83.9% of the population now expected to live beyond 40 years. The adult literacy
" rate is 53.5% and the national school enrolment rate in 1997 as a percentage of relevant age
group was 77.2% for primary school and 59.7% for secondary school. GDP in 1997 was U.S.
,$381.6 billion, with agriculture contributing 25%, industry 30% and services 45%. The GDP per
capita in 1996 was $465, up from $250 in 1976 as a result of an average annual rate of change of
3.0%.
India ranked 112 on the gender-related development index (GDI) in 1997. This index uses the
same variables as the HDI, but adjusts the average achievement of each country in life
expectancy, educational attainment and income in accordance with the disparity in achievement
between women and men. Comparative figures for women and men in 1997 in India were 62.9
■and 62.3 years for life expectancy at birth, 39.4% and 66.7% for adult literacy, 47% and 62% for
combined first-, second- and third-level gross school enrolment ratio, and $902 and $2389 for
real GDP per capita, expressed as purchasing power parity.
1.1.2 Economic situation
Gross national product (GDP plus net income received by residents from abroad for labour and
capital after deductions for payments made to non-residents who contribute to the domestic
economy) was $357.4 billion, or $370 per capita in 1997. The Gross National Product (GNP)
per capita annual growth rate between 1975 and 1995 was 2.8%, as the overall annual growth
■rate of 5% was tempered by significant annual population growth. This was 2.0% in 1975 when
the population was 670 million and slowed to 1.3% by 1997. Annual public education
expenditure in 1996 represented 3.4% of GNP and 11.6% of annual total government
expenditure for the period 1993-96, with health expenditure representing 0.7% and military
expenditure 2.5% of GDP in 1996. Annual inflation averaged 9.0% over the 1985-96 period and
was 6.3% in 1996. Over the last decade India has reduced its reliance on foreign aid from
$2,745 million in 1991 (1.1% of GDP) to $1,678 million in 1997 (0.4% of GDP). However,
external debt has risen from 19.2% to 24.9% of GDP over the same period. Debt service as a
percentage of exports of goods and services fell from 22.7% in 1985 to 19.6% in 1997.
1 United Nations Human Development Programme (UNDP). Human Development Report 1999. New York:
Oxford University Press, 1999.
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1.1.3 Health Status
India’s health profile, using latest available data for the period 1990-97, reveals 33% of infants
with low birth weight, 96% of one year olds fully immunized against tuberculosis and 81%
against measles. Infant mortality was 71 and under-five mortality 108 per 1000 live births.
There were 53% of children who were underweight at age 5 years, there was a total fertility rate
of 3.1, 88% of women were anemic in pregnancy and maternal mortality was 570 per 100,000
live births. Of the 1.2 million deaths per year in the 15-45 age group, an estimated 10 to 40% are
believed to be HIV-related. The Government of India (GOI) estimates that 3.5 million people are
infected with HIV and that 14 million people have tuberculosis, the most common illness among
those who are HIV-infected in India. It was estimated in 1993 that by the end of the year 2000
the HIV epidemic will have cost India $11 billion in both direct medical costs and indirect costs
due to the loss of productive labour. More recent work has shown that it will take India nearly
one year longer to reach the HDI level it would have been expected to reach by the year 2005 as
a result of the HIV epidemic2.
1.1.4 Poverty and Gender
A 1997 World Bank report on HIV/AIDS3 stresses the inter-relationship of premature death and
poverty, and the importance of integrating anti-poverty and HIV mitigation programs. India
ranked 59th on the human poverty index in 1997, with significant proportions of the population
without access to safe water (19%), health services (25%) and sanitation (71%). India’s
vulnerability to HIV as a result of poverty is compounded by the unequal status of women. India
ranks 95th on the United Nations gender empowerment measure, which is constructed from
indices of economic participation and decision-making, political power and decision-making,
and power over economic resources. Women in India hold 8.3% of seats in parliament, 2.3% of
administrative and managerial posts, and 20.5% of professional and technical posts. The female
economic activity rate in India was 50.3% of the male rate in 1997, reflecting gender disparity in
women’s opportunities to supply labour for the production of economic goods and services.
Women’s lack of power over economic resources translates into decreased control over sexual
decision-making, which is so critical to protection against sexually transmitted infections (STI)
and HIV infection. As well, the HIV epidemic carries disproportionate opportunity costs for
women as a result of their traditional roles as caregivers and nurturers of the ill and dying.
Addressing poverty and gender inequity will be essential to the success of India’s HIV
programming.
2 The Looming Epidemic: The Impact ofHIV and AIDS in India. Godwin, P (ed). New Delhi: Mosaic Books,
1998.
3 The World Bank. Confronting AIDS: Public Priorities in a Global Epidemic. New York: Oxford University
Press, 1997.
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1.2
Project Rationale
1.2.1
HIV/AIDS in India
As suggested from the above, there is an urgent need to reduce the spread of HIV infection in
India. Out of an estimated 31 million people currently infected with HIV worldwide, it is
estimated that about 3.5 million live in India. Between 1994 and 1997, the prevalence of HIV
infection among adults in India is believed to have more than doubled. In response to this
rapidly growing epidemic, the Government of India is mounting efforts to address both its
immediate and underlying causes. Accordingly, the GOI, through its National AIDS Control
Organization (NACO) has developed a Second National AIDS Control Project (NACP-II). The
key broad objectives of the NACP-II are to:
1) reduce the spread of HIV infection in India; and
2) strengthen India’s capacity to respond to the HIV/AIDS epidemic on a long term basis.
To achieve these objectives, the NACP-II is designed to apply a strategic, integrated effort at the
national, state and local levels. The principafstrategy in NACP-II is to reduce HIV transmission
within population subgroups with a high risk of acquiring and transmitting HIV infection and to
prevent transmission of HIV from such groups to the general population. This effort will be
complemented by interventions aimed at protecting population groups that are vulnerable to HIV
infection and AIDS, and enhanced provision of care and support for those affected by HIV/AID.
1.2.2
Response by Canada
The Canadian International Development Agency (CIDA) has recognized the enormous
humanitarian and developmental impact of the HIV epidemic in India and has committed to
provide assistance to India by increasing the capacity of national, state and local institutions and
agencies with a five-year project that is intended to complement the efforts of the GOI and state
AIDS societies as they implement the NACP-II. The main focus of the project will be to provide
specific support to the states of Karnataka and Rajasthan. These states were chosen through
consultation with NACO. In addition, certain capacity strengthening activities will be
undertaken at the national level with NACO and designated Technical Resource Groups (TRGs).
Through a competitive selection process, a consortium led by the University of Manitoba,
Winnipeg, in collaboration with Mascen Consultants Inc., Ottawa, and ProAction: Partners for
Community Health/Partenaires Pour La Sante Communautaire, Montreal, was selected by CIDA
in June 1999 as the Canadian Executing Agency (CEA) to design and deliver a bilateral
HIV/AIDS Prevention and Control Project in India.
A contract between CIDA and the University of Manitoba was signed in September 1999, and is
to be executed in two phases: a Design Phase and an Implementation Phase. The Design Phase
started upon signing of the contract. The major activity in this Phase has been for the CEA to
undertake a Design Mission to India to work with the National AIDS Control Organization
(NACO), some of NACO’s Technical Resource Groups (TRGs), the state level AIDS societies
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of Karnataka and Rajasthan, and their implementing partners, to develop a detailed design for the
Implementation Phase. The project duration is planned to be five years and the implementation
target date is six months after submission of a satisfactory Project Implementation Plan to CIDA
and the Government of India, expected to be submitted in February 2000.
1.3
Gender Analysis
1.3.1
Gender and HIV/AIDS Prevention and Care
India’s HIV epidemic is characterized by its heterogeneity. It continues to be strongly driven by
heterosexual transmission, with HIV infection moving beyond its initial foci among female sex
workers (FSWs) and their clients into the wider population. At the same time, there are
important sub-epidemics evolving with potentially explosive spread among injecting drug users
and men who have sex with men. Of the approximately 3.5 million people who are currently
infected with HIV in India, about 75% are men and 25% are women, reflecting among other
things, the tolerance of male access to sex beyond the marital relationship. Among men, HIV is
concentrated in vulnerable populations such as truck drivers, migrant workers and the clients of
commercial sex workers. Among women, HIV is concentrated among FSWs. In Mumbai, an
estimated 60% of these women are HIV infected. As the epidemic continues however, there is a
shift to women who are not FSWs. Recent surveillance data shows a 2% seroprevalence in
antenatal women in certain sites, with an accompanying increase in pediatric HIV infection.
Nearly half of all infections to date have been in the 15-24 year old age group, with the peak age
of infection lower in girls than in boys. It is anticipated that women’s biological,
epidemiological and social vulnerability will greatly intensify this shift over time. The social
and customary controls over women’s social and sexual behavior that protect them from
infection in an early epidemic will also render them vulnerable, as more and more of their male
partners become infected.
1.3.2
The Status of Men and Women in India
The health of Indian women and men is intrinsically linked to their status in society. The
contributions that women make to families are often overlooked, and instead women are often
regarded as economic burdens. There is a strong son preference in India, as sons are expected to
care for their parents as they age. This son preference, in combination with high dowry costs for
daughters, sometimes results in the mistreatment of daughters. The most chilling evidence of
this is the large number of “missing women” (i.e. girls and women who have apparently died as a
result of past and present discrimination, for example, female feticide and infanticide, high
maternal mortality and dowry deaths). Recent estimates place this number at approximately 35
million. Further, Indian women have low levels of both education and formal labour force
participation. They typically have little autonomy, living under the control of, first, their fathers,
then their husbands and finally, their sons. Women comprise approximately 70% of the poorest
sectors of Indian society, and most of these women are heads of households.
India constitutes a challenging but nonetheless positive environment for promoting gender
equality in the HIV/AIDS arena. NACO has recognized the importance of reaching
marginalized groups such as female sex workers through peer-led initiatives within non
governmental organizations (NGOs ). Furthermore, within both the governmental and non-
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govemmental sectors, a strong commitment to the empowerment of women exists. This is
reflected in the adoption of key governmental policy documents. These include the National
Perspective Plan for Women (1988) and the National Policy for Empowerment of Women
(1996). Within the various five-year Plans therein, key commitments to women’s issues were
incorporated. These include the reservation of one-third of seats for women on all institutions of
local governance within the Eighth Five Year Plan (1992-97) and the inclusion of the
empowerment of women as one of the stated objectives of the Ninth Five Year Plan (19972002). In addition, unlike many developing countries, India has a number of existing and newly
emerging gay rights and support groups.
1.3.3
Gender and HIV in India
The gender-related vulnerability of men and women to HIV infection in India can best be
understood as constructed by and operating within a set of roles and norms that may differ
between class, caste, tribe, religion and geographic area, but nevertheless exists within each of
these. Access to and control over resources is profoundly gender-related in both the private and
public domains. Concepts of appropriate expressions of masculinity and femininity in men and
women are seen to be natural expressions of biological sex. How we understand both men and
women’s vulnerability to HIV infection requires a negotiation of the complex arena of gender
roles, expectations, rights and responsibilities. This is equally true of access to care and support.
Understanding gender norms and expectations for both men and women is crucial for promoting
safer sexual practices in both high risk encounters and with regular sexual partners.
In India, as elsewhere, women are particularly at risk of STI and HIV infection for a variety of
economic, biological and cultural reasons. As with other disenfranchised groups, women lack
control over and access to the material and social resources that can assist them in avoiding
STI/HIV infection. For example, 70% of those below the poverty line in India are women.
Women are also more prone to HIV for biological reasons. HIV transmission during sexual
intercourse is significantly more efficient from men to women than from women to men.
Furthermore, it is known that the presence of STI significantly increases the likelihood of HIV
acquisition. Unfortunately, many women with STI remain untreated for long periods of time
because they may be asymptomatic or have limited access to health services, or because cultural
taboos make it impossible for them to attend an STI clinic.
In addition to these factors, young girls and women in India are often at high risk owing to early
marriage traditions, child prostitution, temple/caste-based prostitution, and where older men have
sexual relationships with younger women. Women’s vulnerability to HIV infection is
exacerbated by the fact that the most effective means of prevention currently available require
the active cooperation of men. Prevention strategies that emphasize male condom use, sticking
to one partner or practicing non-penetrative sex are partner-dependent. As such, these strategies
do not represent viable options for the many women who are denied the right to refuse sex or
who are in a social, economic or cultural context that undermines their ability to insist on safer
sex.
The socio-economic factors that are widely recognized as constructing women and men’s
vulnerability to HIV infection are often regarded as requiring long-term measures to redress, and
consequently may be regarded as outside the domain of traditional STI/HIV prevention
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programs. However, emerging knowledge demonstrates that even well-executed intervention
programs fully supported by available, affordable and accessible condoms will have limited
success in the absence of strategies to address the contextual determinants of behaviour change.
For women, contextual determinants include fear of domestic violence, financial dependence on
an unfaithful/infected partner, oppressive legal frameworks, lack of physical mobility and a
(perceived) lack of other options. For gay or transsexual men, contextual determinants include
fear of violence and social ostracism, oppressive legal frameworks and virulent stigmatization.
This is not to deny the necessity or efficacy of well-designed peer-led targeted interventions
among vulnerable populations. These are both logical and needed. Promoting partner
reduction, condom use and STI treatment in high-risk situations will make an extremely valuable
contribution to slowing the progression of the HIV epidemic. However, vulnerable individuals
(sex workers, clients of sex workers, men who have sex with men) do not lead isolated lives. For
example, sex workers have children and husbands or lovers, sex workers’ clients have wives and
families, men who have sex with men also have wives and families. Behaviour change strategies
that work for high-risk encounters may be inappropriate for relationships outside of this arena.
Integral to the successful promotion of responsible, affirming sexuality and protecting against its
opposite, is an understanding of how gender operates in people’s social and sexual lives.
Therefore, in order to promote comprehensive, sustainable HIV prevention strategies and better
care and support, HIV prevention and care programs must include both a greater understanding
of gender and HIV, not reinforce gender stereotypes and promote equal access for all to services,
commodities and information. This must be complemented by simultaneously working with
development and social change organizations, for example, organizations working for positive
legal frameworks, credit programs for women or increasing access for girls to education.
1.3.4 Men and Women's Experiences of HIV/AIDS
Regardless of social class or gender, AIDS is a chronic disease that brings multiple episodes of
acute, serious illness. HIV brings together the taboo subjects of sex and death, and shines an
unwelcome light on people’s most private behaviour. It has almost a unique potential to provoke
fear, misunderstanding, misery and victimization. The following observations will give some
idea of men and women’s lived experiences with HIV/AIDS and highlight some ways in which
HIV is experienced differently by men and women. These observations are drawn primarily
from personal interviews and observations of the project Design Team and a recent unpublished
study entitled HIV/AIDS Related Discrimination, Stigmatization and Denial in India, by Shalini
Bharat, Tata Institute, 1999. In this study, 46 HIV positive people in Mumbai and Bangalore
were interviewed. A majority of the men were married, whereas most of the women were
widowed. Most of the participants were from lower and lower middle socio-economic sections
of society. While there were many examples of exemplary service provision for individuals with
HIV infection, in common with many countries responding to a newly emerging HIV epidemic,
the quality of service delivery and attitudes varies considerably.
Generally speaking, most people’s first point of contact with knowledge of their own or their
spouse’s HIV status is in the health care setting. Quality HIV counselling and testing services
are unevenly available and test results are often not accompanied by appropriate counselling. In
many instances, both men and women’s HIV results are first disclosed to their families. Sex
workers are particularly stigmatized in public hospitals, often preferring to go for private care.
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For many brothel based sex workers in India, home-based care is not an option, when home is a
brothel, and ties to family and community have been severed. According to the Tata Institute
report, most public hospitals are struggling to provide quality medical care. Attempts are made
to minimize contact by wearing gloves, keeping clothes separate, feeding/treating HIV positive
patients last, etc. In the private sector, it is common practice for doctors to refuse to treat HIV
positive patients, but to refer them to a public health facility. There may be significant
discrimination against women in the home setting as well, as they are vulnerable to their
families-in-law for care and support. They may be blamed for their husband’s infection, and
denied medical treatment or a share in their husband's property.
Both Indian men and women’s experience of being HIV positive is often painful and
stigmatized. It is also profoundly influenced by gender. Sexually acquired HIV, which by its
nature reveals sexual relationships beyond mutual monogamy, is highly stigmatized, and the
degree of stigmatization appears to be proportionate to both the degree of illicit behavior and
challenges to accepted gender norms revealed. It is important to note that at this point in the
epidemic in India, it is primarily socially and economically vulnerable people who are infected,
and given the fact that the middle and upper classes often access health care through the private
health care system, very little is known about their experiences.
According to available data, three times more men than women have HIV in India. Men’s role
as breadwinner, the large numbers of migrant male workers and truck drivers spending long
periods of time away from home, control over disposable income, and a degree of societal
expectation and tolerance of extra-marital relationships for men has placed them at high risk of
HIV infection. Furthermore, homosexuality is extremely stigmatized. Gay men are hard to
reach and so stigmatized that they often choose an HIV positive identity while continuing to
deny their gay identity.
Women are vulnerable to HIV infection and inadequate care and support in different ways. The
majority of HIV positive women are sex workers. Such women belong to an already stigmatized
group and this stigmatization is compounded by HIV infection. Women who become sex
workers pay a high price in social cost. Extremely high levels of HIV, resulting in a double
stigmatization, now compound this. As indicated above, many HIV positive pregnant women
are vulnerable to termination of pregnancy or refusal of a health facility to admit for delivery.
Married or widowed HIV positive women are often blamed for their husband’s infection and
vulnerable to inadequate care by their families-in-law.
1.3.5 Key Pertinent Issues
Based on the forgoing, some key issues should be borne in mind when considering HIV/AIDS
and gender equality in India. These include:
•
Men and women are currently HIV infected in a ratio of 3:1, but this ratio is expected to
shift over time as more women become infected.
•
Vulnerable men and women are currently bearing the brunt of HIV infection, but there
are indications that HIV is spreading into the “general” population; for example, recent
surveillance rounds indicate up to a 2% seroprevalence in certain antenatal populations.
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1.4
•
The existing male to female HIV infection ratio requires both current and anticipatory
responses. Current responses are needed to address the particular vulnerability of men
and sex workers and anticipatory responses are needed to address the shift in infection to
women more broadly.
•
There is a high degree of association between female sex workers, men who have sex
with men, truck drivers and other vulnerable groups and HIV infection. People outside of
these defined groups do not see themselves at risk.
•
STI/HIV in India is highly stigmatized. This negatively affects the availability of and
access to quality STI/HIV prevention and care services.
•
Bridging the gap between the uncharted domain of men’s private behaviour and women’s
powerlessness is one of the major cultural and political challenges posed by the HIV
epidemic in India.
•
Sex workers' and married women’s access to HIV-related care is highly variable. Home
based care for sex workers who are brothel-based or for married women living with their
in-laws is often problematic.
•
In Karnataka and Rajasthan, a vast range of sex work exists. It includes child
prostitution, temple prostitution (devadasi), brothel, home bar-based and caste-based
prostitution, and men who have sex with men. Thus, multiple intervention strategies will
be required, based on a peer-mediated education approach.
•
The stigmatization of gay and bisexual men and transsexuals make them particularly
vulnerable to HIV infection, and render it both difficult and urgent to reach and support
them for HIV prevention and care.
•
Linking STI/HIV services with development and human rights initiatives will be central
to providing a continuum of prevention and care for poor people.
•
A dearth of information exists regarding HIV infection and sexual behaviour in India. A
key component of any STI/HIV prevention and care strategy must be the gathering of
reliable biomedical and behavioural gender-specific information.
Lessons Learned from Similar Activities and Previous Experience
India is facing a potentially devastating HIV/AIDS epidemic, but is in a position of being able to
benefit from experience in other countries, particularly in sub-Saharan Africa and Southeast
Asia. Almost two decades of HIV/AIDS programming has demonstrated that some strategies are
highly effective in reducing HIV transmission while others have very little short-term impact.
NACP-II is designed to implement these strategies as widely as possible, through state and
municipal corporation AIDS Societies, and their NGO and other implementing partners. These
intervention strategies are directed at proximate and remedial causes of the HIV/AIDS epidemic.
Worldwide, the underlying causes of HIV epidemics are the same: marginalization, poverty and
inequity. These in turn lead to behaviour and circumstances that result in HIV transmission.
While resolving these underlying causes is an important goal and may be the ultimate solution to
the epidemic, they cannot all be achieved in the time needed to prevent a catastrophic HIV/AIDS
epidemic in India. However, over the past 20 years a number of highly effective interventions,
capable of reducing HIV transmission by 40-80%, have been developed. These interventions
-14-
utilize what may be called the “classic” public health response to epidemics, have a solid
theoretical basis and evidence for their effectiveness is drawn from observational studies or
intervention trials.
The classic public health response addresses factors in the HIV epidemic that are rapidly
amenable to intervention. It first includes identifying proximate causes of HIV spread. For HIV
in India these include unprotected heterosexual sex, particularly in the context of the sex trade;
unprotected sex among men who have sex with men; a high prevalence of treatable bacterial
sexually transmitted infections; and sharing or reuse of needles for injecting drugs. The second
element includes identification of demographic, ethnographic and geographic “hot spots” for
HIV transmission. The third element involves designing and implementing interventions, based
on what has been shown to work from experience or from intervention studies, targeting the
communities or populations groups and the behaviour or conditions that put people at risk of
HIV. From the world-wide experience, there are at least six strategies that have been shown in
observational studies or trials to be highly effective in reducing risky behaviours and/or HIV
transmission. These are:
•
Peer-mediated group education and condom promotion among female sex workers.
•
Peer-mediated group education and condom promotion among men at risk of HIV.
•
Voluntary HIV counseling and testing.
•
Needle exchange and other harm reduction strategies among injection drug users.
•
Provision of effective STI management services to the general population.
•
Antiretroviral prophylaxis and breastfeeding alternatives for the children of HIV infected
women.
Each of these interventions is cost-effective when compared to public health interventions for
other health problems. It is important to note though that these interventions are not formulaic.
They must be responsive to the needs of the target population and undertaken in partnership with
them at every stage. NACP-II is largely designed to apply this response to the HIV/AIDS
epidemic in India. The project will work to enhance the capacity of NACO, the TRGs, RS ACS
and KSAPS to do this in two main ways: first by enhancing their capacity to mount effective
interventions and second by assisting them in the development of new effective intervention
models.
Global experience has also provided several broad lessons learned on the manner and the context
required for effective implementation of HIV prevention interventions. For targeted
interventions to be effective, they must be undertaken in a manner such that they empower the
groups involved in the intervention. In fact, they will predictably fail if they do not. While there
is always a real concern that targeting already disadvantaged groups will stigmatize and further
marginalize them, if undertaken correctly, these interventions can be tremendously empowering.
The best interventions become a spark for community development, as has been seen with the
Sonagachi project in Calcutta, the University of Manitoba/University of Nairobi work in Kenya
and many other examples. Marginalized and disenfranchised people who are shown how to take
control over one measure of their lives, soon begin to look for other ways to change their lives.
- 15-
The project will work extensively with its partners to ensure that the interventions undertaken
maximize empowerment of the target communities.
To succeed, targeted interventions must be undertaken within an environment that enables the
interventions to occur without fear or prejudice. This means that there needs to be a significant
understanding of the issues involved within the general population to counter attitudes that may
undermine interventions. There must also be an appropriate policy framework in place. For
example, it will do little good to educate sex workers about HIV and condoms if they are being
harassed and arrested by the police. This requires continuous and effective public education,
education and training of health workers, partnering with social change and development
initiatives, and continuous advocacy with political leadership.
Finally, prevention and care are part of a continuum. Prevention programs cannot achieve their
potential if there is no capacity for care of those with HIV infection and AIDS. As the numbers
of people who are ill with AIDS continues inexorably to rise over the coming years in India, it
will be important to mobilize communities to respond to the care and support needs of those who
are infected and affected. There must be an environment created where people can see that
disclosure of a positive HIV status can result in continued employment, active community
involvement without discrimination, counselling for positive living, support from others with
HIV and comprehensive health care (acute, out-patient and home-based). Otherwise, few people
will come forward for testing, and valuable prevention opportunities will be lost. Those HIVinfected people who do not know their status are not able to plan for themselves and their loved
ones, take steps to prevent transmission to sex partners and make informed reproductive choices.
While NACP-II emphasizes interventions among those who are at highest risk of transmission of
HIV, it does not ignore individuals with lower risk or individuals with HIV-related disease or
AIDS. General education and information programs for lower risk individuals are undertaken as
a necessary adjunct to high risk group interventions. Also, cost-effective treatment for
opportunistic infections, defined as those that prolong life or prevent secondary transmission, are
provided for individuals with AIDS. The project will work with its partners to develop
demonstration projects for a continuum of care from voluntary counseling and testing to
effective home-based care.
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2.
DESIGN CRITERIA
-2.1
Project Goal and Purpose
2.2
Project Goal and Purpose
As per the terms of reference provided by CID A and NACO, the goal of the project is to
contribute to India’s efforts to slow the progression of the HIV/AIDS epidemic and to mitigate
the impact of the epidemic on vulnerable individuals and groups.
The purpose of the project is to strengthen the institutional capacity of the Karnataka and
Rajasthan state AIDS societies and their implementing partners, as well as NACO and selected
Technical Resource Groups, to plan, design, implement and evaluate initiatives related to the
Government of India’s National AIDS Control Project - Phase 2 (NACP-II).
2.3
Expected Outcomes
The expected project outcomes are:
•
Slowed progression of the STI/HIV epidemic among women and men in project areas,
contributing directly and indirectly to poverty reduction, and to gender equality.
•
Mitigation of the impact of the HIV/AIDS epidemic among women and men in project
areas, contributing directly and indirectly to poverty reduction, and to gender equality.
-17-
3.
DESIGN METHODOLOGY
3.1
Design Team Composition
As accepted by CIDA, the Design Team was composed of the following individuals.
Dr. Stephen Moses, University of Manitoba - Design Team Leader/Specialist in sexually
transmitted infection control for HIV/AIDS prevention and program evaluation.
Dr. Francis A. Plummer, University of Manitoba - Specialist in targeted interventions,
HIV/AIDS related policy development and program evaluation.
Dr. James F. Blanchard -Specialist in epidemiology, HIV surveillance systems and public health
approaches to HIV/AIDS prevention.
Ms. Aine Costigan, University of Manitoba - Specialist in gender issues, community
development, NGO liaison and community HIV care.
Dr. Catherine A. Hankins, ProAction - Specialist in human resource development, capacity
building, gender issues and HIV/AIDS care.
Mr. P. Tota Gangopadhyay, Mascen - Specialist in project design and results-based
management.
In addition, the design team was supported and accompanied throughout the Design Mission by
Ms. Sarada Leclerc, Health and Population Specialist, Asia Branch, CIDA, Canada, Mr. T.
Sampath Kumar, Development Officer, Canadian High Commission, India, and Dr. Thomas
Philip, HIV/AIDS advisor for the Canadian High Commission.
3.2
Design Process and Design Mission Activities
The Design Mission began at the beginning of November 1999, following preparatory work
among the Design Team, NACO, CIDA and the Canadian High Commission in India in
September and October.
Initial meetings were held in New Delhi with CIDA, the Canadian High Commission and
NACO, to carry out a needs analysis and establish the strategy for the participatory design
process to be carried out during the rest of the design mission. Meetings were held subsequently
in New Delhi with representatives of multilateral and bilateral agencies involved in the
HIV/AIDS field in India, including UNAIDS, WHO, the World Bank, UNICEF, UNDP,
UNESCO, UNIFEM, USAID, DFID and AUSAID.
To understand better the roles and needs of selected TRGs, meetings were held with
representatives of the National Labour Institute (TRG on workplace interventions, located just
outside New Delhi), in Chennai with representatives of the Institute of Venereology (TRG on
sexually transmitted diseases) and in Mumbai with representatives of Grant Medical College
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(TRG on clinical management). After meeting with representatives of the latter two TRGs,
opportunity was taken to meet with representatives of the Tamil Nadu State AIDS Control
Society and the Mumbai District AIDS Control Society, as well as with several of their
implementing partners. This included field visits to project sites.
From November 14 to 23, the Design Team divided into two teams to carry out project design
work in Karnataka and Rajasthan. The main counterparts in the two states were the Directors of
the Karnataka State AIDS Prevention Society (KSAPS) and the Rajasthan State AIDS Control
Society (RSACS), and Design Team members were accompanied throughout their visits by
representatives of the two societies, in particular the NGO advisors and the deputy directors. A
variety of methods were used to assess needs and capacities, with a view to developing the
project design. These included meetings with state AIDS society and other government officials;
meetings with implementing partners, including NGOs and academic institutions; and field visits
to project sites. Workshops were also held with stakeholders to discuss and develop the project
design elements. The design strategies and components described below were reviewed during
meetings with the two state AIDS societies at the conclusion of the state visits, and agreed to by
• all parties.
After returning to New Delhi, the Design Team integrated the various elements of the project
design, and made a preliminary presentation to NACO on November 25. Following feedback
and input from NACO, the project design was revised further, and a final presentation was made
to NACO on November 30. Presentations and briefings were also made to the Canadian High
Commission and to the key multilateral and bilateral donor agencies involved in HIV/AIDS
programming in India. A listing of design mission meetings and reports is available.
-19-
4.
OVERALL DESIGN APPROACH
4.1
Design Rationale
On December 15, 1999, the Government of India officially launched the National AIDS Control
Program, Phase II (NACP-II) funded by the World Bank and the Government of India. NACP-II
is designed to decentralize HIV and AIDS control activities to newly formed State AIDS
Societies and rapidly implement evidence-based interventions in priority areas. There is
particular emphasis on vulnerable populations at high risk of acquiring and transmitting HIV and
on cost-effective programming. The focus of NACP-II is based on the following logic. In the
HIV/AIDS epidemic in the Indian context, there are many needs competing for resources. The
Government of India’s priorities are to first stem the spread of HIV and second mitigate the
impact of HIV/AIDS on Indian society. In discussions between CIDA and NACO, it was agreed
that the Canadian contribution to this effort should complement other NACP-II activities, have a
programmatic focus on capacity- building and a geographic focus on the states of Rajasthan and
Karnataka. Thus the CIDA-funded HIV/AIDS project will fit closely within the framework of
NACP-II and within CIDA’s objective of supporting the social and economic reform process in
India through capacity building of institutions and government organizations.
India urgently needs effective interventions at national scale to slow the spread of HIV infection.
To intervene effectively, the causes of the HIV/AIDS epidemic must be understood. Particular
patterns of sexual behaviour and a high prevalence of facilitating STIs drive the HIV/AIDS
epidemic, but these are proximate, not root causes. The contextual determinants of the
HIV/AIDS epidemic are social and economic: poverty, gender inequity, caste inequity,
disenfranchisement and inadequate health infrastructure. While these root causes must be
recognized in HIV/AIDS programming, addressing them is a long-term, complex and uncertain
prospect. If NACP-II were to focus on these root causes alone, the HIV/AIDS epidemic would
progress more or less unabated while solutions for these underlying problems were sought.
There are public health interventions that are highly effective in slowing the spread of HIV.
These interventions, however, are less effective in the longer term without the incorporation of
strategies for simultaneously recognizing and addressing the contextual determinants of the
epidemic. Targeted interventions must, therefore, simultaneously address the constructs of
vulnerability. If not, there is a significant likelihood that targeted interventions would continue
in isolation and perpetuity. For instance, interventions for sex workers are much more effective
if they include a significant element of empowerment, with strategies to address the fundamental
gender issues involved, than if they have a strict health focus. This means that health promotion
for sex workers is built on a program that recognizes and responds to their stated needs. This can
be best effected by collaborating with groups and organizations involved in fundamental
development and social change initiatives in HIV/AIDS programming, for example literacy
programs, legal rights advocacy groups and micro-credit programs.
-20-
4.2
Cross-cutting Issues
In the approach of the Design Team to the Design Mission and following discussions with
stakeholders, several principles emerged which cut across the different elements of the design.
These are:
•
Sustainability.
•
Integration with overall development.
•
Addressing gender issues at every level.
•
Creation of an enabling environment and destigmatization.
•
Participation of People Living With HIV/AIDS (PLWHAs) and vulnerable groups in
programming.
•
Evidence-based grounding of programs.
4.2.1
Sustainability
This project is conceived as a capacity building project to complement the entire NACP-II effort,
with a geographic focus on two states. Its main thrust is to equip those responsible for
HIV/AIDS control in India with the skills necessary to respond effectively to the epidemic.
There was strong sentiment within the Design Team and other participants in the design process
(NACO, C1DA, RSACS, KSAPS) that the project should be integrated into the NACO/state
AIDS society framework for several reasons. While project delivery might be considerably
easier if the project operated independently of the state AIDS societies and worked directly with
implementers, this would be unsustainable and largely ineffective in building capacity within the
state AIDS societies. There would also be the danger of setting up an environment of rivalry or
competition with the state AIDS societies if the project were to have a separate organizational
structure. Furthermore, the reach of the project will be greatly extended by working within the
state AIDS societies. Finally, NACO and the state governments are very concerned that bilateral
projects be closely coordinated with their own. Thus the project was designed for maximal
integration possible with the state AIDS societies, subject to the need for accountability of the
CEA to CID A, and efficiencies that may be achieved through sharing of resources between
Rajasthan and Karnataka.
If the project is successful in building capacity, then this capacity will be in place to maintain
programming efforts after the project ends. The Government of India is already covering most
of the programmatic costs involved in HIV/AIDS prevention control activities, either directly or
through its large World Bank loan, which will ultimately be India's responsibility to repay. By
integrating project activities within NACP-II, and the state and local structures which are
implementing NACP-II, there is every expectation that project activities will be sustainable in
the medium and long terms.
4.2.2
Integration with Overall Development
The ultimate solutions to the HIV/AIDS epidemic are development, empowerment and social
change. While this project cannot directly implement traditional development programs, it will
-21 -
significantly address development in two ways. This is based on the recognition that (depending
upon the speed of its progress in India), the HIV epidemic will be accompanied by a regression
of many development gains (for example, life expectancy and girl child literacy), the
impoverishment of public and private sector services (for example the health sector), the
devastation of household and community resources, and an increase in old and young
dependents. Furthermore, in order to avert the need for targeted interventions in perpetuity, the
contextual determinants of HIV vulnerability need to be addressed as health promotion programs
focus on marginalized and vulnerable populations.
It is important therefore to weave an overall development perspective and approach throughout
the project. The intervention approaches promoted by the project will include development
techniques (community participation, community partnership and empowerment). Interventions
must be designed so that they recognize the needs of vulnerable communities beyond HIV/AIDS,
are empowering, and become a spark for community development. This has been the experience
in Sonagachi in Calcutta, where an initial narrow health focus among sex workers has expanded
into a community development movement. This has also been the experience of the design team
with female sex worker interventions in Kenya, where successful sex worker group formation
helps to rekindle hope among extremely disenfranchised women and shows them that they can
take control of their lives. This will mean that interventions include community partnerships,
group formation, peer leadership training, advocacy for the rights and needs of vulnerable
populations, and supporting them to undertake initiatives for their own development. Leadership
representation from vulnerable groups within project decision-making mechanisms will also be
fostered.
It is also important to work with agencies that are involved in community development or social
change initiatives and build their capacity to incorporate effective HIV/AIDS
programming/advocacy as part of a comprehensive set of development activities and services.
This will enable the project to provide responsible referral services for HIV-affected
communities. Furthermore, the potential to address the underlying causes of HIV vulnerability
can best be addressed by linking with organizations working on development issues and social
change. The same strategies and principles described above will be employed.
4.2.3 Addressing Gender Issues at Every Level
As discussed above, gender norms, relationships and roles, and the relative status of men and
women at every level will construct both men and women’s biological and social vulnerability to
HIV infection. Gender issues will also impact upon HIV-affected men and women’s access to
equal care and support. Accordingly, this project will seek to understand and address gender
concerns at every level. Gender issues will be reflected in project analysis and design, the
dedication of human and financial resources, the implementation of research, prevention and care
activities, in monitoring and evaluation, and in community and institutional partnerships.
While health promotion will provide the raison d ’etre for working with vulnerable or
marginalized groups, their lives will be understood as operating within a set of gender
relationships and assumptions that may render them vulnerable to HIV. Thus, sex workers’
relationships with their children, clients, husbands/lovers, "madams” and business
owners/procurers, or sex worker clients’ relationships with their female/male sex worker
-22-
contacts, their wives/lovers, families and children, will all be explored as part of sexual health
promotion activities. Equally, the contribution that gender roles and norms make to responsible,
affirming sexuality (or not) will be explored. Gender issues will then be addressed in culturally
appropriate ways with project partners.
4.2.4
Creating an Enabling Environment and Destigmatization
Experience from around the world has shown that an enabling environment must be in place for
effective HIV/AIDS prevention and care programming. Policy and decisions makers must have
accurate knowledge of HIV/AIDS issues and their solutions so that counterproductive policies
and pronouncements are avoided. Community leaders and authorities must be engaged, with
sensitivity to the requirements of effective interventions, and at least permissive in their actions
towards people affected by HIV/AIDS and vulnerable groups. The population must have basic
knowledge about HIV/AIDS and be sensitized to the special needs of vulnerable groups.
Condoms must be available at the place and time that they are needed. The social milieu of
vulnerable individuals must support their decisions about sexual behaviour. Appropriate
resources must be in place to meet the demand for voluntary counseling and testing and
HIV/AIDS prevention must be considered within the continuum from prevention to care. The
project will work with the state AIDS societies and implementing partners to help ensure that
these elements of an enabling environment are in place in each state and that work at the state
level informs national programming.
Another dimension of an enabling environment must be destigmatization of AIDS. If people
with HIV/AIDS are rejected and ostracized, their participation and the participation of vulnerable
groups at risk for HIV infection will be limited. HIV/AIDS exposes hidden aspects in any
society. It brings together the taboo topics of sex and death, and requires an unprecedented
openness regarding these subjects to adequately understand and address HIV/AIDS prevention
and care. AIDS has an almost unique potential to provoke the very reactions that are antithetical
to an effective response: denial, fear, judgement, stigmatization and discrimination. This is
especially true in nascent epidemics. Such responses drive the epidemic underground and make
it difficult to reach vulnerable and marginalized populations with the prevention, care and
support that they require. This project will seek to destigmatize HIV disease and those at risk of
infection or already infected. The project will work with policy makers, service institutions,
NGOs, and vulnerable and affected communities to promote a non-judgmental, non-stigmatizing
approach in their HIV-related work. This will provide HIV vulnerable and affected people with
the care and support that they require to adopt and maintain safer sex practices, to access quality
HIV testing, and to live with HIV disease healthfully and positively.
4.2.5
The Involvement of People Living With HIV/AIDS and Vulnerable
Groups in Programming
People living with HIV/AIDS (PLWHAs) have first-hand experiences of the problems that they
face. They are the ones who have periods of ill-health, who struggle to provide for their families,
who face hostility in the communities in which they live, and who try to hold down employment
in the face of discrimination. The involvement of PLWHAs is therefore crucial for any HIV
initiative. Throughout the world, as PLWHAs are supported and empowered, they have made
immeasurable contributions to HIV prevention and care, both informing and complementing the
efforts of policy-makers, researchers and program implementers. Cared for and mobilized,
-23-
PLWHAs provide a voice, a human face to the epidemic. They are integral to destigmatizing
HIV, to effective peer-education and solidarity, and to prevention, care and support programs.
Among HIV affected communities, the involvement of PLWHAs in HIV prevention and care
activities promotes legitimacy and trust. PLWHAs can also identify their changing needs and
provide the necessary leadership in expanding policy and program directions. This project will
actively seek to promote the involvement of PLWHAs in all project activities according to their
defined priorities.
Many of the same issues apply to members of vulnerable groups. Women who are sex workers
or men who are their clients know their own needs far better than others can hope to. Partnership
with them and their engagement in designing and delivering interventions for their peers has
proven to be a key element in the success of interventions throughout the world. In India, sex
work, sodomy and injection drug use are all illegal and stigmatized activities. Reaching
communities of sex workers and their clients, men who have sex with men and drug users,
creating a safe environment for them to meet and address their concerns, and promoting HIV
protecting behaviour can best be achieved through discrete, non-judgmental, peer-led initiatives.
In fact, maximum impact cannot be achieved without the input and leadership of marginalized or
vulnerable groups in programs designed for their participation.
4.2.6 Evidence-based Grounding of Programs
To intervene effectively in India, resources must be directed at the problem in the most effective
way. This means that geographic areas that are the most vulnerable should be targeted first, that
the most vulnerable groups should be targeted first, that strategies that interrupt the most
transmission should be employed first, and that the most cost-effective strategies should be
employed. Relevant and accurate information is required to be able to direct intervention efforts
in a cost-effective manner to the areas where they are most needed; good data are required to
make good decisions. In the HIV/AIDS epidemic in India, there are many needs for
interventions. These include HIV/AIDS awareness, targeted interventions, social change, overall
development and the need for compassionate care of PLWHAs. Over the past two decades, a
large body of experience in HIV/AIDS prevention programming has accumulated around the
world. Some strategies have been shown to be highly effective in changing sexual behaviour and
reducing HIV transmission, while others, particularly those that do not go beyond the creation of
awareness, are ineffective. Data from observational studies, and from clinical and community
trials have shown that community-based peer-mediated group interventions among sex workers
and high risk men, voluntary counseling and testing, and the provision of effective STI
management to the general population can result in 40-90% reductions in risky behaviour and
STI/HIV incidence. A mix of evidence-based strategies will be employed in the interventions
promoted by the project. The project will also rapidly incorporate new interventions emerging
from innovative programming into the range of strategies incorporated into the interventions it is
promoting.
The need for information or evidence goes beyond the requirement for knowledge about where
to intervene, who to intervene with and how best to do it. It is also part of iterative
programming: using lessons learned from the experience of implementation to improve the
efficiency of interventions and maximize their impact. Continuous monitoring and evaluation of
both process and results are needed to adjust programs to suit local needs and changing
-24-
situations. Quantifying impact is a critical step in dissemination of best practices within states
and nationally, so that the reach of the project is maximized. A major focus of the project will be
on building the capacity of state AIDS societies and their implementing partners to collect and
use information in programming.
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5.
GENDER STRATEGY
5.1
Introduction
CIDA's India Program gender equality strategy document notes that “there is a challenging but
positive environment for promoting gender equality in India”. The HIV/AIDS arena provides an
opportunity for addressing the often hidden aspects of men and women’s sexuality in India.
Implicit in HIV prevention and care is the necessity to address not only sexual health, but also
sexuality per se. The challenges are immense and highlighted in the foregoing gender analysis.
In addition, the project will be working largely in male-dominated sectors and institutions, or
with partners who do not necessarily understand the importance of gender or who do not
consider it a priority. Furthennore, given the stigmatized nature of HIV/AIDS and identified
risk groups (sex workers, men who have sex with men, etc.) it will be challenging to ensure that
such constituencies have a voice in project decision-making and regarding the services designed
to meet their needs. Educating policy makers and service providers regarding gender and HIV
will be of central importance to the success of the project. Equally important will be the
selection of gender-sensitive or gender-open implementing partners. However, these challenges
are mitigated by the determination of the Indian government to slow the spread of HIV, the
existence of a strong civil society, and the recognition within government that partnership with
NGOs and vulnerable groups is central to their HIV prevention and care objectives. The lack of
biomedical and behavioural data at all levels provides a real opportunity to gather gender
disaggregated information from the outset.
5.2
Underlying Principles
The following principles underlie the project’s approach to gender equality:
•
The promotion of equal benefit for both men and women from the policies and programs
designed to prevent STI/HIV or to provide STI/HIV care and support.
•
The recognition that gender-related issues to a large extent determine both the
vulnerability of men and women to HIV infection and to access to care and support
services.
•
An appreciation that a gender analysis and strategy applies to both mixed and same-sex
social and sexual relationships.
•
The promotion of culturally appropriate, responsible, affirming sexuality for both men
and women.
•
An appreciation of the need to work with organizations committed to gender equality or
at least open to learning about gender considerations.
•
A commitment to the care and support needs of women and children.
•
A commitment to not reinforcing gender stereotypes within project programs.
•
A commitment to working with sex workers and other marginalized groups in a manner
that promotes the empowerment of such groups and reduces stigmatization.
-26-
•
The resolution to work with organizations addressing legal discrimination and human
rights violations of groups such as sex workers, men who have sex with men and people
living with HIV/AIDS.
•
A recognition of the need to work with development and anti-poverty organizations.
5.3
Gender Strategy
The project will seek to understand and address gender issues in a committed and quantifiable
way at every level. This includes with respect to project design, formative and ongoing research,
capacity building at national, state and local levels, policy development, program
implementation, decision-making, budget allocations and performance indicators. The project
will also ensure that adequate gender expertise is available both within the project and for its
partners.
5.3.1
Project Design
Two gender experts were included in the project Design Team from the outset and multiple
consultations were held in India with gender experts. Every effort has been made to address
gender at each project level in a quantifiable, practicable way.
5.3.2 Formative and Ongoing Research
There is a dearth of information regarding STI/HIV-related issues in the project states of
Karnataka and Rajasthan. One of the central activities of the project will be the generation of
reliable information that can be used for both program planning and policymaking decisions.
Such research will include biomedical and behavioural surveys of important constituencies and a
review of STI/l IIV health care provision in both public and private sectors. To the greatest
extent possible, all research will be disaggregated by gender and will seek to understand gender
issues within each sector or target group. For example, biomedical surveillance will be applied
to both men and women, behavioural/attitudinal research will include both behaviour (number of
sex partners, condom use, health seeking behaviour, etc.) and attitudes (to sexuality, to men and
women, to their own behaviour, etc.). Research on health services will attempt to understand
how gender attitudes operate among health providers and within health services.
5.3.3
Capacity-building at National, State and Local Levels
This project is primarily directed at capacity building at state and local levels. Enhancing the
capacity of Rajasthan and Karnataka State AIDS Societies and their implementing partners to
plan, implement and evaluate STI/HIV prevention and care programs in a manner that is
evidence-based and technically sound is the project’s main focus. Within this focus area,
fonnative and ongoing research will be undertaken which in turn informs policy and program
frameworks. Accompanying this effort will be the enhancement of capacity to plan and evaluate
programs and services. Finally, the implementation of a range of prevention and care initiatives
within defined geographic sites will be supported. In the context of the project, capacity building
will include developing the ability of state AIDS societies and their implementing partners to
address gender equality issues within their areas of responsibility. This may require gender
training in gender issues for state AIDS societies and their implementing partners.
-27-
5.3.4 Policy Development
At the state level, within the policy arena, a focus will be maintained on the ways in which men
and women are affected differently by STI/HIV, how this translates into service/program needs
and how program and service delivery can be monitored for both men and women. This will
require the existence of gender disaggregated data and the participation of people with expertise
on gender issues on policy and decision-making committees.
5.3.5 Decision-Making/Management
Within the area of the project’s direct control (such as project staff and Canadian technical
assistance staff), every effort will be made to hire both women and men and to have both women
and men represented on the Project Steering Committee. In addition, Indian gender expertise
will be hired and made available to the project.
5.3.6 Program Implementation
With regard to the implementation of STI/HIV prevention and care programs and targeted
prevention interventions, gender will be addressed in the following ways. Overall, the project
will support a commitment to a greater understanding of gender and HIV. Negative gender
stereotypes will not be used in project materials or approaches, and equal access to services,
commodities and information will be promoted.
More specifically, access of women to services will be addressed wherever it is relevant, as will
access to services of men. For example, within in the management of STI, if women do not
attend STD clinics, then efforts will be made ensure that women are reached where they access
health services (family planning clinics, gynecologists, private practitioners, etc.). Given the
extent to which women are asymptomatic with STI, the idea of presumptive treatment for
vulnerable women (sex workers) will be explored. Finally, opportunities will be sought to
integrate STI/HIV education into established reproductive health education forums.
In the delivery of targeted interventions for vulnerable groups, the project will make every effort
to work within an empowerment framework. Strategies to prevent STI/HIV transmission must
be relationship-specific; strategies aimed at high-risk impersonal encounters are likely not
appropriate for a more intimate arena. Therefore, targeted interventions will emphasize gender
relationships in every aspect of the lives of vulnerable people and develop STI/HIV prevention
strategies relevant to the continuum of impersonal/intimate sexual relationships.
With regard to the delivery of care in health facilities, every effort will be made to promote HIV
testing that is based on informed consent, with pre- and post-test counseling. Health workers
will be educated to be non-judgmental in their attitudes towards sex workers, gay and transsexual
men, and HIV-infected men and women. Efforts will be made to ensure that pregnant HIV
positive women have access to choice to continue with their pregnancy or not. Health facilities
will be encouraged to admit HIV positive women for the delivery of their babies. With respect
to home-based care, the project will seek to understand the extent to which men and women
receive care and support in the home setting. Particular attention will be paid to brothel-based
sex workers and HFV positive women living with their in-laws.
-28-
5.3.7 Monitoring and Evaluation
Gender-specific performance indicators will be developed for each key project area. It is
important to emphasize that the project’s gender strategy is iterative and will be adjusted as time
and experience in the field provides new information and challenges. It is expected that the
Project Steering Committee and CIDA review the project’s gender progress on gender equality
issues on an annual basis. It is also expected that the state AIDS societies will also regularly
review the gender aspects of their work, including their work with this project.
5.3.8 Budget
Dedicated funds will be set aside where a need for gender training or positive discrimination is
required. For example, gender training will be provided for state AIDS society staff and their
implementing partners and in the arena of HIV/AIDS care, specific funds for the support of HIV
positive women will be set aside.
-29-
6.
LOGICAL FRAMEWORK ANALYSIS
The project's logical framework analysis is given in the table below. Detailed descriptions of the project’s four components (Karnataka, Rajasthan,
National and Management) are given in sections 7-10 that follow.
Project Title
CEA/Partner
Organization
Related CPF
India-Canada Collaborative HIV/AIDS Project
University of Manitoba, in association with Mascen Consultants
Inc, and ProAction: Partners for Community Health
To support the social and economic policy reform process in India.
Project Budget
Project Manager
(CIDA)___________
CID A Project Team
$12 million
Sarada Leclerc
Logical Framework Analysis at Goal and Purpose Level
_____________ Narrative Summary
Project Goal (Program Objective)
To support the social and economic policy reform
process in India by strengthening the capacity of
institutions and government organizations.
__________ Performance Measurement
Performance Indicators
Expected Results
Impact
At the national and state levels:
- Policies implemented to create an enabling
environment for more effective HIV/AIDS
prevention, care and support.
Enhanced capacity of institutions and government
organizations in India to formulate, promote and
implement effective policies and programs on
HIV/A1DS prevention, care and support, thus
satisfying the basic human needs of the country.
Performance Indicators
Project Purpose
Outcomes
To develop the institutional capacity of the
Karnataka and Rajasthan state AIDS societies, as
well as their NGO and their implementing partners,
as well as NACO and selected Technical Resource
Groups, to plan, design, implement and evaluate
initiatives related to the Government of India’s
National AIDS Control Project - Phase 2 (NACP-II).
1) Slowed progression of the STI/HIV epidemic
among women and men in project areas, contributing
directly and indirectly to poverty reduction, and to
gender equality.
1.1) Increase in the prevalence of safer sexual
practices among women and men in project areas.
1.2) Reduced prevalence of conventional STIs
among women and men in project areas.
1.3) Reduced rate of increase in the prevalence of
HIV infection among women and men in project
areas.
2) Mitigation of the impact of the HIV/AIDS
epidemic among women and men in project areas,
contributing directly and indirectly to poverty
reduction, and to gender equality.
2.1) Increased availability of high quality care and
support services for HIV-affected women and men in
project areas.
2.2) Increased sensitivity to the needs of HIVaffected women and men in project areas.
-™-
________ Assumptions/Risk Indicators
Assumptions/Risk Indicators
Continued government willingness to
introduce and support social and economic
reforms (Risk - Low).
Assumptions/Risk Indicators
National and state level political
commitment to HIV prevention and control
continues (Risk - Medium).
Commitment of financial resources from the
national and state governments continues
(Risk - Low).
Logistical Framework Analysis for Karnataka Component
Narrative Summary
______ Resources______
At Karnataka State level:
K1000 Capacity Building for KSAPS and
Implementors:
Expected Results
_______ Outputs_______
At Karnataka State level:
Performance Measurement
Performance Indicators
At Karnataka State level:
KI 100 Improved KSAPS and implementors’
capacity to gather, analyze and integrate information
into decision making.
KSAPS is collecting and using evidence-based
data in strategic planning of its activities.
KSAPS has established systems for monitoring
and evaluating intervention programs.
Technical assistance/mentoring.
Needs-based training.
International linkages and study tours.
Strengthening selected facilities.
Funding selected initiatives.
Increased number of implementers are:
Using situation analysis, community needs
assessment and operational research prior to
program formulation and implementation.
Monitoring and evaluating program outcomes
and impacts.
KI 200 Enhanced KSAPS and implementers’
capacity to mobilize, monitor and disseminate high
quality H1V/A1DS prevention and care programs.
KSAPS and increased number of implementers are:
Using best practices in delivery of targeted
programs.
Disseminating results and scaling up effective
programs.
Establishing culturally sensitive voluntary
counseling & testing.
Establishing STI management systems at local
level.
Increased number of implementers arc:
Using innovative participatory peer group
interventions with vulnerable populations.
K1300 Enhanced KSAPS and implementers’
capacity to create an enabling environment for
H1V/A1DS programming.
Community leaders and politicians are
sensitized on HIV/A1DS issues;
Increased involvement of HIV- infected people
in programming of initiatives and policy
advocacy.
State level policies and programs ensure
occupational health & safety of health workers,
and continuum of prevention, care and support
for HIV infected persons.
Effective and appropriate behaviour change
communication materials are produced and
delivered.
-31 -
Assumptions/Risk Indicators
At Karnataka State level:
Commitment of human and financial
resources by KSAPS to support the
activities (Risk - medium).
Individuals, communities and institutions
accept data gathering activities (Risk - low
to medium).
Implementers willing to participate in
project activities (Risk - low).
Financial resources arc available to the
implementers to carry out suggested
activities prior to and during implementation
of their program (Risk - medium).________
Commitment of human and financial
resources by KSAPS to support the
activities (Risk - medium).
Individuals, communities and institutions
accept data gathering activities (Risk - low
to medium).
Implementers willing to participate in
project activities (Risk - low).
Financial resources are available to the
implementers to carry out suggested
activities prior to and during implementation
of their program (Risk - medium).
State level policy-makers have supportive
attitudes towards HIV infected persons
(Risk - medium).
Community leaders are willing to listen
(Risk - medium).
PLWHAs arc willing to get involved in
programming (Risk - low).
_____________ Narrative Summary____________
_________________ Resources________________
______________ At District level:______________
K2000 District level demonstration project:
Partnering with NGOs and other implementers.
Capacity building of implementing partners.
Technical assistance to implementing partners.
Formative research.
Impact evaluation.
Dissemination of innovations and results.
Needs-based training.
Strengthening of selected facilities.
Funding selected initiatives.
______________ Expected Results____________
__________________ Outputs_______________
_______________ At District level:____________
K2100 Enhanced information base for HIV/AIDS
policy, iterative programming and monitoring and
evaluation (in demonstration project area)
K2200 Community-based participatory interventions
for vulnerable and marginalized women and men (in
demonstration project area).
K2300 Enhanced accessibility to and quality of STI
management (in demonstration project area).
K2400 Improved availability of high quality care and
support for individuals and families affected by
HIV/A1DS (in demonstration project area).
-32-
_____ Performance Measurement__________
_______ Performance Indicators___________
__________ At District level:_______________
Project area selected, mapped and baseline
information gathered.
Partnering with NGOs and other implementers
secured.
Selected labs capable of HIV/STI diagnosis and
surveillance.
Strategic plan for an integrated model of
HIV/AIDS program developed.
Monitoring mechanisms established._________
Implementing partners identified, trained and
are effectively training peer educators,
vulnerable groups identified, baseline
assessment completed and interventions
implemented.
K.SAPS and implementing partners carrying
out, monitoring and evaluating programs in
demo project area, disseminating results,
training other implementers.________________
Baseline information collected on current STI
management practices.
Strategic lab facilities upgraded.
Counseling, condom promotion, partner
notification systems in place.
Baseline information collected on current
hospital and home-based care practices.
Number of care providers trained.
Care and support services improved in project
communities.
Voluntary counseling and testing services
established in selected sites.
Local PLWHA self-help groups established.
Local NGOs producing appropriate plans and
proposals for community-based HIV care
projects.
Assumptions/Risk Indicators
________ At District level:___________
Suitable community organizations for
partnering are available (Risk - medium).
State government supports project activities
through funding selected interventions (Risk
- medium to high).
Suitable implementing agencies available in
demonstration project area (Risk - low).
Suitable and willing public or private
providers are available in demonstration
project area (Risk - low).
Suitable and upgradable laboratory facilities
are available in demonstration project area
(Risk - medium).
Suitable NGOs arc available and
cooperative (Risk - low).
Logistical Framework Analysis for Rajasthan Component
Narrative Summary
______ Resources______
At Rajasthan State level:
R1000 Capacity Building for RS ACS and
Implemented:
Expected Results
_______ Outputs_______
At Rajasthan State level:
Performance Measurement
Performance Indicators
At Rajasthan State level:
R1100 Improved RSACS and implemented’
capacity to gather, analyze and integrate information
into decision making.
Technical assistance/mentoring.
Needs-based training.
International linkages and study tours.
Strengthening selected facilities.
Funding selected initiatives.
RSACS is collecting and using evidence-based
data in strategic planning of its activities.
RSACS has established systems for monitoring
and evaluating intervention programs.
Increased number of implemented are:
Using situation analysis, community needs
assessment and operational research prior to
program formulation and implementation.
Monitoring and evaluating program outcomes
and impacts.
R1200 Enhanced RSACS and implemented’
capacity to mobilize, monitor and disseminate high
quality HIV/AIDS prevention and care programs.
RSACS and increased number of implemented are:
Using best practices in delivery of targeted
programs.
Scaling up effective programs and
disseminating results.
Establishing culturally sensitive voluntary
counseling & testing.
Establishing STI management systems at local
level.
Increased number of implemented are:
Using innovative participatory peer group
interventions with vulnerable populations.
R1300 Enhanced RSACS and implemented’
capacity to create an enabling environment for
HIV/AIDS programming.
Community leaders and politicians are
sensitized on HIV/AIDS issues;
Increased involvement of HIV- infected people
in programming of initiatives and policy
advocacy.
State level policies and programs ensure
occupational health & safety of health worked,
and continuum of prevention, care and support
for HIV infected persons.
Effective and appropriate behaviour change
communication materials are produced and
delivered.
-33-
Assumptions/Risk In d i c a t o rs
At Rajasthan State level:
Commitment of human and financial
resources by RSACS to support the
activities (Risk - medium).
Individuals, communities and institutions
accept data gathering activities (Risk - low
to medium).
Implemented willing to participate in
project activities (Risk - low).
Financial resources are available to the
implemented to carry out suggested
activities prior to and during implementation
of their program (Risk - medium).
Commitment of human and financial
resources by RSACS to support the
activities (Risk - medium).
Individuals, communities and institutions
accept data gathering activities (Risk - low
to medium).
Implemented willing to participate in
project activities (Risk - low).
Financial resources are available to the
implemented to carry out suggested
activities prior to and during implementation
of their program (Risk - medium).
State level policy-makere have supportive
attitudes towards HIV infected pedons
(Risk - medium).
Community leaders are willing to listen
(Risk - medium).
PLWHAs are willing to get involved in
programming (Risk - low).
Narrative Surhmary
1
_________Resources________
At Demonstration Area levels:
Expected Results
__________ Outputs__________
At Demonstration Area levels:
R2000 Implementation of demonstration projects:
R2100 Community-based participatory intervention
for rural migrant men
'______ Performance Measurement__________ Assumptions/Risk Indicators
___________ Performance Indicators___________
________ At Demonstration Area levels:_________
At Demonstration Area levels:
In selected community:
Community needs assessment and baseline
State government supports project activities
evaluation is completed.
through funding selected interventions (Risk
Intervention strategies and tools are developed.
- medium to high).
Interventions are implemented with community
Target population is willing to participate in
participation.
project (Risk - low).
Outcomes and impacts are evaluated.
Lessons learned and best practices from the
initiative are disseminated.
Demonstration project is providing training to
other implementers.______________________
In selected community:
Community needs assessment and baseline
State government supports project activities
evaluation is completed.
through funding selected interventions (Risk
Intervention strategies and tools are developed.
- medium to high).
Interventions are implemented with community
Target population is willing to participate in
participation.
project (Risk - low).
Outcomes and impacts are evaluated.
Lessons learned and best practices from the
initiative are disseminated.
Demonstration project is providing training to
other implementers.
_______________
In selected sites:
Needs assessment is completed for continuum of
State government supports project activities
care.
through funding selected interventions (Risk
Partners are selected, strategies and tools
- medium to high).
developed.
Suitable partners are available (Risk - low).
Care and support programs are implemented;
Outcomes and impacts are evaluated.
Lessons learned and best practices from the
_____ initiative are disseminated.
Partnering with NGOs and other implementers.
Capacity building of implementing partners.
Technical assistance to implementing partners.
Formative research.
Impact evaluation.
Dissemination of innovations and results.
Needs-based training.
Strengthening of selected facilities.
Funding selected initiatives.
R2200 Community-based participatory intervention
for rural caste-based sex work.
R2300 A Rajasthan model of the prevention-care
continuum is developed and implemented.
Logistical Framework Analysis for National Component
Narrative Summary
_____ Resources____
At the National level:
Expected Results
_____ Outputs_____
At the National level:
Performance Measurement
Performance Indicators
At the National level:
Assumptions/Risk Indicators
N1000 Capacity Building for NACO and selected
TRGs:
N1100 Incorporation of international experience and
expertise into national HIV/AIDS policy and
programming by TRGs and NACO.
Studies conducted and considered in policy
formulation by NACO.
NACO and selected TRGs request CEA
inputs (Risk - medium)
International linkages initiated by project are
established.
Policy makers consider HIV/AIDS as a
priority public health and developmental
issue (Risk - medium).
Technical Assistance
Selected policy research
International linkages
N1200 Incorporation of innovations from state and
local level demonstration projects into national
HIV/AIDS programming by TRGs and NACO.
- Demonstration project models, experiences and
components from Karnataka and Rajasthan are
used in other states in India.
-34-
At the National level:
7.
KARNATAKA COMPONENT
7.1
Situation and Needs Assessment
7.1.1
Developmental and Socio-demographic Context
The southern state of Karnataka abounds in geographic, demographic and social diversity. It has
a total area of 192,000 km2 and is bordered by the Indian Ocean on the west and by the states of
Tamil Nadu, Kerala, Goa, Maharashtra and Andhra Pradesh. Karnataka is now divided into 27
administrative districts including Bangalore, which is divided into urban and rural districts. The
population of Karnataka is estimated at approximately 50 million with a population density of
235 per km2. Approximately 31% of the population is urbanized, with many concentrated in the
city of Bangalore, which has an estimated population of approximately five million and is among
the fastest growing cities in Asia.
The total fertility rate in Karnataka was 3.87 in 1991, down from 4.70 a decade earlier. The
crude birth rate (23 per 1,000) and crude death rate (7.3 per 1,000) are both below the national
average. The infant mortality rate declined from 81 to 53 per 1,000 between 1981 and 1997. The
infant mortality rate varies substantially by district, ranging from 29 to 75 per 1,000. The life
expectancy is 62.1 for males and 63.3 for females. The female to male ratio is 960:1000 and has
declined over the past decade.
. The overall literacy rate has been increasing from approximately 30% in 1961 to 56% in 1991.
However, there are substantial variations across the state, with rural areas having a much lower
literacy rate (48%) than urban areas (74%). Females have a much lower literacy level than males
’ (44% vs. 67%). School attendance by children also varies substantially by district. Overall, in
1996 it was estimated that 27.7% of children in Karnataka were out of school but this figure
ranged from 12.7% in Urban Bangalore to over 30% in many districts.
" There are wide variations in the average annual per capita income in Karnataka, ranging from
just over Rs. 6,000 in some districts to over Rs. 15,000 in others. In 1997, approximately 33% of
the state’s population was below the poverty line compared to 35% nationally. Poverty rates are
higher in urban areas (40%) than rural areas (30%). The overall unemployment rate is reported
to be around 1%. In 1991, 29% of the workforce was female, compared to 25% in 1981.
The Human Development Index (HDI) is an indicator that summarizes the state of development
for a population. It is comprised of measures of a population’s longevity (life expectancy),
knowledge (literacy rate) and standard of living (per capita income). The Gender-related
Development Index (GDI) summarizes the same components but also integrates measures'of
inequality between men and women in each of the domains. Among Indian states in 1991,
' Karnataka ranked 7th in HDI (above the national average) and 5th in GDI. This suggests that
Karnataka has performed better overall in gender-related development than many other states.
However, in all districts of Karnataka, the GDI is lower than the HDI, suggesting that the socio' economic development of women is worse than that for the population as a whole throughout the
state.
-35-
7.1.2 HIV Situation and Vulnerability
The first persons with AIDS in Karnataka were identified in 1988. Since then, there is evidence
that the HIV epidemic has taken hold in the state. Up to October, 1999 there had been 5,616
persons testing positive for HIV in the state and HIV infection has now been detected in every
district. There have also been 221 persons diagnosed with AIDS. So far, it appears that the
epidemic is more advanced in some districts than in others. The majority of HIV cases reported
so far are from the districts of urban Bangalore and Mangalore. Sentinel HIV surveillance has
shown that the prevalence of HIV in Bangalore is approximately 10% among STD clinic
attenders and is approaching 2% among women attending antenatal clinics. Sentinel surveillance
data also suggest that the epidemic is advancing in some rural districts. In some northern
districts, HIV prevalence among STD clinic attenders ranges from 20-40% in certain sites and
antenatal prevalence in one antenatal clinic in the northern area of Hubli was 1.75% in 1998.
The advance of the epidemic is now being reflected in hospitals, as there are reports of a rapid
growth in the number of patients being admitted to hospital with HIV-related illness, particularly
tuberculosis.
There is little information regarding HIV transmission dynamics in Karnataka. However, data
from HIV testing centres have documented very few cases where an identified risk factor was
men having sex with men or injection drug use. Although these data are likely influenced by
reporting biases, it suggests that much of HIV transmission is heterosexual.
There are a number of factors that contribute to Karnataka’s vulnerability to the HIV epidemic.
It is bordered by several other states that have well-established and growing HIV epidemics
(notably Maharashtra, Tamil Nadu and Andhra Pradesh). Karnataka shares many demographic
and economic ties to these neighbouring states. There is extensive migration to and from these
states and there are major transportation routes connecting Karnataka to them. This may
promote more rapid dissemination of HIV from the epicentres of the epidemic to the population
of Karnataka. Karnataka also has an important seaport (Mangalore) on the Indian Ocean. Since
this attracts migratory populations and is situated on major national and international trade
routes, it will be particularly vulnerable to the introduction and spread of HIV. Karnataka’s large
and growing urban population will likely promote more rapid spread of HIV as well.
There are also patterns of sexual activity in Karnataka that render it vulnerable to the HIV
epidemic. Commercial sex work appears to be prevalent throughout the state. However, unlike
some parts of India (such as Mumbai), commercial sex work in many parts of Karnataka is less
visible. In the major cities, there are not clearly defined geographic areas where sex work is
concentrated. Rather, much of the sex trade is based on the street or in home settings. This
pattern of sex work presents enormous challenges for understanding the dimensions of HIV
transmission and the delivery of health promotion programs. There are other unique challenges
outside of the major urban settings. In some of the northern districts of Karnataka, the
prevalence of HIV infection in sentinel sites is as high or higher than in urban Bangalore. Much
of this may be related to the presence of important transportation routes. However, it also
appears that sex work occurs and may be widespread in some villages and rural areas. In some
northern districts, much of this is related to the devadasi system wherein there are historical,
cultural and religious dimensions to the sex trade.
-36-
There are also economic and social factors that contribute to Karnataka’s vulnerability. Poverty
levels are high (32%, 1987-88 estimate), leading to economic pressures that promote commercial
sex work. Furthermore, economic pressures result in migration and social dislocation of
labourers (primarily men) who are seeking work. Low levels of literacy, especially among
women, retards effective and widespread behaviour change communication. Furthermore, the
low social status of women in many settings inhibits the adoption of safer sexual practices.
•- 7.2
Institutional Resources and Responses
- 7.2.1
Overview
HIV prevention and control activities in Karnataka are largely under the direction of the
Karnataka State AIDS Prevention Society (KSAPS). KSAPS was established in December,
1997, replacing the previous State AIDS Cell. KSAPS has moved rapidly to create efficient
administrative structures to distribute funds from the NACP-II. It has also helped to mobilize a
variety of NGOs to assist in the implementation of HIV/AIDS prevention, care and support
activities. After consultations with KSAPS and other institutional partners, and through a
participatory design process with KSAPS, several strengths were identified in the KSAPS
response to the HIV epidemic. These are described briefly below.
In Karnataka, there is a relative wealth of highly skilled and committed individuals contributing
to HIV prevention, care and support activities. There is also an increasing number of NGOs that
wish to contribute to these efforts. In 1998-999, there were 97 NGOs registered with KSAPS; 19
of these were already involved in HIV prevention activities. In addition, Karnataka has many
- strong medical institutions that are interested in providing technical support to HIV prevention,
care and support activities. Many ongoing implementation projects are related to improving
general awareness of HIV related issues. There is also an increasing number of NGOs that are
“ engaged in the implementation of preventive interventions, and care and support activities for
vulnerable populations. In addition, a network of six NGOs (AIDS Forum Karnataka, AFK) has
been created to increase community HIV/AIDS awareness, provide mutual support and
coordinate activities in this field.
Ability to mobilize activities
, KSAPS has been able to develop relationships with and mobilize institutional partners and
NGOs to implement a variety of activities. These activities include:
•
•
The establishment of 8 HIV voluntary testing sites and 14 HIV sentinel surveillance sites
throughout the State.
•
The creation 10 functional Zonal Blood Testing Centres for the Blood Safety program.
•
Initiation of several initiatives for IEC at the population level using a variety of media
and approaches.
•
Involvement and mobilization of many NGOs in HIV prevention work in Karnataka.
•
Implementation of training in HIV-related issues for a variety of health care providers
and public health officials.
-37-
Ability' to manage and distribute funds
KSAPS has developed an effective and efficient administrative structure that has demonstrated a
strong capacity to flow funds from NACO through to implementation activities.
Involvement ofpersons living with HIV/AIDS (PLWHAs)
KSAPS has involved PLWHAs in many of the processes related to the planning and
implementation of activities.
7.2.2
Opportunities for Capacity Building
While KSAPS and its implementing partners share many strengths, we identified a number of
opportunities for capacity building through our discussions with them. These are summarized
below.
Improved availability of information for program planning
Thus far, the only consistently available information about the status of the epidemic is based on
HIV sentinel surveillance. Population-based data on the prevalence of STIs and HIV-related
knowledge and behaviour are generally not available. It was agreed that enhancement of
surveillance systems to provide this type of information would facilitate an improvement in the
planning and targeting of HIV programming. In addition to improving the surveillance systems,
it was determined that both KSAPS and its implementing partners would benefit from an
enhanced capacity to analyze and integrate health information into program planning.
Monitoring and evaluation ofprograms
Although there are many activities underway, the extent of the quality and impact of many of
these activities is uncertain due to a lack of monitoring and evaluation. Improved capacity in this
area would allow KSAPS and its implementing partners to modify and improve existing
programs and to identify best practices for wider implementation.
High quality training programs for implementers
In some areas, there are already training programs available for implementers. However, there
are important areas in which training methods and materials can be improved. These areas
include situational analysis and needs assessment, operational research for program formulation
and implementation, the design and implementation of HIV prevention programs for vulnerable
populations, and the monitoring and evaluation of programs.
STI management systems
Within the public system, STI management is concentrated in clinics at large hospitals. High
quality STI management at the “grassroots” level is generally not available through the public
system. Most STI management is provided outside of the public system. However, the quality
and reach of STI management in the private sector is uncertain. It was agreed that improved
systems for STI management at the ’’grassroots" level is required.
Creation of an enabling environment for HIVprogramming
While some segments of the population have a high degree of awareness and sensitivity to HIV
related issues, this is distributed unevenly. There is still extensive stigmatization of HFV/AIDS
-38-
throughout Karnataka society and its institutions. Systems (education and otherwise) for
creating awareness in the general population regarding HIV/AIDS can be improved. There is
also room to improve the sensitivity and involvement of the medical sector with regard to
HIV/AIDS issues. While some medical institutions are well-informed and sensitive to HIVrelated issues, this is not uniform. As yet, the private sector (medical and non-medical) has not
been fully engaged in HIV prevention efforts.
Gender issues
It was agreed that there is much room for improvement with respect to the status and
vulnerabilities of women and the incorporation of gender issues at all levels of planning and
implementation.
Integrated models for implementation
While there are many strengths in the systematic response to HIV/AIDS in Karnataka, it was
agreed that integration of activities across different sectors and systems could be improved. It
was also agreed that there are weaknesses in the linkage between prevention activities and
care/support activities at the community level. In particular, there are opportunities for
strengthening the cycle of strategic planning, iterative program implementation, and evaluation
at the local or district level.
7.3
Karnataka Component Project Description
7.3.7
Overview
As described in Section 4.2 above, throughout the design and implementation of the program in
Karnataka, we will pay close attention to the cross-cutting themes that are critical success factors
for the prevention of HIV and the mitigation of the impact of HIV/AIDS on the population.
These cross-cutting themes are:
♦
♦
♦
♦
♦
♦
Sustainability and working within KSAPS.
Integration with overall development.
Addressing gender issues at every level.
Creation of an enabling environment and destigmatization.
Maximal participation of PLWHAs and vulnerable groups in programming.
Evidence-based grounding of programs.
Based on consultations and the participatory identification of current strengths and opportunities
for capacity development, a program plan to improve the capacity in Karnataka to respond to the
HIV/AIDS epidemic was developed. There are two main program components:
1) Capacity building of KSAPS and their implementing partners at the state level.
2) Implementation of a high quality demonstration project at the district level.
Capacity building for KSAPS and implementers at the state level (component 1) will be
primarily achieved through technical inputs into the planning, implementation and evaluation of
HIV prevention and control activities. These technical inputs will include direct consultation
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from Canadian and international experts and the provision of high quality training and training
materials. Through the implementation of a high quality demonstration project at the district
level, we plan to work with NGOs and other implementing partners to plan, implement, evaluate
and disseminate effective models and strategies for HIV prevention at local level. Through this
mechanism, we intend to build the capacity of implementers, to provide opportunities for applied
training, and to provide insights and innovations for replication throughout Karnataka and also in
other states.
7.3.2 Work Breakdown Structure
The work breakdown structure (WBS) for activities in Karnataka has two components. The first
component (KI000) is “Capacity Building for KSAPS and Implemented, State Level”. There are
three main outputs for this component with associated activity streams. The second component
(K2000) is “Implementation of Area Demonstration Project”, which has activities organized
under four main outputs. These activity streams are summarized in the figure below. The
detailed activities under each of the streams are described in the following sections.
Component K1000 - Capacity Building for KSAPS and Implementers, State Level
• Output KI 100 - Improved KSAPS' and implementers’ capacity to gather, analyze and
integrate information into decision making.
• Output KI200 - Enhanced KSAPS' and implementers’ capacity to mobilize, monitor and
evaluate evidence-based HIV/AIDS programming.
• Output K1300 - Enhanced KSAPS' and implementers’ capacity to create an enabling
environment for HIV/AIDS programming.
Component K2000 - Implementation of Area Demonstration Project
• Output K2100 - Enhanced information base for HIV/AIDS policy, iterative
programming, and monitoring and evaluation.
• Output K2200 - Development of community-based participatory interventions for
vulnerable and marginalized men and women.
• Output K2300 - Increased accessibility to and quality of STI management.
• Output K2400 - Improved availability of high quality care and support for individuals
and families affected by HIV/AIDS.
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Component K1000
Capacity Building for KSAPS and Implementers - State
Level
Component K2000
Implementation of Area Demonstration Project
K1100 Improved
KSAPS’ and
implementers’
capacity to
gather, analyze &
integrate
information into
decision making
K1200 Enhanced
KSAPS’ and
implementers’
capacity to
mobilize, monitor
& evaluate
evidence-based
HIV/AIDS
programming
K1300 Enhanced
KSAPS’ and
implementers
’capacity to create
an enabling
environment for
HIV/AIDS
programming
K2100 Enhanced
information base
for HIV/AIDS
policy, iterative
programming,
and monitoring
and evaluation
K2200
Development of
community-based
participatory
interventions for
vulnerable and
marginalized men
and women
K2300
Development of a
model for STI
management at
the "grassroots"
level
K2400 Improved
availability of high
quality care and
support for
individuals and
families affected
by HIV/AIDS
X1101 Train
KSAPS &
implementers in
rapid
'epidemiologic
assessment
K1201 Train
KSAPS and
implementers in
best practices in
delivery of
targeted
HIV/AIDS
programming
K1301 Assist
KSAPS and
implementers to
increase the
awareness,
sensitivity and
capacity of public
& private sector
policy makers and
community
leaders on
HIV/AIDS issues
K2101 Select
project area and
build partnerships
with community,
NGOs and other
partners
K2201 Identify
vulnerable groups
and NGOs and
other
implementers
K2301 Conduct a
baseline
assessment of STI
services at the
community level
K2401 Review
and document
current hospital
and home-based
care practices and
resources
K2201 Train and
mobilize NGOs
and other
implementers
K2302 Select
and partner with
public and private
providers
K1102 Train &
assist KSAPS &
implementers in
collection and
analysis of
information on
-STI/HIV,
behaviours, and
gender &
development
indicators
K1202 Train and
assist
implementers for
innovative
participatory peer
group
interventions with
vulnerable
populations
K1103 Train and
assist KSAPS and
implementers in
conducting
situational
analysis and
needs
assessments
K1203 Assist
KSAPS and
implementers in
the dissemination
and scaling up of
effective
HIV/AIDS
programs
K1104 Train &
assist KSAPS in
conducting
directed research
for advocacy and
policy formulation
K1204 Train and
assist KSAPS and
implementers in
the development
of appropriate
voluntary
counseling and
testing
K1105 Train and
assist
implementers in
conducting
operational
research for
program
formulation and
implementation
K1106 Train and
assist KSAPS and
implementers in
monitoring and
evaluating
program outcome
and impact
K1107 Train
'KSAPS and
implementers in
population-based
strategic planning
of HIV programs
K1205 Train and
assist KSAPS and
implementers to
establish effective
STI management
at the
"grassroots" level
K1206 Train and
assist KSAPS and
implementers to
integrate
prevention, care
and support along
a continuum
K1302 Assist
KSAPS and
implementers to
involve PLWHAs
and vulnerable
groups in all
aspects of
program design,
implementation
and evaluation of
prevention, care
and support
programming
K1303 Assist
KSAPS and
implementers to
incorporate
HIV/AIDS issues
into development,
social & gender
issues
K1304 Train and
assist KSAPS and
implementers to
develop effective
policy and
practice for
occupational
safety of health
professionals
K1305 Assist
KSAPS and
implementers to
effectively link
prevention to care
and support
activities
K2102 Zone and
map project area
K2103 Review
and document
current
information base
and develop
strategies for
information
gathering
K2303 Develop
and implement
training for
providers
including training
K2204 Train peer in counseling,
condom
educators and
promotion and
supervisors
partner
K2104
K2205
notification
Strengthen
Implement
selected
interventions
K2304 Develop a
laboratories for
using an iterative strategy for
HIV/STI
approach
extending STI
diagnostics and
services to
surveillance
women
K2206 Evaluate
outcomes and
K2105 Conduct
impacts and
K2305 Upgrade
baseline STI/HIV
disseminate
selected
and behavioural
innovations,
laboratories to
surveys and
lessons learned
support STI
formative
treatment
and
best
practices
assessments
services
K2207 Provide
K2106 Analyze
resources and
and disseminate
opportunities for
information to
program planners hands on training
and implementers for other
implementers in
K2107 Develop a interventions
strategic plan for
an integrated
model of
HIV/AIDS
programming in
project area
K2108 Develop
mechanisms for
monitoring
activities and
impact
K1306 Develop
effective and
appropriate
training materials
and methods
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K2203 Conduct
baseline
assessments of
vulnerable groups
K2402 Work with
communities and
health care
providers to
identify
opportunities and
priorities to
improve care and
support services
K2403 Develop
and implement
training for care
providers
K2404
Strengthen and
develop
appropriate
voluntary
counseling and
testing services in
selected sites
K2405 Support
the development
of local PLWHA
self-help groups
K2406 Train and
assist NGOs to
develop plans and
proposals for
community-based
HIV care projects
7.3.3 Description of Outputs and Activities
Component K1000 - Capacity Building for KSAPS and Implementers - State Level
In this component of the program, a number of strategies will be used to strengthen the capacity
of KSAPS and its implementing partners at the state level. These strategies will include:
Technical Assistance/Mentoring: A network of Canadian and international technical
specialists will provide direct technical advice, consultation and mentoring for members of
KSAPS and implementing agencies. Local Indian technical expertise will also be engaged to
offer the same opportunities.
Needs-based Training: Where necessary, direct training for KSAPS members and
implementers will be provided, using high quality and validated training materials and methods.
This training will involve both short courses and training workshops.
Study Tours and International Linkages: There are many examples of high quality
HIV/AIDS prevention, care and support programs both in India and elsewhere. Mechanisms will
be developed for linking KSAPS and its implementing partners to these programs, such as
through organization and support for study tours, to promote the use of national and international
best practices.
Strengthening Facilities and Funding Selected Initiatives: Direct support will be provided for
the strengthening of selected facilities that can serve as state-wide resources. For example, this
could include the strengthening of a designated facility for the diagnosis of STIs, in support of
enhanced STI surveillance and validation of syndromic management guidelines.
Outputs and Activities
The outputs and specific activities under Component KI 000 are described below.
Output KI 100 - Improved KSAPS’ and implementers’ capacity to gather, analyze and
integrate information into decision making.
Activity KI 101 - Train KSAPS and implementers in rapid epidemiologic assessment
Rapid epidemiologic assessment (REA) includes a set of methods and tools that can be used
to quickly assess a population’s situation with respect to the prevalence and incidence of HIV
infection and other STIs, and the transmission dynamics of HIV/STIs in a community. Thus,
improving KSAPS’ and implementers’ capacity to perform REA can support the formulation
of HIV prevention strategies. Training activities will include:
KI 101.1 - Prepare and convene training sessions and workshops on REA with
designated KSAPS representatives and members of implementing organizations and
academic institutions.
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KI 101.2 - With KSAPS and implementers, develop appropriate tools for REA that can
be used in various settings throughout the state.
K1101.3 - Assist KSAPS and implementers to undertake RE As in key population groups
or districts where required.
Activity KI 102- Train and assist KSAPS and implementers in the collection and analysis
of information on STI/HIV9 behaviours, and gender and development indicators.
In addition to REA, organized and ongoing systems for the collection and analysis of
population-level information on the prevalence and incidence of STI/HIV, risk behaviours
and other parameters are necessary to describe the burden of illness related to STI/HIV, to
identify at-risk populations, and to monitor the impact of prevention efforts. Activities to
enhance capacity in this area will include:
KI 102.1 - Establish a state level Working Group to develop information priorities,
review existing information systems, develop a strategic plan for information collection,
analysis and dissemination, and develop methods and tools for information gathering and
epidemiologic surveillance. The Working Group will be resourced by the Technical
Support Unit (TSU) and will include membership from the TSU, KSAPS, NGOs,
medical and academic institutions, and the community (including PLWHAs).
KI 102.2 - Provide training in quantitative and qualitative methods for the collection,
analysis and interpretation of relevant population information through workshops and
field experiences.
KI 102.3 - Under the guidance of the Working Group, establish pilot systems for
information gathering, including surveys and disease surveillance.
Activity KI 103 - Train and assist KSAPS and implementers in conducting situation
analyses and needs assessments.
To plan and implement effective HIV programming, there must be the capacity to conduct a
high quality situation analysis and needs assessments. This process involves analyzing and
integrating information regarding the status and drivers of the HIV epidemic in the
population, understanding the various intervention options and their rationale, and critically
reviewing the available resources and resource gaps. To enhance capacity in this area the
following activities will be undertaken.
KI 103.1 - Provide training for KSAPS and its implementing partners in the conduct of
situation analyses and needs assessments. This training would include the convening of
workshops and the development of training materials.
KI 103.2 - With KSAPS and its implementing partners, identify priority regions and
populations, and formulate plans for and assist in conducting situational analyses and
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needs assessments in those areas. These assessments would be used to provide hands-on
training opportunities.
Activity KI 104 - Train and assist KSAPS in conducting directed research for advocacy and
policy development.
Policy decisions are key to creating an enabling environment and ensuring that the most
effective interventions are given priority. Evidence from relevant research can be a valuable
tool for selecting and advocating policy directions. For example, it can be used to estimate the
population impact and cost- effectiveness of various intervention options.
KI 104.1 - Together with KSAPS, a set of policy-relevant research questions will be
developed and addressed. Technical expertise will be provided to conduct the research
and to provide consultation to KSAPS on the process and implications of the findings.
Activity KI 105 - Train and assist implementers in conducting operational research for
program formulation and iterative implementation.
Operational research is directed at assessing the processes and impacts of programmatic
activities. The results of this kind of research are beneficial because they identify ways by
which the efficiency and effectiveness of programs can be improved.
KI 105.1 - Training in operational research will be delivered through workshops and
hands-on training experiences.
KI 105.2 - With KSAPS and implementers, an agenda for operational research will be
developed that focuses on important intervention activities in the state. Subsequently,
operational research projects will be jointly developed and the results integrated into
program formulation and implementation.
Activity KI 106 — Train and assist KSAPS and implementers in monitoring and evaluating
program outcomes and impacts.
Program monitoring and evaluation is necessary to ensure that programmatic activities are
using efficient processes and achieving desired results.
KI 106.1 - Direct training will be provided for KSAPS and implementers in the conduct
of program monitoring and evaluation through workshops and hands-on training.
KI 106.2 - With KSAPS and its implementing partners, systems for monitoring and
evaluating key state level programs will be developed.
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Activity KI 107 - Train KSAPS and implementers in population-based strategic planning of
HIVprograms.
To maximize the impact and cost-effectiveness of HIV/AIDS program activities, planning
should be strategic, evidence-based and appropriate to the local population situation. The
following activities will be undertaken to enhance capacity in this area.
KI 107.1 - Provide direct training for KSAPS and implementers in strategic planning.
KI 107.2 - Convene strategic planning workshops that involve KSAPS, implementers,
community participants and other key stakeholders.
Output K1200 - Enhanced KSAPS’ and implementers’ capacity to mobilize, monitor and
evaluate evidence-based HIV/AIDS programming.
Activity KI 201 — Train KSAPS and implementers in best practices in delivery of targeted
HIV/AIDS programming.
There are many examples of excellent programs that are delivering targeted HIV/AIDS
interventions in India and elsewhere that could be described as representing best practice in
the field. The capacity of KSAPS and implementers to deliver targeted interventions will be
strengthened by increasing their knowledge of these high quality programs.
K1201.1 - Review and summarize examples of best practices in India and elsewhere and
translate this infonnation to KSAPS and implementers through structured meetings and
workshops. This process will include reviewing and disseminating best practice
documentation from national Technical Resource Groups.
K1201.2 - Arrange for interaction between KSAPS and implementing partners and best
practice programs by convening joint meetings and supporting study tours.
Activity KI202 — Train and assist implementers for innovative participatory peer group
interventions with vulnerable populations.
K1202.1 - Provide technical training to KSAPS, NGOs and other implementers in
executing peer education programs. This would include training on the rationale for
targeted interventions, the methodology for selecting target sites and zones and for
recruiting peer educators, and the importance of focus and intensity. It would also
include how to conduct baseline surveys and formative assessments, how to develop and
use participatory methods and materials, how to train peer educators to train their peers
and how to monitor program outputs for the duration of the program. Such training
expertise can be sourced within India or internationally.
K1202.2 - Provide technical assistance to NGOs implementing peer group interventions.
Follow-up technical support would be provided to the NGOs who receive the initial
training. Such technical support would include the provision of support in carrying out
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comprehensive mapping and zoning exercises, designing formative and baseline
assessment tools, recruiting and training peer educators, and in developing a range of
participatory educational materials. Support would also be provided to NGOs in
developing and designing monitoring and evaluation indicators and related data
collection tools.
K1202.3 - Initially, the project, in partnership with KSAPS, implementers and target
groups, will jointly develop processes and indicators of empowerment for vulnerable
target populations. In the interests of sustainability and community ownership, work with
vulnerable populations will try to emulate the lessons learned by the Sonagachi project
and similar high quality projects in India. Some such projects are now largely run by the
sex workers themselves and has extended the range of issues addressed to include such
social issues as legal reform, literacy and affirming sexuality. An exchange visit
involving KSAPS, implementers and sex workers will help inform this process.
Activity KI203 - Assist KSAPS and implementers in the dissemination and scaling up of
effective HIV/AIDSprograms.
As effective programs are developed by implementers in specific populations, an important
challenge is to disseminate the knowledge and scale up capacity across the state.
K1203.1 - Working with KSAPS and implementing partners, effective programs will be
reviewed and documented. This information will then be shared with implementers in
other parts of the state through written documentation, and presentations at meetings and
conferences.
K1203.2 - Workshops or symposiums will be convened to promote interaction and the
sharing of experiences between implementers that are already engaged in effective
programming and those that are at an earlier stage of implementation.
Activity KI204 - Train and assist KSAPS and implementers in the development of
appropriate voluntary counseling and testing services.
KI204.1 - Conduct initial VCT training for KSAPS and implementers.
K1204.2 - In partnership with KSAPS and implementers, conduct a review of VCT
services in the public and private sectors in Karnataka State. Identify strengths and
weaknesses and develop an agreement within KSAPS and health institutions regarding
the steps required to improve existing VCT services.
K1204.3 - Following the review of VCT services, develop an agreement with KSAPS
and partners regarding the expansion of cost-effective, quality VCT services in
Karnataka.
K1204.4 - Provide pre and post-test HIV counseling training for KSAPS and relevant
staff in key health institutions providing VCT. Such training would include a review of
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the legal framework in India for HIV testing, the key components of pre and post-test
counseling, the vital importance of informed consent and confidentiality (individual or
shared) regarding test results, and follow-up counseling support and referral for HIV
positive clients.
K1204.5 - Provide feedback to the HIV/AIDS forum (cf. K1301.1) regarding findings,
conclusions and recommendations on VCT in Karnataka State.
Activity KI205 - Train and assist KSAPS and implementers to establish effective STI
management at the i(grassroots" level
K1205.1 - Conduct initial STI syndromic management training for KSAPS and relevant
partners.
K1205.2 - In collaboration with KSAPS and its key partner health institutions, conduct a
review of STI management in Karnataka. Assess the extent to which STI treatment is
laboratory dependent or syndromic, stigmatized or freely used by men and women.
Provide feedback to the KSAPS Management Committee on key findings. Develop an
agreement within KSAPS and the health sector regarding the institutions to which STI
management should be initially devolved (for example, primary health care centers,
district hospitals, family planning services, and/or gynecologists).
K1205.3 - Provide information for KSAPS and partners regarding the required technical
supports for STI management such as simple algorithm flow-charts, drug lists for
syndromic management of STI and a drug record card, partner referral cards, penile
models and condoms, an examination couch and a separate room for carrying out the
physical exam and counseling. Provide technical support to KSAPS and the health sector
in developing the foregoing supports, and well as relevant back-up laboratory services.
K1205.4 - Train the trainers from targeted health institutions to provide the following
training: syndromic management, supervision of syndromic management and counseling
skills.
K1205.5 - Assist health facilities to set up an STI treatment reporting system within the
health sector with information transfer to KSAPS.
K1205.6 - Assist KSAPS in carrying out training of health providers. Provide ongoing
technical support in the implementation of all the foregoing.
Activity K1206 - Train and assist KSAPS and implementers to integrate prevention^ care
and support along a continuum.
A key challenge in HIV/AIDS programming is the integration of a wide range of activities
from prevention to care and support. This type of integration is beneficial since the various
activities are mutually supportive and the complementary strengths of various implementers
-47-
can be promoted. Training of KSAPS and implementers in this activity will rely on lessons
learned through the district level demonstration project.
KI206.1 - Integrated activities in the demonstration project will be documented and
communicated to KSAPS and implementing partners.
KI206.2 - Visits to the demonstration project to review the integrated model will be
arranged for KSAPS and implementers.
Output K1300 - Enhanced KSAPS and implementors’ capacity to create an enabling
environment for HIV/AIDS programming.
Activity KI301 - Assist KSAPS and implementers to increase the awareness, sensitivity and
capacity ofpublic and private sector policy makers and community leaders on HIV/AIDS
issues.
K1301.1 - Set up a state level HIV/AIDS forum for policy makers. This forum would be
made up of senior government, public and private health sector, research and NGO
personnel. The purpose of this forum would be to review and discuss HIV policy and
program issues with a focus on inter-sectoral linkages, and to educate policy makers
regarding HIV/AIDS issues. This forum would be convened a minimum of twice yearly
by KSAPS and would set priorities for its work, review up-to-date research and
information within priority programming areas and advise on problem areas as they arise.
The forum would be convened by KSAPS. Preparing materials for the forum’s
consideration and input would be the joint responsibility of KSAPS and the project. To
the fullest extent possible the forum will be made up of both men and women and have
representation from women’s organizations. Policy makers from the demonstration site
area would also participate in this forum.
K1301.2 - An information newsletter/bulletin will be produced by the project at least
twice a year. This newsletter/bulletin will cover areas of relevance to HIV/AIDS policy
and program frameworks for HIV/AIDS prevention and care. It will be produced in
English, Kannada and Hindi. Gender issues will be integrated. This newsletter could be
produced jointly with the Rajasthan office.
K1301.3 - Sensitize community leaders to HIV/AIDS issues. In order to work at the
community level, it is vital to have the support of local community leaders. Ignored or
poorly educated community leaders can sabotage an initiative’s best efforts if their
understanding and support has not been solicited in advance. The project will provide
technical assistance to KSAPS and NGOs in understanding the importance of sensitizing
community leaders, in how to identify relevant community leaders for sensitization, and
in the provision of educational materials/talks to such leaders. One appropriate
mechanism for providing technical support to the NGOs is through the KSAPS’ NGO
network.
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Activity KI302 - Assist KSAPS and implementers to involve PLWHAs and vulnerable
groups in all aspects ofprogram design, implementation and evaluation ofprevention, care
and support programming.
The involvement of PLWHAs and vulnerable groups in the design and implementation of
HIV/AIDS programming helps to ensure that programming is appropriate, effective and
sensitive to the needs of those most affected by the programs.
K1302.1 - The Project will include PLWHAs and affected vulnerable groups in all
aspects of the design and implementation of its program activities, thus providing a
model for other implementing agencies.
K1302.2 - Meetings and workshops will be convened to engage PLWHAs and
vulnerable populations in focused discussions regarding programmatic needs and policy
issues related to HIV/AIDS.
.
Activity KI303 - Assist KSAPS and implementers to incorporate HIV/AIDS issues into
development, social and gender issues.
KI303.1 - This component is designed to work with organizations not directly involved
with KSAPS or the Project. Therefore, the first task will be to map the range and type of
organizations that exist. The second task will be to understand how people are currently
being educated about HIV/AIDS transmission and how their current HIV-related care and
support needs are being met. The third task will be to identify organizations with
potential and interest in collaborating with KSAPS and the project. Ranges of social
change, development and gender initiatives exist in both rural and urban Karnataka. The
project will encourage KSAPS’ implementers to work with a selected number of these
initiatives. This is in order to promote HIV/AIDS education and prevention within these
organizations and to link to service organizations providing a continuum of care for those
who are sick, dying or orphaned. This can be accomplished in a number of ways.
K1303.2 - One strategy for integrating HIV/AIDS issues into social change, development
and gender initiatives is through strengthening the existing KSAPS NGO network and
bringing members together with a view to sharing information with each other. This
information could include identifying which organizations have potential for networking.
The KSAPS NGO network could then develop strategies for expanding their HIV
prevention efforts through such organizations and at the same time carry out advocacy
and HIV information provision among service providers relevant for HIV-related
prevention, care and advocacy.
K1303.3 - Another strategy for integrating HIV/AIDS issues into social change,
development and gender initiatives is to encourage KSAPS' NGO implementers to
participate in other NGO coalitions and advocacy groups addressing development, social
change and gender issues, e.g. FEVORD (rural development NGO network). The idea
would be to provide a voice for HIV/AIDS issues and to advocate for the inclusion of
HIV issues in information and advocacy agendas, for example, human rights
organizations and reproductive health organizations. In addition, HIV/AIDS
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implementers’ participation in other coalitions could provide an advocacy forum to
encourage service providers not to turn away PLWHAs.
K1303.4 - Another strategy would be to encourage NGOs implementing HIV prevention
and care programs to liaise directly with certain groups on a one-to-one basis.
K1303.5 - To support the above activities the project would help the NGO network to
develop relevant information and advocacy materials. These could include simple onepage fact sheets on a range of HIV-related issues in order to support their advocacy and
information sharing agenda. Such fact sheets could include for example, The urgency of
preventing HIV in India, how a person can and cannot get infected with HIV, HIV as a
reproductive health issue, the care and support needs of PLWHAs, myths concerning
HIV. It is anticipated that this component will start up sometime after the second year of
the project.
Activity KI304 - Train and assist KSAPS and implementers to develop effective policy and
practice for occupational safety of health professionals.
K1304.1 - The convening of an expert committee drawn from the Indian health sector
(public and private) can best effect the development of an occupational safety policy on
HIV for health professionals. In addition, project staff and KSAPS representatives would
also participate on this committee. Such a committee should include both doctors and
nurses. This committee could make its initial recommendations to the policy forum and
the KSAPS Management Committee.
K1304.2 - Any policy developed should be context-specific and realistic, and address the
real and perceived risks of health workers. Such a policy should keep in mind the cost of
universal precautions versus discrete use of such precautions - gloves, for example - and
the likely stigmatization of PLWHAs arising from such use. Such a policy should also
address the very real risk of tuberculosis infection and the precautions necessary for its
prevention among health workers. Given that blood and body fluid exposure during the
delivery of newborns is one area of grave concern to heath workers, specific attention
should be given to this issue.
K1304.3 - In order to promote the occupational safety of health professionals, they first
need to thoroughly understand how they are and are not at risk. Then they need to be
guided by their health facility’s policy on occupational safety and HIV, and be supervised
in ensuring that adequate, but non-discriminatory precautions are taken. Some training
on occupational safety and HIV for health workers and their supervisors will be required.
Therefore, the project will assist KSAPS in the development of training materials on
occupational safety and HIV.
Activity KI305 — Assist KSAPS and implementers to effectively link prevention to care and
support activities.
K1305.1 - Emerging best practices from around the world indicate that at the level of
vulnerable communities at least, sustainable success is associated with integrated
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programming. Two examples are the link between HIV testing and PLWHA support
groups, and care and support for peer educators who have worked to promote safer sex
practices who become sick and/or leave orphaned children behind when they die.
Building an environment where people feel safe to be tested for HIV requires more than
clean needles and test kits. It requires some change in legal frameworks, employment
laws, counseling support and the support of others living with HIV. Building sustainable
community responses to HIV prevention and care requires a strong link between the two
from the outset. The more cared for a person with HIV feels, the better chance she or he
will care about infecting others.
KI305.2 - The project will encourage KSAPS to make strong policy and program links
between prevention and care. This will be done initially by providing input to the policy
forum and the KSAPS Management Committee. This input will be based on two
elements, a literature review of experiences from other countries and from within India,
and working with KSAPS' implementing partners to document their experiences to date
in the link between prevention and care. Finally, the demonstration project experience
will actively link prevention and care programming, and these experiences and lessons
learned will be available to KSAPS by the fourth and fifth years of the Project.
Activity K1306 — Develop effective and appropriate training materials and methods.
K1306.1 - The Project Office will constitute a technical resource to KSAPS and
implementing partners. The project will hire a training materials development expert,
and where necessary help produce a range of training manuals and materials for program
implementers. One of the first tasks for the project will be to identify the training to be
carried out within each program area and the support materials needed for this training.
Possible training courses/materials include, Syndromic Management of STI, STI/HIV
Counseling Skills for Health Workers, STI/HIV Supervision Skills for Health Workers,
Home-based Care for People with HIV/AIDS, Mobilizing and Training Vulnerable
Groups, and HIV and Gender. Training materials could also include materials and
methods developed for peer educators with low literacy skills working in low literacy
environments. Many of the above training manuals have already been developed in India
or elsewhere. Such manuals may be adapted in a culturally and linguistically appropriate
way. Negative gender stereotypes will not be reinforced in any of these training
materials. Technical assistance can be provided from within and without India.
Component K2000 - Implementation of Area Demonstration Project
In this component, a comprehensive demonstration project within a district in Karnataka will be
developed and implemented. An integrated implementation program will be established that will
not only improve the HIV/AIDS situation within the selected district but will also serve as a
model whose processes, methodologies and materials can be replicated in other districts across
the state and in other states. Selection of the district for implementation will be based upon
discussions with KSAPS. The criteria that will be used in the selection process include
vulnerability to HIV/AIDS, size of the district, availability of basic infrastructure, and motivation
and interest of the district.
pis -51 -
4-/ X:'
/
,?
There are several reasons for using this approach. First, there are currently few examples of high
quality, integrated models for HIV/AIDS prevention, care and support in India or elsewhere.
Second, by focusing at the district level it will be possible to gain and share insights into the
processes, costs and impacts of various program activities at the organizational level, where
many HIV/AIDS prevention and control efforts will ultimately be delivered. Third, although
there are currently many activities and resources being directed to major urban areas such as
Bangalore, there are fewer resources being applied in non-urban districts. Fourth, such an
approach could provide a single venue for the provision of high quality, hands-on training for
implementers from across the state and the country. Finally, this approach will allow for
concentration of resources in a way that maximizes the ability to build capacity through the
transfer of skills and knowledge. The main strategies will be used in implementing the
demonstration project are listed below.
Partnering with NGOs and other implementers: Partnerships with key NGOs and other
implementers will be identified and developed within the district.
Capacity building of implementing partners: The capacity of implementing partners will be
built through training and other initiatives.
Technical assistance to implementing partners: In addition to training, a network of technical
resources using both Canadian, international and Indian expertise will be made available to
implementing partners.
Formative research: Formative research will be conducted with implementing partners to
guide the development of implementation activities.
Rigorous outcome evaluation: Mechanisms to rigorously document the outcome of
interventions will be developed. This will be used as part of an iterative process to understand,
modify and improve interventions.
Dissemination of innovations and results: Innovations, results and lessons learned in the
demonstration project will be actively disseminated. The goal will be to replicate effective
programmatic components across the state and elsewhere in India.
Outputs and Activities
Output K2100 - Enhanced information base for HIV/AIDS programming and monitoring
and evaluation.
A central principle guiding the development of the demonstration project is that program
planning will be strategic and based on a strong foundation of population level information
regarding the epidemiologic, social and cultural aspects of HIV/AIDS in the district. Therefore,
the initial set of activities will focus on assessing and improving the information base within the
district.
-52-
Activity K2101 - Select project area and build partnerships with community, NGOs and
other partners.
K2101.1 - The first activity will be to work with KSAPS to select the project area district
based on the criteria described above.
K2101.2 - Once the project area is selected, the next step will be to develop partnerships
with communities and implementers within the district. With implementing NGOs,
group and one-on-one information sessions with relevant community leaders will be
convened. Such sessions can be held with a range of representatives - governmental,
business, community representatives, or representatives from target populations. Such
information sessions are a prerequisite for any entry into a community.
K2101.3 - A district level project team will be established. This team will include
membership from the Technical Support Unit, KSAPS, the District Medical Officer, key
NGOs and institutions, and community representatives including PLWHAs and members
of vulnerable populations. The mandate of the project team will be to develop a strategic
plan for project activities, establish working groups to plan and execute programs, help to
coordinate activities in the state, develop and review proposed activities, review the
progress of the program and participate in the dissemination of innovations to other
jurisdictions.
Activity K2102 - Zone and map the project area.
Before developing an information strategy, the project area will need to be zoned and
mapped.
K2102.1 - In partnership with NGOs and other implementers procure maps of the project
area and conduct more detailed mapping of key geographic areas within it.
K2102.2 - Carry out zoning of the project area with an emphasis on key geographic sites
within the district.
K2102.3 - Produce a number of copies of final, zoned maps - one for the project district
office, one for each implementing NGO and one for the Karnataka project office.
Activity K2103 - Review and document current information base and develop strategies for
information gathering.
2103.1 - Establish an information technical working group to develop strategies for.
information gathering.
2103.2 - Work with district level health system personnel, medical institutions, NGOs
and other agencies to identify current relevant information available in the district and to
document information gaps.
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2103.3 - Based on the review, the working group will develop a comprehensive strategy
and specific plans for enhancing the information base.
Activity K2104 - Strengthen selected laboratories for HIV/STI diagnostics and
surveillance.
K2104.1 - Through the working group, determine the requirements for HIV/STI
laboratory support in the district and specify capacity strengthening needs.
K2104.2 - Identify and partner with selected laboratories.
K2104.3 - Engage technical experts in HIV/STI laboratory methods to develop specific
plans for capacity strengthening at the selected laboratories.
K2104.4 - Implement laboratory strengthening activities.
Activity K2105 - Conduct baseline STI/HIV and behavioural surveys andformative
assessments.
Before embarking on planning programmatic activities, a baseline assessment of the current
STI/HIV transmission dynamics is required. This baseline assessment is also necessary to
monitor progress. In addition to collecting epidemiologic data, an assessment of the social,
cultural and institutional context is required.
K2105.1 - Conduct a rapid ethnographic assessment and qualitative investigation of the
social and cultural context to guide the development of survey methods and instruments.
K2105.2 - Plan and conduct population-based surveys of the prevalence of STIs and HIV
in high risk and general population samples.
K2105.3 - Plan and conduct surveys regarding knowledge, attitudes and practices in high
risk and general populations.
K2105.4 - Conduct a formal assessment of the social, cultural and institutional context.
Activity K2106 -Analyze and disseminate information to program planners and
implementers.
Once the baseline assessments are completed, the information will need to be disseminated to
program planners and implementers to assist in a strategic planning.
K2106.1 - Prepare and disseminate reports based on the baseline assessment.
K2106.2 - Convene meetings to present the results of the baseline assessment.
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Activity K2107 — Develop a strategic plan for an integrated model ofHIV/AIDS
programming in the project area.
The next step will be to use the information from the situational assessment to develop a
strategic plan for an integrated model of HIV/AIDS programming.
K2107.1 - Conduct workshops with the district project team to review the findings and
implications of the situational assessment.
K2107.2 - Assist the district project team to develop a strategic plan for programming in
the project area that includes an identification of priority populations and interventions.
K2107.3 - Develop a specific workplan with the district project team.
Activity K2108 - Develop mechanisms for monitoring activities and impacts.
Once the strategies and workplans are developed, mechanisms to monitor the impact of
activities will be created.
K2108.1 - Work with the district project tarn to develop a model for project monitoring
and evaluation.
K2108.2 - Develop a workplan for monitoring activities.
Output K2200 - Development of community-based participatory interventions for
vulnerable and marginalized men and women.
Activity K2201 — Identify vulnerable groups, and NGOs and other implementers.
K2201.1 - In partnership with KSAPS, conduct an assessment of the demonstration
project area. Make initial identification of vulnerable groups (migrant male workers,
truckers, sex workers, devadasi, etc.). Choose which groups to work with.
K2201.2 - Identify and assess relevant NGOs working in the area. Select NGO
implementers.
Activity K2202 - Train and mobilize NGOs and other implementers.
K2202.1 - Provide training for NGOs and other implementing partners in the basic facts
about HIV transmission, the epidemiology of HIV, and the rationale for targeted
interventions. NGO training would also include the following: how to map and zone
target areas, how to mobilize vulnerable groups, how to select and train peer leaders, how
to support peer leaders in their ongoing work of promoting partner number reduction,
condom use, STI, care and support referral, and finally, how to monitor and evaluate their
work.
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Activity K2203 - Conduct baseline assessments of vulnerable groups.
K2203.1 - Design survey tool for each target group. Ensure that questions regarding
attitudes to men and women and sexuality are included as well as basic questions
concerning sexual behavior and knowledge about STI/HIV transmission and prevention.
K2203.2 - NGOs/implementers to pre-test survey tools.
K2203.3 - NGOs to carry out surveys of each target community.
K2203.4 - Project/NGOs/implementers to enter and analyze data.
Activity K2204 — Train peer educators and supervisors.
K2204.1 - With NGOs and other implementers, agree on criteria for peer educators.
K2204.2 - NGOs and vulnerable communities to select peer educators. Each peer
educator to be responsible for 50 peers.
K2204.3 - Conduct training of peer educators. Provide training materials to
NGOs/implementers. Provide selected training support to NGOs/implementers.
K2204.4 - Agree, what (if any) remuneration will be provided to the peer educators.
K2204.5 - Equip peer educators with participatory education materials, group registers,
and checklists to register attendance, topics discussed, number of condoms distributed,
number of STI referrals and other areas of concern to the group.
K2204.6 - Ensure that NGOs/implementers collect and compile peer leader data on a
monthly basis.
Activity K2205 — Implement interventions using an iterative approach.
K2205.1 - Mentor NGO staff and peer educators’ collaboration in health promotion
activities and empowerment activities among target groups.
K2205.2 - Assist NGO staff and peer educators in establishing and maintaining effective
peer group structure, dynamics and organization by ensuring that appropriate monitoring
and supervisory tools are in place, and adequate supplies (of condoms and other
materials) are available. Encourage groups to organize around issues of common concern
whether directly HIV-related or not. Peer leaders may be issued with T-shirts and bags
and receive a small monthly stipend.
K2205.3 - Assist NGO staff in supporting peer educators in their functions by advising
on the development of specific educational approaches (one-minute sketches, role-plays).
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K2205.4 - Train NGO staff to respond to emerging needs and problems of the peer
educators or their groups and resolve conflicts.
K2205.5 - Plan, conduct and analyze surveys of the impact of the demonstration project
on sexual attitudes and behaviour and other indicators in target groups.
Activity K2206 - Evaluate outcomes and impacts and disseminate innovations, lessons
learned and best practices.
K2206.1 - Create documentation of all aspects of the intervention, including procedure
manuals, survey instruments and training materials.
K2206.2 - Conduct periodic systematic reviews of the processes and outcomes of the
intervention project.
K2206.3 - Analyze and synthesize the processes and impacts and identify the critical
success factors for the project. Provide written documentation of this analysis for
KSAPS, implementers and national groups such as relevant technical resource groups.
Activity K2207 - Provide resources and opportunities for hands-on training for other
implementers in interventions.
It is anticipated that the intervention project will provide opportunities for training of
implementers in the design and implementation of high-quality interventions.
K2207.1 - Develop training manuals and materials based on the demonstration project
activities.
K2207.2 - Train leaders in the demonstration project to provide hands-on training for
personnel from various implementing agencies.
K2207.3 - Provide hands-on training programs within the demonstration project.
- Output K2300 - Development of a model for STI management at the ’’grassroots” level.
The management of STIs plays a central role in HIV prevention. Effective STI management
programs provide effective treatment and counseling services through accessible and acceptable
delivery models. However, in India there are few models for STI management at the local level.
Activity K2301 - Conduct a baseline assessment ofSTI services at the community level
The first step will be to assess the current patterns of delivery and practice of STI
management within the project area.
K2301.1 - Through interviewing key informants from the community and public and
private health care systems, identify current patterns of STI service delivery.
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K2301.2 - Conduct a review of current practices by surveying community members, STI
clients and providers.
Activity K2302 — Select and partner with public and private sector providers.
K2302.1 - Public and private health sector care providers will be identified for
partnership in the development of a model for STI management at the "grassroots" level.
This process will likely involve identifying a geographically-bounded area for
implementation.
Activity K2303 - Develop and implement training for providers, including training in
counseling, condom promotion and partner notification.
Once a cadre of providers have been identified, they will be provided with training for
optimal care delivery.
K2303.1 - An initial workshop will be convened to assess training needs.
K2303.2 - Training materials will be developed and tested.
K2303.3 - Training in syndromic management and counseling, condom promotion and
partner notification will be provided.
Activity K2304 — Develop a strategy for extending STI services to women.
A key component of the STI model will be establishing mechanisms to extend STI services to
women.
K2304.1 - Conduct a review of the current patterns of STI care delivery to women.
K2304.2 - Assess the accessibility and acceptability of services through surveying
women.
K2304.3 - Review opportunities to extend services to women through public and private
providers and through reproductive health care systems.
K2304.4 - Develop a training and implementation strategy for extending STI services for
women.
Activity K2305 — Upgrade selected laboratories to support STI treatment services.
Much of this activity is described under Activity 2104. The focus for this activity is on
providing diagnostic support to providers.
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K2305.1 - Once a group of providers has been selected for the STI model, identify and
partner with an appropriate and accessible laboratory.
K2305.2 - Develop a protocol for screening and testing samples for STIs that is
appropriate for the support of a syndromic management model. The focus will be on
validating treatment algorithms including an assessment of the prevalence and antibiotic
resistance patterns of etiologic agents.
K2305.3 - Develop a system for obtaining and processing clinical specimens through the
laboratory.
Output K2400 - Improved availability of high quality care and support for individuals and
families affected by HIV/AIDS.
An important component of any HIV control program is the availability of high quality care and
support for individuals and families affected by H1V/AIDS. Therefore an important part of the
demonstration project will be to enhance the quality of care and support in the project area. The
following activities will be conducted.
Activity K2401 - Review and document current hospital and home-based care practices and
resources.
K2401.1 - Within the project area conduct a systematic review of the current hospital
and home-based care practices and resources.
K2401.2 - Document the findings of the review and share it with care providers and
institutions to validate the findings.
Activity K2402 - Work with communities and health care providers to identify opportunities
and priorities to improve care and support services.
K2402.1 - Once the review has been completed, institute a process to identify
opportunities and priorities for improved care and support. This process will include
workshops and will ensure the participation of health care providers from the institutional
and community sector as well as affected populations, especially PLWHAs.
Activity K2403 - Develop and implement training for care providers.
Care providers may not have the appropriate training or resources to improve care and support
in institutions or in the community. Therefore, training for care providers will be provided.
K2403.1 - Conduct a survey of community and institution-based health care providers,
assess their current knowledge of care issues and determine training needs.
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K2403.2 - Develop a training program for care providers that is responsive to their
training needs.
K2403.3 - Develop or adapt training materials for care providers.
K2403.4 - Implement training programs with an emphasis on practical training
approaches.
Activity K2404 — Strengthen and develop appropriate voluntary counseling and testing
services in selected sites.
An important component of care and support is the availability of appropriate voluntary
counseling and testing (VCT) for HIV.
K2404.1 - Review the availability and processes of VCT in the project area.
K2404.2 - Provide training for providers in VCT with an emphasis on the principles of
confidentiality and in counseling techniques.
Activity K2405 - Support the development of local PL WUA self-help groups.
K2405.1 - Identify any local PLWHA groups.
K2405.2 - Support collaboration and linkages between any existing local PLWHA
groups and state and national groups.
K2405.3 - If no groups exist, work through community groups and with state-level and
national PLWHA groups to encourage the development of local groups.
K2405.4 - Involve local PLWHA groups in all aspects of project design and particularly
in the development of care and support services.
Activity K2406 — Train and assist NGOs to develop plans and proposals for community
based HIV care projects.
The current process for the funding of new community-based HIV care projects is centralized
with NACO. Based on working with local communities in the project area, we will encourage
and support the development of plans and proposals for innovative community-based HIV
care projects.
K2406.1 - With the local community conduct and document a situation analysis and
needs assessment for community-based care.
K2406.2 - Work with community-based and institutional care providers to develop
proposals for new community-based care projects.
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•
8.
RAJASTHAN COMPONENT
8.1
Situation and Needs Assessment
8.1.1
Developmental and Socio-demographic Context
Covering an area of 342,000 sq. km. representing 10.4% of India’s land mass, Rajasthan is the
second largest state in India and supports a population of about 50 million. Situated in the
northwest of the country, it shares an international boundary and the Thar Desert with Pakistan
and state boundaries with Punjab, Haryana, Uttar Pradesh, Madhya Pradesh and Gujarat.
National highways cross 60% of Rajasthan’s 32 districts, with the busiest being the Delhi-JaipurMumbai Highway Number 8, with an estimated 25,000 vehicles passing daily. With slowing
growth, an admitted fiscal crisis, increasing groundwater depletion and environmental
degradation combined with shortages of electrical power, the indicators of social development in
Rajasthan are poorer than many Indian states. In 1997, the infant mortality rate was 85 per 1000
live births (All India 71), the overall literacy for the population aged 7 years and above was 55%
(All India 62%), and the female literacy rate was 35% (All India 50%). The total fertility is 4.4
children (versus 3.1 for All India) and child malnutrition measured by height for weight is
41.6%. About 12% of the population is tribal, inhabiting mainly the hilly, rugged southeast
region.
Gender disparities are evident in Rajasthan’s skewed sex ratio of 913 females for 1000 males.
The female literacy rate remains less than half the male literacy rate and is particularly low
among disadvantaged social and ethnic groups. Only 17% of 6-14 year old girls from the
poorest 40% of households in Rajasthan are in school and 2% of 15-19 year old girls from the
poorest households have completed 8 years of primary school.
’
The Government of Rajasthan (GOR) is expending moderately high levels of state finances on
health (6.3% of government expenditure and 1.3% of gross state domestic product), but the vast
size of Rajasthan and its desert and tribal regions pose challenges to the delivery of accessible
good quality health care. Allocation of resources in the health sector is heavily weighted in
favour of tertiary care services. Salary costs absorb most of the resources, leaving operations
and maintenance chronically under-funded. Among the innovations in health care delivery are
the variety and reach of various peripheral health workers. There are more than 16,000 female
health workers (FHWs) and male multipurpose workers (MPWs). Within a UNICEF sponsored
program, over 27,000 health workers are providing health care services through the Integrated
Child Development Scheme (ICDS).
Private sector participation in health care delivery is relatively low throughout Rajasthan.
Composed of a heterogeneous group of unqualified practitioners (also known as "quacks"),
practitioners of traditional medicine, and not-for-profit and for-profit allopathic providers, the
private sector appears to be weakly organized, has little or no contact with the pubic sector, and
has little accountability to the public. There are few standards for quality of health care, pricing,
or patient protection. To date, public-private partnerships have not been well explored in
Rajasthan and as a result, work to improve the quality, performance, scope, and involvement in
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the prevention and promotion aspects of HIV/STD care in both the public and private sectors
will break new ground.
8.1.2 HIV Situation and Vulnerability
The first case of AIDS in Rajasthan was detected in 1987 at Pushkar (Ajmer) and as of August
1999, 108 AIDS cases (exposure category: heterosexual activity 78.7%, blood transfusion 4.6%,
unknown 16.7%) and 2,229 HIV-positive persons had been reported to the Rajasthan State AIDS
Control Society (RSACS). A state HIV surveillance centre was established in 1987 at the
Microbiology Department of SMS Medical College, Jaipur. Sentinel HIV surveillance is
conducted in 3 antenatal (ANC) clinics (Jaipur, Kota and Jodhpur) and 2 STD clinics (Jaipur and
Udaipur). In 1998, 0/1200 ANC samples and 14/300 (4.7%) STD samples were positive. In
1999, 3/1,200 (0.25%) ANC samples and 16/500 (3.2%) STD samples were positive. In 1998
for Rajasthan as a whole, 21/3,019 (0.69%) of female blood donors and 388/109,310 (0.35%) of
male donors were HIV-positive.
In 1998, estimates of the number of people living with HIV in the state ranged from 107,000 to
167,000. STD surveillance figures for January to August 1999 indicate 4,285 new STD cases
(38.6% men and 61.4% women). Of 438 genital ulcers reported, herpes genitalis accounted for
46.1%, chancroid for 25.3%, and syphilis for 20.8%. In the first Rajasthan Family Health
Awareness Week, which attracted 27.9% of the 1.9 million population for which it was designed,
8,337 STD diagnoses were made and treatment provided at primary health care centres.
Tuberculosis was the most common diagnosis among AIDS cases (59%). A study in 1997 found
low levels of knowledge about STI and HIV in sex workers (9% and 18%), truck operators (28%
and 37%), injection drug users (5% and 8%), rural inhabitants (14% and 34%) and urban
inhabitants (18% and 59%). Having suffered from an STI in the previous 12 months was
reported by 74% of truck operators, 42% of sex workers, 21% of intravenous drug users (IDU),
44% of rural and 36% of urban inhabitants. Low levels of knowledge about STI and HIV and
the high prevalence of STI in Rajasthan indicate high vulnerability for HIV transmission in the
state.
Additional factors contributing to Rajasthan’s vulnerability to HIV are labour migration, both
inward migration from surrounding states and Bihar, as well as outward migration, particularly
to high HIV prevalence urban centres such as Mumbai. Male mobility is associated with sex
work, particularly along the national highway corridors and in specific areas of the major cities,
although in urban settings sex work appears diffusely located. Scattered throughout the state are
Scheduled Caste communities whose entire economy is dependent on sex work by their women.
Among these castes are the Nats and the Rajnats, both of which were traditionally entertainer
castes. These communities now live in sex work villages, dotted along the major highways and
near other centres of commercial activity. The communities are networked to one another and
women move between villages. Women from these communities may also migrate to large
urban centers or neighbouring countries, remitting their earnings to their families. These
communities are so economically tied to sex work by their women that females are highly valued
by their families. The birth of a girl child is welcomed and the female male sex ratio is closer to
normal in these communities. The villages may be relatively affluent compared to surrounding
villages but they are extremely marginalized and stigmatized, which poses challenges to HIV
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prevention activities. NGO and other development partners reported open hostility and threats of
violence toward anyone other than customers approaching these villages. However, these
communities are very important in HIV prevention in Rajasthan as they are a major source of
commercial sex in the state.
Throughout Rajasthan, high poverty levels promoting sex work, geographic dispersion of the
population, low levels of literacy (particularly among women), repeated droughts encouraging
‘-within state and out-of-state migration, reticence to seek STI treatment, and the low status of
women are all contributing factors which are facilitating the spread of HIV in Rajasthan.
'8.2
Institutional Resources and Responses
8.2.1
Overview
’ HIV prevention and control activities in Rajasthan are largely under the direction of the
Rajasthan State AIDS Control Society (RSACg). RSACS was established in December 1998
, under the Chair of the Health Secretary of the state. Its governing body includes both
government and NGO representatives but, as yet, no person living with HIV/AIDS. At the
district level, the District Chief Medical and Health Officer has been designated the nodal officer
for implementation of the program. In its first year of operation RSACS experienced difficulties
in creating efficient administrative structures to distribute funds from the NACP-I and NACP-II.
No NGOs have received support since the inception of RSACS. A variety of NGOs responded
to two calls for proposals for prevention and control activities and with the recent hiring of an
NGO advisor, the process of selection of NGOs and disbursement of funds is underway. The
RSACS organizational chart shows many unfilled positions, and other than that of the NGO
advisor, the five filled posts are occupied by individuals deputized from the state government,
several of whom have other significant other responsibilities.
8.2.2
Opportunities for Capacity Building
Following consultations with RSACS, NGOs and other institutional partners during the
Rajasthan site visits, several strengths and opportunities for capacity building in Rajasthan’s
response to the HIV epidemic are evident. The strengths include:
•
The leadership and knowledge of the Secretary of Health and the Project Director.
•
The commitment and skills of the deputy director, NGO advisor and other RSACS staff
(with whom site visits were conducted).
•
The evident concern and willingness to contribute in a meaningful way shown by a
number of NGO partners.
•
The caring and sensitivity of the clinicians delivering AIDS care.
•
The provision of non-discriminatory in-patient care in state institutions.
•
The safety of the blood bank program.
•
The extent of training sessions that have been held for health sector personnel.
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The opportunities for capacity building include:
8.3
•
Increasing the involvement of PLWHA in RS ACS.
•
Gathering population-based information about sexual behaviour among vulnerable
populations and in the general population.
•
The ability of NGOs to develop high quality community-based prevention and care
programs.
•
The creation of an enabling environment for HIV/AIDS programming.
•
The creation of integrated models for implementation linking prevention activities with
care and support activities at the community level.
Rajasthan Component Project Description
8.3.1 Overview
Based on the design team's consultations and participatory identification of strengths and
opportunities with RS ACS, a program plan to improve the capacity in Rajasthan to respond to
the epidemic was developed. The two main program components are:
1) Capacity building of RS ACS and its implementing partners.
2) Implementation and rigorous evaluation of novel high quality demonstration projects.
Capacity building for RS ACS and implementing partners (component 1) will be primarily
through technical inputs into the planning, implementation and evaluation of HIV prevention,
care and support activities. Through the implementation of high quality demonstration projects,
the project will work with NGOs and other implementing partners to develop, evaluate and
disseminate effective strategies for HIV prevention, care and support. Through this mechanism,
the project will build the capacity of implementers, provide opportunities for applied training,
and provide insights and innovations for replication throughout Rajasthan and in other states.
8.3.2 Work Breakdown Structure
The work breakdown structure (WBS) for activities in Rajasthan has two components. The first
component (R1000) is “Capacity Building for RS ACS and Implementers, State Level”. There are
three main outputs for this component with associated activity streams. The second component
(R2000) is “Implementation of Demonstration Projects”, which has activities organized under
three main outputs. These activity streams are summarized in the figure below. The detailed
activities under each of these streams are described in the following sections.
Component R1000 - Capacity Building for RS ACS and Implementers, State Level
• Output R1100 - Improved RS ACS' and implementers’ capacity to gather, analyze and
integrate information into decision making.
• Output R1200 - Enhanced RS ACS' and implementers’ capacity to mobilize, monitor and
evaluate evidence-based HIV/AIDS programming.
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•
Output R1300 - Enhanced RSACS' and implementers’ capacity to create an enabling
environment for HIV/AIDS programming.
Component R2000 - Implementation of Demonstration Pro jects
• Output R2100 - Development and implementation of a community-based participatory
intervention for rural migrant men.
• Output R2200 - Development and implementation of a community-based participatory
intervention for rural caste-based sex work.
• Output R2300 - Development and implementation of a Rajasthan model of the
prevention-care continuum.
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Component R1000
Capacity Building for RSACS and Implementers - State
Level
Component R2000
Implementation of Demonstration Projects
R1100 Improved
RSACS’ and
implementers’
capacity to
gather, analyze &
integrate
information into
decision making
R1200 Enhanced
RSACS' and
implementers’
capacity to
mobilize, monitor
& evaluate
evidence-based
HIV/AIDS
programming
R1300 Enhanced
RSACS’ and
implementers’
capacity to create
an enabling
environment for
HIV/AIDS
programming
R2100
Development of a
community-based
participatory
intervention for
rural migrant men
with partners
R2200
Development of a
community-based
participatory
intervention for
rural caste-based
sex work with
partners
R2300
Development of a
Rajasthan model
of the prevention
care continuum
R1101 Train
RSACS &
implementers in
rapid
epidemiologic
assessment
R1201 Train
RSACS and
implementers in
best practices in
delivery of
targeted
HIV/AIDS
programming
R1301 Assist
RSACS and
implementers to
increase the
awareness,
sensitivity and
capacity of public
& private sector
policy makers and
community
leaders on
HIV/AIDS issues
R2101 Identify
community of
rural migrant men
for intervention
R2201 Identify
community or
area for
intervention
R2301 Conduct a
needs assessment
and determine
model site
R2101 Train and
mobilize NGOs
and other
implementing
partners
R2201 Train and
mobilize NGOs
and other
implementing
partners
R2302 Identify
and review best
practice models
that could be
adapted
R2103 Conduct
baseline
assessment of
migrant
population
R2203 Conduct
baseline
assessment of
intervention
population
R2303 Design
and implement
the model project
using a
participatory
approach
R2104 Train
peer educators
and supervisors
R2204 Train
peer educators
and supervisors
R2105
Implement
interventions
using an iterative
approach
R2205
Implement
interventions
using an iterative
approach
R2106 Evaluate
outcomes and
impacts and
disseminate
innovations,
lessons learned
and best practices
R2106 Evaluate
outcomes and
impacts and
disseminate
innovations,
lessons learned
and best practices
R2107 Provide
resources and
opportunities for
hands-on training
for other
implementers in
interventions
R2207 Provide
resources and
opportunities for
hands on training
for other
implementers in
interventions
R2108 Expand
intervention to
networked
communities
R2208 Expand
intervention to
networked
communities
R1102 Train &
assist RSACS &
implementers in
collection and
analysis of
information on
STI/HIV,
behaviours, and
gender &
development
indicators
R1202 Train and
assist
implementers for
innovative
participatory peer
group
interventions with
vulnerable
populations
R1103 Train and
assist RSACS and
implementers in
conducting
situational
analysis and
needs
assessments
R1203 Assist
RSACS and
implementers in
the dissemination
and scaling up of
effective
HIV/AIDS
programs
R11O4 Train &
assist RSACS in
conducting
directed research
for advocacy and
policy formulation
R1204 Train and
assist RSACS and
implementers in
the development
of appropriate
voluntary
counseling and
testing
R1105 Train and
assist
implementers in
conducting
operational
research for
program
formulation and
implementation
R1205 Train and
assist RSACS and
implementers to
establish effective
STI management
at the
"grassroots" level
R1106 Train and
assist RSACS and
implementers in
monitoring and
evaluating
program outcome
and impact
R1206 Train and
assist RSACS and
implementers to
integrate
prevention, care
and support along
a continuum
R1107 Train
RSACS and
implementers in
population-based
strategic planning
I of HIV programs
R1302 Assist
RSACS and
implementers to
involve PLWHAs
and vulnerable
groups in all
aspects of
program design,
implementation
and evaluation of
prevention, care
and support
programming
R1303 Assist
RSACS and
implementers to
incorporate
HIV/AIDS issues
into development,
social & gender
issues
R1304 Train and
assist RSACS and
implementers to
develop effective
policy and
practice for
occupational
safety of health
professionals
R1305 Assist
RSACS and
implementers to
effectively link
prevention to care
and support
activities
R1306 Develop
effective and
appropriate
training materials
and methods
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R2304 Develop
mechanisms for
the ongoing
evaluation of the
model
R2305 Document
and disseminate
lessons learned
and project
impact
R2306 Provide
resources and
opportunities for
hands-on training
for other
implementers
8.3.3
Description of Outputs and Activities
Component R1000 - Capacity Building for RSACS and Implementers - State Level
In this component of the program, a number of strategies will be used to strengthen the capacity
of RSACS and its implementing partners at the state level. These strategies will include:
Technical Assistance/Mentoring: A network of Canadian and international technical
.specialists will provide direct technical advice, consultation and mentoring for members of
RSACS and implementing agencies. Local Indian technical expertise will also be engaged to
offer the same opportunities.
• Needs-based Training: Where necessary, direct training for RSACS members and
implementers will be provided, using high quality and validated training materials and methods.
This training will involve both short courses and training workshops.
Study Tours and International Linkages: There are many examples of high quality
HIV/AIDS prevention, care and support programs both in India and elsewhere. Mechanisms will
be developed for linking RSACS and its implementing partners to these programs, such as
through organization and support for study tours, to promote the use of national and international
best practices.
Strengthening Facilities and Funding Selected Initiatives: Direct support will be provided for
the strengthening of selected facilities that can serve as state-wide resources. For example, this
could include the strengthening of a designated facility for the diagnosis of STIs, in support of
.enhanced STI surveillance and validation of syndromic management guidelines.
Outputs and Activities
-The outputs and specific activities under Component R1000 are described below.
Output R1I00 - Improved RSACS’ and implementers’ capacity to gather, analyze and
'integrate information into decision making.
Activity R1101 - Train RSACS and implementers in rapid epidemiologic assessment
Rapid epidemiologic assessment (REA) includes a set of methods and tools that can be used
to quickly assess a population’s situation with respect to the prevalence and incidence of HIV
infection and other STIs, and the transmission dynamics of HIV/STIs in a community. Thus,
improving RSACS’ and implementers’ capacity to perform REA can support the formulation
of HIV prevention strategies. Training activities will include:
R1101.1 - Prepare and convene training sessions and workshops on REA with
designated RSACS representatives and members of implementing organizations and
academic institutions.
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R1101.2 - With RSACS and implementers, develop appropriate tools for REA that can
be used in various settings throughout the state.
R1101.3 - Assist RSACS and implementers to undertake REAs in key population groups
or districts where required.
Activity R1102 — Train and assist RSACS and implementers in the collection and analysis
of information on STI/HIV, behaviours, and gender and development indicators.
In addition to REA, organized and ongoing systems for the collection and analysis of
population-level information on the prevalence and incidence of STI/HIV, risk behaviours
and other parameters are necessary to describe the burden of illness related to STI/HIV, to
identify at-risk populations, and to monitor the impact of prevention efforts. Activities to
enhance capacity in this area will include:
R1102.1 - Establish a state level Working Group to develop information priorities,
review existing information systems, develop a strategic plan for information collection,
analysis and dissemination, and develop methods and tools for information gathering and
epidemiologic surveillance. The Working Group will be resourced by the Technical
Support Unit (TSU) and will include membership from the TSU, RSACS, NGOs,
medical and academic institutions, and the community (including PLWHAs).
R1102.2 - Provide training in quantitative and qualitative methods for the collection,
analysis and interpretation of relevant population information through workshops and
field experiences.
R1102.3 - Under the guidance of the Working Group, establish pilot systems for
information gathering, including surveys and disease surveillance.
Activity R1103 — Train and assist RSACS and implementers in conducting situation
analyses and needs assessments.
To plan and implement effective HIV programming, there must be the capacity to conduct
high quality situation analyses and needs assessments. This process involves analyzing and
integrating information regarding the status and drivers of the HIV epidemic in the
population, understanding the various intervention options and their rationale, and critically
reviewing the available resources and resource gaps. To enhance capacity in this area the
following activities will be undertaken.
R1103.1 - Provide training for RS ACS and its implementing partners in the conduct of
situation analyses and needs assessments. This training would include the convening of
workshops and the development of training materials.
R1103.2 - With RS ACS and its implementing partners, identify priority regions and
populations, and formulate plans for and assist in conducting situational analyses and
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needs assessments in those areas. These assessments would be used to provide hands-on
training opportunities.
Activity R1104 - Train and assist RSACS in conducting directed research for advocacy and
policy formulation.
Policy decisions are key to creating an enabling environment and ensuring that the most
effective interventions are given priority. Evidence from relevant research can be a valuable
tool for selecting and advocating policy directions. For example, it can be used to estimate the
population impact and cost- effectiveness of various intervention options.
R1104.1 - Together with RSACS, a set of policy-relevant research questions will be
developed and addressed. Technical expertise will be provided to conduct the research
and to provide consultation to RSACS on the process and implications of the findings.
Activity R1105 - Train and assist implementers in conducting operational research for
program formulation and iterative implementation.
Operational research is directed at assessing the processes and impacts of programmatic
activities. The results of this kind of research are beneficial because they identify ways by
which the efficiency and effectiveness of programs can be improved.
R1105.1 - Training in operational research will be delivered through workshops and
hands-on training experiences.
R1105.2 - With RSACS and implementers, an agenda for operational research will be
developed that focuses on important intervention activities in the state. Subsequently,
operational research projects will be jointly developed and the results integrated into
program formulation and implementation.
Activity R1106 - Train and assist RSACS and implementers in monitoring and evaluating
program outcomes and impacts.
Program monitoring and evaluation is necessary to ensure that programmatic activities are
using efficient processes and achieving desired results.
R1106.1 - Direct training will be provided for RSACS and implementers in the conduct
of program monitoring and evaluation through workshops and hands-on training.
R1106.2 - With RSACS and its implementing partners, systems for monitoring and
evaluating key state level programs will be developed.
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Activity R1107 - Train RSACS and implementers in population-based strategic planning of
HIVprograms.
To maximize the impact and cost-effectiveness of HIV/AIDS program activities, planning
should be strategic, evidence-based and appropriate to the local population situation. The
following activities will be undertaken to enhance capacity in this area.
R1107.1 - Provide direct training for RS ACS and implemented in strategic planning.
R1107.2 - Convene strategic planning workshops that involve RSACS, implementers,
community participants and other key stakeholders.
Output R1200 - Enhanced RSACS* and implementers’ capacity to mobilize, monitor and
evaluate evidence-based HIV/AIDS programming.
Activity R1201 - Train RSACS and implementers in best practices in delivery of targeted
HIV/AIDS programming.
There are many examples of excellent programs that are delivering targeted HIV/AIDS
interventions in India and elsewhere that could be described as representing best practice in
the field. The capacity of RSACS and implementers to deliver targeted interventions will be
strengthened by increasing their knowledge of these high quality programs.
R1201.1 - Review and summarize examples of best practices in India and elsewhere and
translate this information to RSACS and implementers through structured meetings and
workshops. This process will include reviewing and disseminating best practice
documentation from national Technical Resource Groups.
R1201.2 - Arrange for interaction between RSACS and implementing partners and best
practice programs by convening joint meetings and supporting study tours.
Activity R1202 — Train and assist implementers for innovative participatory peer group
interventions with vulnerable populations.
R1202.1 - Provide technical training to RSACS, NGOs and other implementers in
executing peer education programs. This would include training on the rationale for
targeted interventions, the methodology for selecting target sites and zones and for
recruiting peer educators, and the importance of focus and intensity. It would also
include how to conduct baseline surveys and formative assessments, how to develop and
use participatory methods and materials, how to train peer educators to train their peers
and how to monitor program outputs for the duration of the program. Such training
expertise can be sourced within India or internationally.
R1202.2 - Provide technical assistance to NGOs implementing peer group interventions.
Follow-up technical support would be provided to the NGOs who receive the initial
training. Such technical support would include the provision of support in carrying out
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comprehensive mapping and zoning exercises, designing formative and baseline
assessment tools, recruiting and training peer educators, and in developing a range of
participatory educational materials. Support would also be provided to NGOs in
developing and designing monitoring and evaluation indicators and related data
collection tools.
R1202.3 - Initially, the project, in partnership with RSACS, implementers and target
groups, will jointly develop processes and indicators of empowerment for vulnerable
target populations. In the interests of sustainability and community ownership, work with
vulnerable populations will try to emulate the lessons learned by the Sonagachi project.
Sonagachi is now largely run by the sex workers themselves and has extended the range
of issues addressed to include such social issues as legal reform, literacy and affirming
sexuality. An exchange visit involving RSACS, implementers and sex workers will help
inform this process.
Activity R1203 - Assist RSACS and implementers in the dissemination and scaling up of
effective HIV/AIDS programs.
As effective programs are developed by implementers in specific populations, an important
challenge is to disseminate the knowledge and scale up capacity across the state.
R1203.1 - Working with RSACS and implementing partners, effective programs will be
reviewed and documented. This information will then be shared with implementers in
other parts of the state through written documentation, and presentations at meetings and
conferences.
R1203.2 - Workshops or symposiums will be convened to promote interaction and the
sharing of experiences between implementers that are already engaged in effective
programming and those that are at an earlier stage of implementation.
Activity R1204 - Train and assist RSACS and implementers in the development of
appropriate voluntary counseling and testing services.
R1204.1 - Conduct initial VCT training for RSACS and implementers.
R1204.2 - In partnership with RSACS and implementers, conduct a review of VCT
services in the public and private sectors in Rajasthan State. Identify strengths and
weaknesses and develop an agreement within RSACS and health institutions regarding
the steps required to improve existing VCT services.
R1204.3 - Following the review of VCT services, develop an agreement with RSACS
and partners regarding the expansion of cost-effective, quality VCT services in
Rajasthan.
R1204.4 - Provide pre and post-test HIV counseling training for RSACS and relevant
staff in key health institutions providing VCT. Such training would include a review of
the legal framework in India for HIV testing, the key components of pre and post-test
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counseling, the vital importance of informed consent and confidentiality (individual or
shared) regarding test results, and follow-up counseling support and referral for HIV
positive clients.
R1204.5 - Provide feedback to the HIV/AIDS forum (cf. R1301.1) regarding findings,
conclusions and recommendations on VCT in Rajasthan State.
Activity R1205 — Train and assist RSACS and implementers to establish effective STI
management at the “grassroots” level
R1205.1 - Conduct initial STI syndromic management training for RSACS and relevant
partners.
R1205.2 - In collaboration with RSACS and its key partner health institutions, conduct a
review of STI management in Rajasthan. Assess the extent to which STI treatment is
laboratory dependent or syndromic, stigmatized or freely used by men and women.
Provide feedback to the RSACS Management Committee on key findings. Develop an
agreement within RSACS and the health sector regarding the institutions to which STI
management should be initially devolved (for example, primary health care centers,
district hospitals, family planning services, and/or gynecologists).
R1205.3 - Provide information for RSACS and partners regarding the required technical
supports for STI management such as simple algorithm flow-charts, drug lists for
syndromic management of STI and a drug record card, partner referral cards, penile
models and condoms, an examination couch and a separate room for carrying out the
physical exam and counseling. Provide technical support to RSACS and the health sector
in developing the foregoing supports, and well as relevant back-up laboratory services.
R1205.4 - Train the trainers from targeted health institutions to provide the following
training: syndromic management, supervision of syndromic management and counseling
skills.
R1205.5 - Assist health facilities to set up an STI treatment reporting system within the
health sector with information transfer to RSACS.
R1205.6 - Assist RSACS in carrying out training of health providers. Provide ongoing
technical support in the implementation of all the foregoing.
Activity R1206 — Train and assist RSACS and implementers to integrate prevention, care
and support along a continuum.
A key challenge in HIV/AIDS programming is the integration of a wide range of activities
from prevention to care and support. This type of integration is beneficial since the various
activities are mutually supportive and the complementary strengths of various implementers
can be promoted. Training of RS ACS and implementers in this activity will rely on lessons
learned through the continuum of care demonstration project.
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R1206.1 - Integrated activities in the continuum of care demonstration project will be
documented and communicated to RSACS and implementing partners.
R1206.2 - Visits to the demonstration project to review the integrated model will be
arranged for RSACS and implementers.
Output R1300 - Enhanced RSACS and implementers’ capacity to create an enabling
environment for HIV/AIDS programming.
Activity R1301 -Assist RSACS and implementers to increase the awareness, sensitivity and
capacity ofpublic and private sector policy makers and community leaders on HIV/AIDS
issues.
R1301.1 - Set up a state level HIV/AIDS forum for policy makers. This forum would be
made up of senior government, public and private health sector, research and NGO
personnel. The purpose of this forum would be to review and discuss HIV policy and
program issues with a focus on inter-sectoral linkages, and to educate policy makers
regarding HIV/AIDS issues. The forum would be convened a minimum of twice yearly
by RSACS and would set priorities for its work, review up-to-date research and
information within priority programming areas and advise on problem areas as they arise.
The forum would be convened by RSACS. Preparing materials for the forum’s
consideration and input would be the joint responsibility of RSACS and the project. To
the fullest extent possible the forum will be made up of both men and women and have
representation from women’s organizations. Policy makers from the demonstration
project areas would also participate in the forum.
R1301.2 - An information newsletter/bulletin will be produced by the project at least
twice a year. This newsletter/bulletin will cover areas of relevance to HIV/AIDS policy
and program frameworks for HIV/AIDS prevention and care. Gender issues will be
integrated. This newsletter could be produced jointly with the Karnataka office.
R1301.3 - Sensitize community leaders to HIV/AIDS issues. In order to work at the
community level, it is vital to have the support of local community leaders. Ignored or
poorly educated community leaders can sabotage an initiative’s best efforts if their
understanding and support has not been solicited in advance. The project will provide
technical assistance to RSACS and NGOs in understanding the importance of sensitizing
community leaders, in how to identify relevant community leaders for sensitization, and
in the provision of educational materials/talks to such leaders. One appropriate
mechanism for providing technical support to the NGOs is through the RSACS’ NGO
network.
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Activity R1302 - Assist RSACS and implementers to involve PLWHAs and vulnerable
groups in all aspects ofprogram design, implementation and evaluation ofprevention, care
and support programming.
The involvement of PLWHAs and vulnerable groups in the design and implementation of
HIV/AIDS programming helps to ensure that programming is appropriate, effective and
sensitive to the needs of those most affected by the programs.
R1302.1 - The Project will include PLWHAs and affected vulnerable groups in all
aspects of the design and implementation of its program activities, thus providing a
model for other implementing agencies.
R1302.2 - Meetings and workshops will be convened to engage PLWHAs and
vulnerable populations in focused discussions regarding programmatic needs and policy
issues related to HIV/AIDS.
Activity R1303 -Assist RSACS and implementers to incorporate HIV/AIDS issues into
development, social and gender issues.
R1303.1 - This component is designed to work with organizations not directly involved
with RSACS or the project. Therefore, the first task will be to map the range and type of
organizations that exist. The second task will be to understand how people are currently
being educated about HIV/AIDS transmission and how their current HIV-related care and
support needs are being met. The third task will be to identify organizations with
potential and interest in collaborating with RSACS and the project. Ranges of social
change, development and gender initiatives exist in both rural and urban Rajasthan. The
project will encourage RSACS’ implementers to work with a selected number of these
initiatives. This is in order to promote HIV/AIDS education and prevention within these
organizations and to link to service organizations providing a continuum of care for those
who are sick, dying or orphaned. This can be accomplished in a number of ways.
R1303.2 - One strategy for integrating HIV/AIDS issues into social change, development
and gender initiatives is through strengthening the existing RSACS NGO network and
bringing members together with a view to sharing information with each other. This
information could include identifying which organizations have potential for networking.
The RSACS NGO network could then develop strategies for expanding their HIV
prevention efforts through such organizations and at the same time carry out advocacy
and HIV information provision among service providers relevant for HIV-related
prevention, care and advocacy.
R1303.3 - Another strategy for integrating HIV/AIDS issues into social change,
development and gender initiatives is to encourage RSACS’ NGO implementers to
participate in other NGO coalitions and advocacy groups addressing development, social
change and gender issues, e.g. FEVORD (rural development NGO network). The idea
would be to provide a voice for HIV/AIDS issues and to advocate for the inclusion of
HIV issues in information and advocacy agendas, for example, human rights
organizations and reproductive health organizations. In addition, HIV/AIDS
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implementers’ participation in other coalitions could provide an advocacy forum to
encourage service providers not to turn away PLWHAs.
R1303.4 - Another strategy would be to encourage NGOs implementing HIV prevention
and care programs to liaise directly with certain groups on a one-to-one basis.
R1303.5 - To support the above activities the project would help the NGO network to
develop relevant information and advocacy materials. These could include simple onepage fact sheets on a range of HIV-related issues in order to support their advocacy and
information sharing agenda. Such fact sheets could include for example, the urgency of
preventing HIV in India, how a person can and cannot become infected with HIV, HIV as
a reproductive health issue, the care and support needs of PLWHAs, myths concerning
HIV, etc. It is anticipated that this component will start up sometime after the second
year of the project.
Activity R1304 - Train and assist RSACS and implementers to develop effective policy and
practice for occupational safety of health professionals.
R1304.1 - The convening of an expert committee drawn from the Indian health sector
(public and private) can best effect the development of an occupational safety policy on
HIV for health professionals. In addition, project staff and RS ACS representatives would
also participate on this committee. Such a committee should include both doctors and
nurses. This committee could make its initial recommendations to the policy forum and
the RSACS Management Committee.
R1304.2 - Any policy developed should be context-specific and realistic, and address the
real and perceived risks of health workers. Such a policy should keep in mind the cost of
universal precautions versus discrete use of such precautions - gloves, for example - and
the likely stigmatization of PLWHAs arising from such use. Such a policy should also
address the very real risk of tuberculosis infection and the precautions necessary for its
prevention among health workers. Given that blood and body fluid exposure during the
delivery of newborns is one area of grave concern to heath workers, specific attention
should be given to this issue.
R1304.3 - In order to promote the occupational safety of health professionals, they first
need to thoroughly understand how they are and are not at risk. Then they need to be
guided by their health facility’s policy on occupational safety and HIV, and be supervised
in ensuring that adequate, but non-discriminatory precautions are taken. Some training
on occupational safety and HIV for health workers and their supervisors will be required.
Therefore, the project will assist RS ACS in the development of training materials on
occupational safety and HIV.
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Activity R1305 — Assist RSACS and implementers to effectively link prevention to care and
support activities.
R1305.1 - Emerging best practices from around the world indicate that at the level of
vulnerable communities at least, sustainable success is associated with integrated
programming. Two examples are the link between HIV testing and PLWHA support
groups, and care and support for peer educators who have worked to promote safer sex
practices who become sick and/or leave orphaned children behind when they die.
Building an environment where people feel safe to be tested for HIV requires more than
clean needles and test kits. It requires some change in legal frameworks, employment
laws, counseling support and the support of others living with HIV. Building sustainable
community responses to HIV prevention and care requires a strong link between the two
from the outset. The more cared for a person with HIV feels, the better chance she or he
will care about infecting others.
R1305.2 - The project will encourage RSACS to make strong policy and program links
between prevention and care. This will be done initially by providing input to the policy
forum and the RSACS Management Committee. This input will be based on two
elements, a literature review of experiences from other countries and from within India,
and working with RSACS’ implementing partners to document their experiences to date
in the link between prevention and care. Finally, the demonstration project experience
will actively link prevention and care programming, and these experiences and lessons
learned will be available to RSACS by the fourth and fifth years of the Project.
Activity R1306 — Develop effective and appropriate training materials and methods.
R1306.1 - The Project Office will constitute a technical resource to RSACS and
implementing partners. The project will hire a training materials development expert,
and where necessary help produce a range of training manuals and materials for program
implementers. One of the first tasks for the project will be to identify the training to be
carried out within each program area and the support materials needed for this training.
Possible training courses/materials include, Syndromic Management of STI, STI/HIV
Counseling Skills for Health Workers, STI/HIV Supervision Skills for Health Workers,
Home-based Care for People with HIV/AIDS, Mobilizing and Training Vulnerable
Groups, and HIV and Gender. Training materials could also include materials and
methods developed for peer educators with low literacy skills working in low literacy
environments. Many of the above training manuals have already been developed in India
or elsewhere. Such manuals may be adapted in a culturally and linguistically appropriate
way. Negative gender stereotypes will not be reinforced in any of these training
materials. Technical assistance can be provided from within and without India.
Component R2000 - Implementation of Demonstration Pro jects
In this component, the project will implement three demonstration projects in Rajasthan
addressing three specific programming needs. These projects will have a focus on social
phenomena important in HIV prevention and care rather than a geographic focus. The projects
will be rigorously monitored and evaluated so that they can serve as models that can be
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replicated in other districts across the state and in other states. Sites for implementation will be
selected based on discussions with the RSACS and criteria including HIV prevalence,
vulnerability to HIV, geographical location, strengths of potential NGO partners, availability of
basic infrastructure, and motivation and interest of the community.
The first demonstration project will focus on rural migrant men and the second on caste-based
female sex worker villages. The rationale for selecting these populations is that both are likely to
be important in the spread of HIV and there are few examples of innovative programs for these
populations in India. These two projects will be geographically and operationally linked. There
are several reasons for using this approach. First, by focusing on prevention at the rural level in
the first project, we will be able to gain and share insights into the processes, costs and impacts
of various activities at the rural level where the majority of the Rajasthan population lives and
where few HIV/AIDS prevention efforts are underway. Second, caste-based sex work is an
important phenomenon in Rajasthan and there have been few successful attempts to engage these
groups in HIV/AIDS prevention. Furthermore, the linkages of sex worker villages to others
provides a natural route for later expansion. Finally, it allows the project to concentrate
resources in a way that maximizes the ability to build capacity through the transfer of skills and
knowledge regarding HIV prevention, care and support.
The third demonstration project will be to develop a model of the prevention-care continuum.
For this pilot project, a site will be selected in conjunction with RSACS and its implementing
partners. The goal will be to create a model that demonstrates the processes and benefits of
linking HIV-related program activities along a continuum from prevention to care. This model
will be evaluated and documented so that lessons learned can then be disseminated to other sites
in Rajasthan and in other states.
These demonstration projects will provide a venue for the provision of high quality, hands on
training for implementers who may then serve as resources for the training and mentoring of
other implementers in prevention, care and support activities. Selection of the populations for
implementation of the demonstration projects will be based upon discussions with RSACS,
NGOs and other implementing partners, and community groups.
Outputs and Activities
Output R2100 - Implementation of a community-based participatory intervention for rural
migrant men.
Activity R2101 - Identify community of rural migrant men for intervention.
R2101.1 - In partnership with RSACS, NGOs and other implementers, and community
groups, identify the community and site for the demonstration project.
R2101.2 - Identify and assess relevant NGOs working in the area. Select NGO
implementers.
-T1 -
Activity R2102 - Train and mobilize NGOs and other implementers.
R2102.1 - Provide training for NGOs and other implementing partners in basic issues
regarding HIV transmission, the epidemiology of HIV, and the rationale for targeted
interventions. NGO training would also include the following: how to map and zone
target areas, how to mobilize vulnerable groups, how to select and train peer leaders, how
to support peer leaders in their ongoing work of promoting partner number reduction,
condom use, STI care and support referral, and finally, how to monitor and evaluate their
work.
Activity R2103 — Conduct baseline assessments of rural migrant population.
R2103.1 - Design survey tools for rural migrant men and their sexual partners, including
sex workers. Ensure that questions regarding attitudes to men and women and sexuality
are included as well as basic questions concerning sexual behaviour and knowledge about
STI/HIV transmission and prevention.
R2103.2 - Pre-testing of survey tools by NGOs/implementers.
R2103.3 - Surveys of the target community by NGOs/implementers.
R2103.4 - Processing and analysis of survey data by project/NGOs/implementers.
Activity R2104 - Train peer educators and supervisors.
R2104.1 - With NGOs and other implementers, agree on selection criteria for peer
educators.
R2104.2 - Mentor NGOs/implementers in selection of peer educators . Each peer
educator to be responsible for 50 peers.
R2104.3 - Assist NGOs/implementers in training of peer educators by providing training
materials and selected training support to NGOs/implementers.
R2104.4 — Agree on what, if any, remuneration or other considerations to be provided to
the peer educators.
R2104.5 - Equip peer educators with participatory education materials, group registers,
and checklists to register attendance, topics discussed, number of condoms distributed,
number of STI referrals and other areas of concern to the group.
R2104.6 - Ensure that NGOs/implementers collect and compile peer educator data on a
monthly basis.
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Activity R2105 - Implement interventions using an iterative approach.
R2105.1 - Mentor NGO Staff and peer educators’ collaboration in health promotion
activities and empowerment activities among target groups.
R2105.2 - Assist NGO staff and peer educators in establishing and maintaining effective
peer group structure, dynamics and organization by ensuring appropriate monitoring and
supervisory tools are in place, and adequate supplies (of condoms and other materials) are
available. Encourage groups to organize around issues of common concern, whether
directly HIV related or not. Peer leaders may be issued with T-shirts and receive a small
monthly stipend.
R2105.3 - Assist NGO staff in supporting peer leaders in their functions by advising on
the development of specific educational approaches (one-minute sketches, role-plays).
R2105.4 - Train NGO Staff to respond to emerging needs and problems of the peers or
their groups and resolve conflicts.
R2105.5 - Plan, conduct and analyze surveys of the impact of the demonstration project
on sexual attitudes and behaviour and other indicators in target groups.
Activity R2106 - Evaluate outcomes and impacts and disseminate innovations, lessons
learned and best practices.
A key objective of the demonstration projects will be to determine the impact of programming
and to disseminate innovations and lessons learned to other implementers across the state.
R2106.1 - Establish a system of evaluation and monitoring activities to assess inputs,
costs, processes and impacts.
R2106.2 - Collect, process and analyze data for monitoring and evaluation.
R2106.3 - Create written documentation of processes and summaries of the outcomes
and impacts in written reports.
R2106.4 - Disseminate innovations and lessons learned through written communications
and workshops for policy makers and implementers.
Activity R2107 - Provide resources and opportunities for hands on training for other
implementers in interventions.
The demonstration project will provide excellent opportunities for training program planners
and implementers from across the state. Once the demonstration project is operational these
opportunities will be promoted.
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R2107.1 - Develop training manuals and materials based on the demonstration project
activities.
R2107.2 - Train leaders in the demonstration project to provide hands-on training for
personnel from various implementing agencies.
R2107.3 - Provide hands-on training programs within the demonstration project.
Output R2200 - Implementation of a community-based participatory intervention for rural
caste-based sex work.
Activity R2201 — Identify community for intervention.
R2201.1 - In partnership with RSACS, NGOs and other implementers, and community
groups, identify the population for the demonstration project.
R2201.2 - Identify and assess relevant NGOs working in the area as potential partners.
Develop partnership with NGO implementers.
Activity R2202 — Train and mobilize NGOs and other implementers.
R2202.1 - Provide training for NGOs and other implementing partners in the basic issues
regarding HIV transmission, the epidemiology of HIV, and the rationale for targeted
interventions. NGO training would also include the following: how to map and zone
target areas, how to mobilize vulnerable groups, how to select and train peer leaders, how
to support peer leaders in their ongoing work of promoting partner reduction, condom
use, STI care and support, referral, and finally, how to monitor their work.
Activity R2203 - Conduct baseline assessments of all aspects of caste-based sex work.
R2203.1 - Conduct an ethnographic and epidemiologic assessment of rural caste-based
sex work. Ensure that the assessment addresses issues regarding the social and cultural
aspects as well as basic questions concerning sexual behaviour and knowledge about
STI/HIV transmission and prevention.
R2203.2 - Pre-testing of survey tools by NGOs/implementers.
R2203.3 - Survey of target community by NGOs/implementers.
R2203.4 — Processing and analysis of data by project/NGOs/implementers.
Activity R2204 - Train peer educators and supervisors.
R2204.1 - With NGOs and other implementers, agree on selection criteria for peer
educators.
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R2204.2 - Mentor NGOs/implementers in selection of peer educators. Each peer
educator to be responsible for 50 peers.
R2204.3 - Assist NGOs/implementers in training of peer educators by providing training
materials and selected training support to NGOs/implementers.
R2204.4 - Agree on what, if any, remuneration or other considerations to be provided to
the peer educators.
R2204.5 - Equip peer educators with participatory education materials, group registers,
and checklists to register attendance, topics discussed, number of condoms distributed,
number of STI referrals and other areas of concern to the group.
R2204.6 - Ensure that NGOs/implementers collect and compile peer educator data on a
monthly basis.
Activity R2205 - Implement interventions using an iterative approach.
R2205.1 - Mentor NGO Staff and peer educators' collaboration in health promotion
activities and empowerment activities among target groups.
R2205.2 - Assist NGO Staff and peer educators in establishing and maintaining effective
peer group structure, dynamics and organization by ensuring appropriate monitoring and
supervisory tools are in place, and adequate supplies (of condoms and other materials) are
available. Encourage groups to organize around issues of common concern whether
directly HIV-related or not. Peer leaders may be issued with T-shirts and receive a small
monthly stipend.
R2205.3 - Assist NGO staff in supporting peer leaders in their functions by advising on
the development of specific educational approaches (one-minute sketches, role-plays).
R2205.4 - Train NGO staff to respond to emerging needs and problems of the peers or
their groups and resolve conflicts.
R2205.5 - Plan, conduct and analyze a survey of the impact of the demonstration project
on sexual attitudes and behaviours and other indicators in target groups in the last year of
the project.
Activity R2206 - Evaluate outcomes and impacts, and disseminate innovations, lessons
learned and best practices.
A key objective of the demonstration projects will be to determine the impact of the
programming and to disseminate innovations and lessons learned to other implementers
across the state.
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R2206.1 - Establish a system of evaluation and monitoring activities to assess inputs
costs, processes and impacts.
R2206.2 - Collect, process and analyze data for monitoring and evaluation.
R2206.3 - Create written documentation of processes and summaries of the outco
and impacts in written reports.
I
R2206.4 - Disseminate innovations and lessons learned through written communica.
and workshops for policy makers and implementers.
Activity R2207 - Provide resources and opportunities for hands-on training for othe.
implementers in interventions.
The demonstration project will provide excellent opportunities for training program pla
and implementers from across the state. Once the demonstration project is operational f
opportunities will be promoted.
*1
R2207.1 - Develop training manuals and materials based on the demonstration pre
activities.
R2207.2 - Train leaders in the demonstration project to provide hands-on training
personnel from various implementing agencies.
R2207.3 - Provide hands-on training programs within the demonstration project.
Output R2300 - Development of a Rajasthan model of the prevention-care continuur
Emerging best practices from around the world indicate that sustainable success in address
the determinants and consequences of the HIV epidemic depends on integrated programmir
linking prevention and care. Examples include creating strong ties between voluntary
counselling and testing (VCT) and PLWHA support groups, and engaging PLWHAs in
community-based prevention activities. Building an enabling environment where people f
safe to come forward to be tested for HIV requires changes in legal frameworks, including
employment laws, to counter discrimination and the creation of supportive networks facilitaf
counselling and peer support by others living with HIV. Building sustainable community
responses to HIV prevention and care requires a strong link between the two from the outset
People can then realize that finding out one’s HIV status is the first step to living positively,
allowing healthy choices to be made to the extent possible concerning nutrition, prophylaxis
opportunistic illnesses, stress reduction, and permitting informed reproductive health decis
making and ongoing participation in community activities without discrimination or
marginalization. Others then will be encouraged to come forward for voluntary counseling
testing. Learning one’s HIV status is the first step towards adopting prevention practices to
avoid infecting others.
4
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The project will encourage RSACS to make strong policy and program links between prev
and care at all levels and in various aspects of the program. A demonstration project initially
operating in one site will link VCT with facilitation of the establishment of both support groi
for people living with HIV/AIDS and home-based care. This project aims to develop an
affordable integrated model of care and support that will strengthen community and family
coping mechanisms and ultimately encourage more people to come forward for VCT and le; >
positive living skills if they test positive. Elements of the program will include family
counseling and identification of key family members for training in home-based care, nutr'
advice and supplementation, and care and support for HIV-related disease and other health
psycho-social problems. The care continuum, which will include outpatient care, day care, ar
care, and home care, is not linear in nature because of the alternating illness/remission cyci
HIV-related disease. Rather, it is holistic in encompassing the physical, emptional, spiritual
social needs of the patient and in aiming to provide comprehensive care, support and comfc.
all stages of HIV-related disease.
Activity R2301 - Conduct a needs assessment and determine the model site.
R2301.1 - Conduct a needs assessment of the continuum of care in Jaipur, Jodhpur
Udaipur to determine where the first pilot project should be situated. Selection critei'
will include: prevalence of HIV disease, availability and accessibility of current VC
services, physician interest in working in the continuum of care model, attitudes of he:
care providers to the concept of a shared care model, potential for establishment or
strengthening of support groups for PLWHAs, availability of mentors to teach coun
skills to volunteers, and the potential for creating a non-stigmatizing, caring and
confidential environment.
R2301.2 - Document the current situation in the selected sites by collecting data thr<
key informant interviews and focus groups and by using available data sources for
information on local epidemiology, hospital bed occupancy rates, profiles of clinical
disease patterns and current care practices.
Activity R2302 - Identify and review best practice models that could be adapted.
R2302.1 - Conduct a comprehensive literature review including guidelines for
comprehensive care developed by organizations such as NACO, WHO and Horizons.
R2302.2 - Conduct site visits to care models in other parts of India.
R2302.3 - Conduct preliminary costing studies to determine which elements to incluci
and assess the potential for cost recovery for various elements of the program.
Activity R2303 — Design and implement the model project using a participatory appro'
R2303.1 - Develop a project planning group and process that involves PLWHAs,
families affected by HIV, community volunteers, physicians, nurses, social workers,
counselors and other key players.
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R2303.2 - Develop training materials and hold training workshops to strengthen the
skills among professional staff and community members who will become the training
resource for family members and community volunteers.
R2303.3 - Implement the model under the supervision and support of an advisory
committee composed of key stakeholders, including people living with HIV/AIDS.
Activity R2304 - Develop mechanisms for the ongoing evaluation of the modeL
R2304.1 - Develop strategies and tools to evaluate patient and family member
satisfaction with the services received, changes in patients’ perceived quality of life,
hospital bed utilization, costs to the client, the family and the project, community
attitudes toward the project, uptake of VCT services, and other indicators to be
determined during the design phase with stakeholders.
R2304.2 - Periodically summarize and report on the project evaluation to the advisory
committee, participants in the program and the community through workshops and
community meetings.
Activity R2305 - Document and disseminate lessons learned and project impacts.
R2305.1 - Lessons learned in the implementation of the project will be documented and
disseminated through RSACS and its implementing partners after validation of findings
at the community level.
R2305.2 - An assessment of the potential for replication and associated costs will be
determined, with a view to scaling up this approach to other sites.
Activity R2306 - Provide resources and opportunities for hands-on training for other
implementers.
The demonstration project will be used to provide training opportunities for program planners
and implementers from across the state. Once the demonstration project is operational these
opportunities will be promoted.
R2306.1 - Develop training manuals and materials based on the demonstration project
activities.
R2306.2 — Train leaders in the demonstration project to provide hands-on training for
personnel from various implementing agencies.
R2306.3 - Provide hands-on training programs within the demonstration project.
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.
9.
NATIONAL COMPONENT
9.1
Situation and Needs Assessment
At the national level there are two national level organizations or bodies with which are of
central importance to HIV/AIDS control in India. These are the National AIDS Control
" Organization (NACO) and the Technical Resource Groups (TRGs).
9.1.1
National AIDS Control Organization
NACO, situated within the Ministry of Health and Family Welfare, is the main agency
responsible for providing leadership to HIV prevention and control efforts in India, as well as
efforts to mitigate the impact of AIDS. On December 15, 1999, the Government of India
• launched NACP-II, funded in large part through a credit from the World Bank, International
Development Agency. This five-year program represents India’s main effort to combat the
HIV/AIDS epidemic. Th program is being supported by the Government of India, the
Department for International Development (UK), USAID, AUS AID and most recently the
Canadian International Development Agency. The strategic focus of NACP-II is to implement
interventions to prevent the spread of HIV that have been shown to be both effective and costeffective. As a result of some of the implementation problems encountered during NACP-I, and
the size and diversity of India, responsibility for program planning and implementation has been
devolved to the state level, where implementation of interventions will occur primarily through
NGOs and CBOs. The responsibilities of NACO under NACP-II are to set strategic directions
for state level AIDS programming, provide financing, offer technical support to state AIDS
programs, document the impact of interventions, identify best practices and conduct annual
sentinel HIV surveillance. It is also responsible for acquiring commodities important in
HIV/AIDS prevention and control, such as condoms, and drugs for the treatment of opportunistic
infections and STI. In addition to being supported by the Government of India and bilateral
donor agencies, NACO has commitments of substantial technical and financial support from
UNAIDS, other UN agencies such as the World Health Organization and several bilateral donor
' agencies. NACO has considerable political support and has highly capable and effective
leadership and senior personnel. However, the capacity of NACO is quite thinly stretched when
it is considered that it has to serve India’s nearly one billion population.
Through its work in the planning of NACP-II and through the design mission for the current
project, the CEA has developed a relationship of mutual respect and trust with NACO. In the
implementation of the current project, the CEA will maintain and solidify that relationship. This
will be achieved by assisting in the development of excellent state AIDS control programs in
Karnataka and Rajasthan, the development and documentation of new best practices in its
demonstration projects and through capacity building at NACO.
9.1.2
Technical Resource Groups
As indicated previously, NACP-II is designed to implement highly effective, evidence-based
interventions to rapidly reduce HIV transmission. The strategies for interrupting transmission
are of necessity community-based or community-oriented and must involve the targeted
population at all stages. These approaches cannot be implemented nationally or even at the state
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level.
These
organizations may be within local government or may be NuUs or other community-based
organizations (CBOs). To effect this strategy, and to overcome some of the problems with
implementation of NACP-I, NACO has adopted a decentralized plan for implementation, with
funds flowing to para-governmental State or Municipal Corporation AIDS Societies, which in
turn contract local agencies for implementation. This decentralization means that different levels
of the system (states, municipal corporations, districts, NGOs and CBOs) will need the technical
capacity to effectively mount interventions. It is widely recognized that there is a wealth of
technical expertise and practical experience in India outside of government (in NGOs, academic
departments, in the private sector and elsewhere), which can be brought to bear on the problem
of HIV/AIDS control. However, this expertise is scattered, inadequate for the size of the need
and in some areas incomplete. To mobilize and strengthen this expertise, NACO and its partners
have devised a network of Technical Resource Groups (TRGs) based in key Indian institutions.
The plan is that the TRGs will become technical resources for the state, municipal, district and
NGO/CBO program implementers, for NACO and for each other.
Twelve TRGs have been constituted and 11 have been convened, their TORs developed, and the
chair of each TRG appointed. The individual members of TRGs were chosen by NACO in
March/April 1998, and in April 1998, each TRG was provided with start-up resources. From
December 1998 each TRG has had a chair, a secretariat (the institution to which the chair
belongs), finance, terms of reference, members, and they are now completing their initial best
practice documents. In addition, UNAIDS has committed significant financial resources for
TRG operations for a two-year period (approximately US $2 million total) and is separately
providing the hardware and software for electronic linking of TRGs. Although NACO had
envisioned a “trust” fund process whereby multilateral and bilateral donors could contribute to
the entire TRG network, this has proved unworkable. Currently, if bilateral funding of TRGs is
required, it would flow directly to particular TRGs through NACO. The terms of reference for
TRGs are as follows:
•
Review the relevant portion of the strategic plan in the current phase of the GOI program
and prepare a technical paper describing the state-of-the-art in the identified area under
THE HIV/AIDS Prevention and Control Program;
•
Identify best practices through systematic evaluation of the present program. The
assessment should identify past successes and articulate the elements and context of these
successes.
•
Determine realistic and achievable program goals in their particular technical area over a
period of time. Identify the outcomes and end points for each goal, and both the technical
and human resources which may be required to achieve these goals.
•
Determine the specific steps that a state would need to take to achieve each set of goals
under the identified areas;
•
Develop a strategy for interaction with states and union territories in the identified area as
a technical resource.
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•
Develop mechanisms for transfer of technical knowledge to all states and union territories
in the relevant field.
•
Convene members of the TRG as frequently as required.
While the TRGs have been established, the TRG concept is one in evolution and development,
and considerable effort is needed to operationalize the TRGs as technical resources for states,
implementers and NACO. Not all TRGs will ultimately have the same functions, and some will
have functions that are central to the success of state level implementation, while others will
have a more removed policy level role.
There is some concern at the state level as to how the TRGs were constituted. State AIDS
society officers feel that they have expertise as well and that there is other expertise in their
states that is not being utilized in the TRGs. Thus, the TRGs are to successfully go forward,
there must be greater participation by the states in the TRG process and there must be a flow of
information on best practices at the state level to the TRGs for analysis and dissemination.
Cross-representation of TRGs is also needed, so that those involved in particular technical areas
are cognizant of needs in other areas. From a functional perspective, it might also be useful to
have terms on TRG membership or conditions for maintaining membership, so that inactive or
ineffective TRG members can be removed gracefully.
From the project’s perspective, TRGs would ideally have the following functions:
•
Critical analysis and evaluation of key interventions.
•
Ongoing documentation and dissemination of best practices in India and globally.
•
Serving as a resource center for the states and NACO.
•
Acting as the centre of a network of centres of special expertise in specific technical areas
(linking with states and NGOs with special expertise).
•
Advising NACO on policy areas of their competence and providing technical assistance
to NACO.
•
Advising other TRGs in areas of their competence.
•
Providing technical assistance to state program implementers.
•
Serving as a mechanism for international organizations (donors and potential donors) to
better understand HIV/AIDS programming and to link up with groups in India with
similar interests.
As noted above, UNAIDS has taken the lead with many areas of assistance to the TRGs. The
project will participate in TRGs through state participation in TRGs and will also remain '
responsive to potential needs within the TRGs that it can help to meet. In working with NACO,
the leadership of selected TRGs and UNAIDS, we will revisit TRG structure, operation and
function to determine how the project can contribute to their development and have maximal
impact.
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9.2
National Component Project Description
9.2.1
Overview
When CIDA initially committed to make a contribution to the Government of India’s NACP-II, a
substantial involvement at the national level, particularly with the nascent Technical Resource
Groups, was envisioned. There was also interest in providing support to NACO’s surveillance,
and monitoring and evaluation activities. Many of these needs are now being met adequately
with support from UNAIDS and other UN agencies such as the World Health Organization.
Thus, during the design mission, it was agreed that the project should focus on implementing
excellent and innovative HIV/AIDS programming that would inform the national level through
the development of innovations and best practices at state and local level, rigorously
demonstrating their effectiveness and cost-effectiveness. Similarly, it was felt that the best way
that the project could contribute to the development and strengthening of the TRGs was from
within, as active members working at the state level.
At the same time, the project has access to a body of world-class expertise in HIV/AIDS
programming that can be of benefit to NACO and the TRGs. Thus the project will focus some of
its energy and resources to strengthen the capacity of NACO and the TRGs to access and utilize
results from effective international and Indian interventions.
This area of activity will consist of one component: capacity building for NACO and selected
TRGs.
The expected outputs are the incorporation of international experience and expertise into national
HIV/AIDS policy and programming by TRGs and NACO, and the incorporation of innovations
from state and local level demonstration projects into national HIV/AIDS programming.
9.2.2 Work Breakdown Structure
There are two main outputs for this single WBS component, each with associated activity
streams. These are summarized in the figure below. The detailed activities under each of the
streams are describe in the following sections.
Component N1000 - Capacity Building for NACO and selected TRGs
• Output Nil 00 - Incorporation of international experience and expertise into national
HIV/AIDS policy and programming by TRGs and NACO.
•
Output N1200 - Incorporation of innovations from state and local level demonstration
projects into national HIV/AIDS programming by TRGs and NACO.
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Component N1000
Capacity Building for NACO and Selected TRGs
N11OO Incorporation of
international experience
and expertise into national
HIV/AIDS policy and
programming by TRGs and
NACO
N1200 Incorporation of
innovations from state and
local level demonstration
projects into national
HIV/AIDS programming by
TRGs and NACO
N1101 Documentation of
best practices from India
and elsewhere
N1201 Quantify impacts
and costs of HIV/AIDS
interventions in Rajasthan
and Karnataka
N1102 Increase the
utilization of international
best practices in India by
NACO and TRGs
N1103 Conduct directed
research to inform decision
making in selected areas
with NACO and TRGs
N1202 Disseminate
innovations and best
practices to other state and
local programs
N1203 Disseminate
innovations and best
practices nationally and
internationally
N11O4 Increase the use of
evidence-based advocacy
and policy formulation by
NACO and TRGs
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9.2.3
Description of Outputs and Activities
Component N1000 - Capacity Building for NACO and selected TRGs
The following strategies will be used as required to enhance capacity at NACO and the TRGs.
Technical Assistance/Mentoring: A network of Canadian and international technical
specialists will provide direct technical advice, consultation and mentoring for members of
NACO and the TRGs as required. Local Indian technical expertise will also be engaged to offer
the same types of support. The areas where the project is highly competent to assist NACO and
the TRGs include sentinel surveillance and other aspects of surveillance, evaluation of
interventions, implementing syndromic STD management approaches, implementing targeted
HIV prevention interventions among high risk groups, HIV voluntary counseling and testing,
cost-effectiveness analysis and modeling of intervention options.
Study Tours and International Linkages: There are many examples of high quality
HIV/AIDS prevention, care and support programs both in India and elsewhere. Mechanisms for
linking NACO and the TRGs to these programs, such as organization and support for study
tours, will be developed to promote the use of national and international best practices.
Selected Research: The results of research are perhaps the most powerful tool of advocacy
policy. The project can draw on world-class expertise in several research areas that may be
needed by NACO. These include policy analysis, operational research on interventions,
evaluation of syndromic management efficacy, impact evaluation of interventions, cost
effectiveness analysis and mathematical modeling of the HIV epidemic, including the impact of
various interventions on the epidemic. The project will thus reserve a small portion of its
resources for selected research initiatives to be undertaken in partnership with NACO or selected
TRGs in a responsive manner.
Outputs and Activities
Output N1100 - Incorporation of international experience and expertise into national
HIV/AIDS policy and programming by TRGs and NACO.
Activity N1101 - Documentation of best practices from India and elsewhere.
The first step will be to document current best practices from India and elsewhere. This will
be effected through literature, key informant interviews and field trips within India.
Activity Nil 02 - Increase the utilization of international best practices in India by NACO
and TRGs.
There are a wide range of best practices in HIV/AIDS programming from around the world
of which India could be better informed. This activity will assist in bringing the knowledge
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gained from these best practices into programming at national level in India. Sub-activities
to achieve this will include:
Nil 02.1 - Evaluate the impact of selected interventions from India and identify best
practices, with NACO and the TRGs..
Nil02.2 - Document, compile and analyze best practice interventions from India and
other countries.
N1102.3 - Disseminate best practices through workshops, conferences and publications.
Activity N1103 - Conduct directed research to inform decision making in selected areas
with NACO and TRGs.
The project’s experience in India and elsewhere to date has shown the power of research to
inform and direct policy. In this activity, research on specific topics will be undertake to
fulfill specific policy research needs at NACO and the TRGs. The sub-activities will
include:
N1103.1 - Identify selected areas for research with NACO and the TRGs.
Nil03.2 - Design, conduct and analyze specific research undertakings, with NACO and
the TRGs.
N 1103.3 - Analyze and report on impact and policy implications to NACO and TRGs.
N1103.4 - Disseminate findings widely in India and internationally through publications,
workshops and conferences.
Activity N1104 - Increase the use of evidence-based advocacy and policy formulation by
NACO and TRGs.
The use of evidence from research or program evaluation in advocacy or to influence policy
formulation is an important acquired skill. The project will work with NACO and the TRGs
to develop the necessary skills through the following sub-activities:
N1104.1 - Select specific advocacy areas, within project competency, with NACO and
the TRGs.
N1104.2 - Develop specific advocacy and dissemination strategies, materials and .
timetables for different audiences (multilateral agencies, bilateral agencies, Government
of India) using workshops, presentations and field visits.
Nil04.3 - Execute advocacy strategies.
N11044 - Assess impact on policy and planning.
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Output N1200 - Incorporation of innovations from state and local level demonstration
projects into national HIV/AIDS programming by TRGs and NACO.
Activity N1201 - Quantify impacts and costs of HIV/AIDS interventions in Rajasthan and
Karnataka.
A major factor that should be an element of decision-making in HIV/AIDS programming in
in
developing countries is the amount of “effect” a particular intervention is capable of
producing for the cost input. This needs to be compared both in terms of effect and cost for
effect to other potential interventions. The project will work with NACO and the TRGs to
determine the effect of specific interventions and the cost they incur to produce the effect in
the following sub-activities:
N1201.1 - Evaluate interventions from project demonstration projects or other
implementers to identify innovations and best practices at state level, with RSACS and
KSAPS.
N1201.2 - Document, compile and analyze innovations and best practices with RS ACS
and KSAPS.
N1201.3 - Estimate numbers of HIV infections prevented and the cost of various
interventions, and compare cost-effectiveness.
Activity N1202 - Disseminate innovations and best practices to other states and local
programs.
N1202.1 - Develop dissemination strategies and materials for different audiences
(multilateral agencies, bilateral agencies, Government of India) using publications,
workshops, presentations and field visits.
N1202.2 - Execute dissemination plan.
N1202.3 - Assess impact on policy, planning and funding of interventions at state and
national levels, and with programming by multilateral and bilateral agencies.
Activity N1203 - Disseminate innovations and best practices nationally and
internationally.
In addition to dissemination within India, it is important to disseminate innovations and best
practices to a wider national and international audience. This will be effected through
publications, workshops and presentations at national and international conferences.
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10.
MANAGEMENT COMPONENT
Effective project management will ensure that the activities described in the preceding sections
of this document will take place in a timely fashion, using an effective and efficient mix of
resources, and that the project will be managed to the best of the ability of all project partners in
order to achieve the stated project results. According to CIDA’s Results-Based Management
principles4, the responsibility for achieving these results are shared between the key project
stakeholders, i.e. executing agencies, developing country partners and CID A. Therefore, the
responsibility of overall project management is also shared between these key stakeholders. In
the case of this project, key stakeholders are:
•
The Government of Canada (GOC), represented by the Canadian International
Development Agency (CIDA) and the Canadian High Commission (CHC) in India.
•
The Government of India (GOI), represented by the Department of Economic Affairs
(DEA) of the Ministry of Finance (MOF) and the Ministry of Health and Family Welfare.
•
The National AIDS Control Organization (NACO) of the Ministry of Health and Family
Welfare.
•
The Karnataka State AIDS Prevention Society (KSAPS) and its implementing partners.
•
The Rajasthan State AIDS Control Society (RSACS); and its implementing partners.
•
The Canadian Executing Agency (CEA), represented by its management team in Canada
and in India.
10.1 Work Breakdown Structure
The Work Breakdown Structure (WBS), listing all management activities that have to be carried
out by each of the above stakeholders to ensure successful implementation of the project, is
presented below and the key activities are described in the following section.
4 Planning and Reporting for Results (page 7), Strategic Planning and Policy Division, CIDA Asia Branch, March
1999
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WORK BREAKDOWN STRUCTURE FOR PROJECT MANAGEMENT
PM1000
CIDA
PM2000
CMC
PM1001
Review and approve
PIP
PM1002
Obtain GOC approval
of project__________
PM1003
Amend CEA contract
for Project delivery
PM1004
Provide initial advance
and disburse funds
PM2001
Sign MOU with GOI
and NACO
PM3000
GOI
PM4000
NACO
PM5000
KSAPS
PM6000
RSACS
PM7000
CEA in Canada
PM3001
Approve project
PM4001
Review and Approve
PIP
PM5001
Review and approve
PIP
PM6001
Review and approve
PIP
PM7001
Submit PIP to CIDA &
finalize after feedback
PM3002
Sign MOU with CHC
PM4002
Sign agreements with
CEA, KSAPS and
PM5002
Sign agreements with
NACO and CEA
PM6002
Sign agreements with
NACO and CEA
PM4003
Disburse funds to
KSAPS and RSACS
on schedule
PM5003
Facilitate
establishment of field
office and relocation of
resident coordinator
PM6003
Facilitate
establishment of field
office and relocation of
resident coordinator
PM5004
PM6004
P,K'.«llV‘’ I'lixl-j. Ihiiii
11' I
I ’ li III'I
PM7002
Sign agreements with
CIDA. NACO. KSAPS
uiid RSACS________
PM 7003
Mobilize project
personnel, including
resident coordinators,
and establish field
offices
PM7004
RiimjIvv Ii iiii.l-i Imm
I Ji,,
PM2002
Facilitate
establishment of field
office and relocation of
resident coordinators
I' I
liiml-. Ik mi
- ■/ li Ilin .
iiiLiiii.
PM1005
Review and approve
reports and
workplans on time
PM1006
Participate in project
committees as
required
PM3003
Review and approve
reports and workplans
on time at appropriate
committees
PM2003
Participate in project
committees as
required
PM3004
Participate in project
committees as
required__________
PM4004
Collect data for
internal performance
monitoring__________
PM4005
Support Canadian
consultants as
necessary__________
PM4006
Support preparation of
reports and workplans
PM4007
Review and approve
reports and workplans
on time at appropriate
committees_________
PM4008
Provide input to the
project as necessary
in a timely fashion
PM4009
Participate in project
committees as
required
PM5005
Collect data for
internal performance
monitoring__________
PM5006
Support Canadian
consultants as
necessary
PM5007
Support preparation of
reports and workplans
PM5008
Review and approve
reports and workplans
on time at appropriate
committees_________
PM5009
Provide input to the
project as necessary
in a timely fashion
PM5010
Participate in project
committees as
required
-94-
iiiLiuL
PM6005
Collect data for
internal performance
monitoring
PM6006
Support Canadian
consultants as
necessary__________
PM6007
Support preparation of
reports and workplans
PM6008
Review and approve
reports & workplans
on time at appropriate
committees_________
PM6009
Provide inputs to the
project as necessary
in a timely fashion
PM6010
Participate in project
committees as
required
PM8000
CEA in India
PM8001
Establish field office,
procure office
furniture and
equipment
PM8002
Put.iilU uiolu'/.loii il
...
activities___________
PM7005
Carry out internal
performance
monitoring_________
PM7006
Deploy Canadian
consultants as
necessary__________
PM7007
Prepare and submit
reports and workplans
PM8003
Collect data for
internal performance
monitoring__________
PM8004
Support Canadian
consultants as
necessary__________
PM8005
Prepare and submit
reports and workplans
PM7008
Provide overall project
management and
administration_______
PM7009
Participate in project
committees as
required___________
PM8006
Provide project
management and
administration in India
PM8007
Participate in project
committees as
required___________
10.2 Description of Activities and Outputs
The following activities are described in sequence, as they will occur from the time when the
Project Implementation Plan is submitted.
10.2.1
Activity PM7001 - Prepare and Submit PIP to CIDA (CEA)
After completion of the Project Design Mission to India, the CEA will produce the
draft PIP and submit it to CIDA. It will then be forwarded to NACO, KSAPS and
RSACS for comments. The draft will be submitted in February 2000. As soon as
comments are received, the CEA will produce the final PIP and submit it to CIDA.
Output: A Project Implementation Plan (PIP) finalized and completed
10.2.2
Activity PM1001 - Review and Approve PIP (CIDA)
Activity PM4001 - Review and Approve PIP (NA CO)
Activity PM5001 - Review and Approve PIP (KSAPS)
Activity PM6001 - Review and Approve PIP (RSACS)
The draft PIP will be submitted by the CEA to all its partners (CIDA, NACO,
KSAPS and RSACS) they will be expected to provide comments. The CEA will
incorporate the comments and submit the final PIP to CIDA. CIDA will then
distribute the final PIP to all the partners for approval. This approval is expected to
take approximately 3 months.
Output:
10.2.3
PIP approved by CIDA, NA CO, KSAPS and RSA CS.
Activity PM1002 - Obtain GOC Approval of Project (CIDA)
Activity PM3001 - Obtain GOI Approval of Project (DEA, GOI)
The project will have to go through the normal approval process in CIDA for GOC,
and DEA for GOI.
Output: Project Approved by CIDA (GOC) and DEA (GOI).
10.2.4
Activity PM2001 - Sign MOU with GOI (CIIC, GOC)
Activity PM3001 - Sign MOU with CHC (DEA, GOI)
On approval of the project by the governments of both countries, a Memorandum of
Understanding (MOU) for implementation of the project will be signed between the
two governments.
Output: MOU between GOC and GOI on implementation of the project.
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10.2.5
Activity PM1003 — Amend CEA fs Contract for Project Delivery (CIDA)
Activity PM7002 - Sign Agreement (Amendment) with CIDA (CEA)
CIDA will amend the CEA’s contract to incorporate the activities and resources
required to deliver the project. The contract will be amended in accordance with this
PIP.
Output: Amended CEA Contract for Project Delivery.
10.2.6
Activity PM4002 - Sign Agreement with CEA, KSAPS and RSA CS (NA CO)
Activity PM5002 - Sign Agreement with NA CO, RSA CS and CEA (KSAPS)
Activity PM6002 - Sign Agreement with NACO, KSAPS and CEA (RSACS)
Activity PM7002 - Sign Agreement with NACO, KSAPS and RSACS (CEA)
The finalized PIP will be signed by the CEA and its partners in India.
Output: A four-way agreement between NACO, RSACS, KSAPS and the CEA for
implementation of the project.
10.2.7
Activity PM1004 - Provide Initial Advance and Disburse Funds to CEA (CIDA )
CIDA will be responsible for advancing funds to the CEA for initial project
mobilization and for procurement of project-related equipment and furniture as
required.
Output: Project funds received by the CEA on schedule.
10.2.8
Activity PM7003 - Mobilize project personnel including Field Coordinators (CEA)
Immediately after signing the contract amendment with CIDA, the CEA team will
mobilize for project activities. To provide on-going technical assistance and to
coordinate project activities jointly with the directors of the state AIDS societies, a
full-time Resident Canadian Coordinator (RCC) will be recruited and provided in
each state. This activity will be on-going with deployment of short-term Canadian
Advisers for technical assistance activities, as necessary.
Output: RCCs recruited and placed in Bangalore and Jaipur.
10.2.9
Activity PM8001 - Establish and operate field office (CEA ).
The RCCs will establish the field offices and arrange for office space rental and
procurement of furniture and equipment in India.
Output: CEA Field offices established in Bangalore and Jaipur.
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10.2.10
Activity PM2002 - Facilitate establishment offield office and relocation offield
coordinator (CHC)
The CHC in New Delhi will facilitate obtaining work permits for the CEA’s Resident
Canadian Coordinators. The CHC will also assist the CEA in obtaining duty-free
privileges for project-related shipments.
Output: CEA RCCs placed andfield offices established in Bangalore and Jaipur.
10.2.11
Activity PM5003 - Facilitate establishment offield office and relocation of RCC
(KSAPS)
Activity PM6003 - Facilitate establishment offield office and relocation of RCC
(RSACS)
KSAPS and RSACS will facilitate the establishment of the field offices and
relocation of RCCs by securing any government approvals, if required, such as
acceptance of CVs of the individuals, obtaining work permits, permits to set up
offices in India etc. They will also assist the CEA to procure furniture and equipment
for the project, to get any project-related shipments released from customs, securing
duty free privileges, etc.
Output: RCCs placed and field offices established in Bangalore and Jaipur.
10.2.12
Activity PM4003 — Disburse funds to KSAPS and RSA CS on schedule (NACO)
NACO will be responsible for the timely disbursement of funds to KSAPS and
RSACS for project activities. NACO will ensure that this flow of funds is not
interrupted to an extent that project activities suffer.
Output: Funds received by KSAPS and RSACS on time.
10.3.13
Activity PM5004 - Receive and disburse funds from NACO on schedule (KSAPS)
Activity PM6004 - Receive and disburse funds from NACO on schedule (RSACS)
KSAPS and RSACS will be responsible for timely disbursement of funds to project
activities. They will ensure that this flow of funds does not get interrupted to an
extent that project activities suffer.
Output: Funds disbursed by KSAPS and RSACS on time.
10.2.14
Activity PM7004 - Receive funds from CIDA and disburse for project management
and to NACO for project activities (CEA)
According to the contract between the CEA and CIDA, the CEA will receive funds
from CIDA on a reimbursement basis, other than mobilization costs (relocation
expenses, office establishment costs, etc.). The CEA will also have an agreement
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with NACO to the effect that for predetermined project activities, the CEA will
reimburse funds to NACO when NACO has spent the funds.
Output: Efficiently managed project activities.
10.2.15
Activity PM8002 — Recruit professional and support staff (CEA)
To provide technical assistance on project activities in each state, the RCC will be
supported by a pool of technical specialists from Canada and India, and a project
support unit. The pool of Indian specialists will be contracted as required on a fulltime or part-time basis. The expertise of the RCCs and the technical specialists in
each state will be complementary to their counterparts in the other state, to ensure that
as wide a range as possible of technical expertise is available to support activities.
Support staff will be recruited locally as well. Support staff may include an
accountant, a secretary, drivers and other staff. The professional staff may include
specialists in training, STD, HIV-related care and support, communications,
research, targeted interventions etc. All staff will recruited in consultation with
KSAPS and RSACS.
Output: Fully staffedfield project offices in Bangalore and Jaipur.
10.2.16
Activity PM7005 - Carry out Internal Performance Monitoring (CEA)
To ensure achievement of results throughout the project, the CEA will establish an
internal performance monitoring system on the basis of which project reports will be
prepared and submitted to CIDA. The CEA will appoint an Internal Monitoring
Coordinator (IMC). Once the specific project activities are designed, the
performance measurement framework for project components will be finalized with
the participation of other stakeholders. Data on these indicators of performance will
be collected on a regular basis and will be reviewed twice a year by the IMC.
Regular reports will be prepared for submission to CIDA.
Output: PMF established and project activities and results monitored
10.2.17
Activity PM4004 - Collect data for internal performance monitoring (NACO)
Activity PM5005 - Collect Data for Internal Performance Monitoring (KSAPS)
Activity PM6005 — Collect data for internal performance monitoring (RSACS)
Activity PM8003 - collect data for internal performance monitoring (CEA)
The performance monitoring data on the indicators will be collected according to the
PMF for each project component by NACO, KSAPS and RSACS. The CEA will
assist and advise in this data collection.
Output: Data on Performance Indicators.
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10,2.18
Activity PM7006 - Deploy Canadian consultants as necessary (CEA)
To provide technical assistance on project activities in each state, the RCCs will be
supported by a pool of technical specialists from Canada, as necessary. Timely
deployment of these Canadian specialists is essential for the success of the project.
Output: Canadian consultants deployed as required.
10.2.19
Activity PM4005 - Support Canadian consultants as necessary (NACO)
Activity PM5006 - Support Canadian consultants as necessary (KSAPS)
Activity PM6006 - Support Canadian consultants as necessary (RSACS)
Activity PM8004 - Support Canadian consultants as necessary (CEA)
NACO, KSAPS and RSACS will provide support to Canadian and other external
consultants, as will the Technical Support Units and the RCCs in India.
Output: Canadian consultants successfully carry out their assignments in India.
10.2.20
Activity PM7007 - Prepare and submit reports and workplans (CEA in Canada)
Activity PM8005 - Prepare and submit reports and workplans (CEA in India)
Semi-annual and annual progress reports will be prepared by the CEA and submitted
to CIDA. Annual workplans will also be prepared by the CEA and its implementing
partners and submitted to the Project Steering Committee for approval.
Outputs: Periodic Reports and Annual Workplans.
10.2.21
Activity PM4006 - Support the preparation of reports and workplans (NACO)
Activity PM5007 - Support the preparation of reports and workplans (KSAPS)
Activity PM6007 - Support the preparation of reports and workplans (RSACS)
The implementation teams of NACO, KSAPS and RSACS will support the CEA on
the preparation of reports and workplans in the field.
Outputs: Periodic Reports and Annual Workplans
10.2.22
Activity PM1005 - Review and approve reports and workplans (CIDA)
CIDA will approve the semi-annual and annual reports and workplans within four
weeks of submission.
Outputs: Approved reports and workplans.
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10.2,23
Activity PM4007 — Review and approve workplans (NACO)
Activity PM5008 — Review and approve workplans (KSAPS)
Activity PM6008 — Review and approve workplans (RSACS)
The project workplans have to be approved by the appropriate committees at the
national (NACO) and the state (KSAPS/RSACS) levels.
Outputs: Approved workplans in India.
10.2.24
Activity PM4008 — Provide inputs to the project as necessary (NACO)
Activity PM5009 - Provide inputs to the project as necessary (KSAPS)
Activity PM6009 - Provide inputs to the project as necessary (RSACS)
As stipulated by the workplan, timely inputs from the national and state level partners
are necessary for the success of the project.
Output: Efficient and effective completion ofproject activities.
10.2.25
Activity PM8006 - Provide project management in India (CEA in India)
This activity will entail all project management and administrative activities in India
including financial management, management of staff and assets of the project field
offices in Bangalore and Jaipur., liaison with government agencies at the national and
state levels, and with others as necessary.
Output: Effectively and efficiently managed project activities in India.
10.2.26
Activity PM7008 - Provide overall project management (CEA in Canada)
This activity will include all project management and administrative activities in
India and in Canada, including financial management, management of human
resources, liaison with CIDA, and with others as necessary.
Output: Effectively and efficiently managed project.
10.2.27
Activity PM1006 - Participate in Project Steering Committee (CIDA)
Activity PM2003 - Participate in Project Steering Committee (CHC)
Activity PM3004 - Participate in Project Steering Committee (GOI)
Activity PM4009 - Participate in Project Steering Committee (NACO)
Activity PM5010 - Participate in Project Steering Committee (KSAPS)
Activity PM6010 — Participate in Project Steering Committee (RSACS)
Activity PM7009 - Participate in Project Steering Committee (CEA in Canada)
Activity PM8007- Participate in Project Steering Committee (CEA in India)
All of the key stakeholders will participate in the Project Steering Committee and
thus in the project’s policy decision-making.
Output: Well Directed Project.
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r
11.
STRATEGY FOR RESULTS-BASED MANAGEMENT
11.1
RBM and Performance Monitoring Approach
The India-Canada Collaborative HIV/AIDS Project is innovative and iterative in nature. The
project will be implemented using results-based management (RBM) principles. On-going
perfonnance assessment will be necessary to ensure effective project management and
implementation. In keeping with RBM principles, the project will carry out on-going
performance monitoring by establishing and using an effective Performance Measurement
System (PMS). The PMS will include the use of the following tools:
•
•
•
•
•
Logical Framework Analysis (LFA).
Performance Measurement Framework (PMF).
Risk Management Framework (RMF).
Management Information System (MIS).
Key Success Factors.
All of these tools either have been developed with or will incorporate ideas from the Design
Mission, but at the present time they should be viewed as provisional, to be further developed
with the full participation of project partners and stakeholders in India. An important feature of
RBM is that ongoing adjustments are made to revise and adapt project activities to stay focused
on results that the project has set out to achieve within a project context which is dynamic.
Based on the established PMF and RMF, a framework for a baseline evaluation will be created.
This will include the indicators for which data will be collected. Preliminary data for testing the
method of collection and the suitability of the indicators will first be gathered. All data will be
disaggregated by gender. Before each major activity begins, data on the performance indicators
for achievement of results by the activity as well as data on risk indicators will be collected and
the conditions recorded and/or documented. Mechanisms will be established to track both
quantitative and qualitative aspects of the project’s performance with respect to attainment of
target performance indicators at the activity/output, outcome and impact levels. According to the
frequency established in the PMF and RMF, data will be collected and analyzed on a regular
basis. Monitoring at the output level will be more frequent than at the outcome level.
Monitoring at impact level may be at mid-project and on project completion. Milestones will be
established for review of result achievement so that the project design can be reassessed for
achievement of desired results. A reporting framework during project implementation will also
be established.
The PMF and the RMF will be used as the basis for internal monitoring. The annual report will
contain the data collected on the performance indicators and the performance of the project
towards achievement of the intended results will be reviewed, analyzed and conclusions
presented. This information will be used to guide the annual strategic planning process which
will result in changes in the project design or performance indicators, as necessary, to achieve
the desired results.
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■ ';7'
’A Q *
XT
y
11.2 Organizational Strategy
For effective and efficient operation of the PMS within the project, the CEA has created a
position of Internal Monitoring Coordinator. The IMC will be responsible for:
•
Facilitating the participatory process for the establishment of results, indicators and the
performance measurement framework.
•
Facilitating the establishment of the logical framework analysis.
•
Facilitating the identification of risks and establishment of the risk management strategy.
•
Facilitating the establishment of the management information system based on the data
on indicators for performance and risks.
•
Supervising the ongoing collection and analysis of data on indicators and risks and
utilizing them for results-based management of the project.
•
Periodic reporting on results and recommending changes in indicators and collection
methods as necessary.
11.3 Integration of Stakeholder Participation
RBM and participatory development approaches are complementary. To successfully achieve
results, projects must be designed and implemented using a participatory approach where all
stakeholders are involved throughout the project cycle. Expected results and their performance
indicators must be mutually defined and agreed upon through a consensus-building process
involving all major stakeholders. They should be involved in the establishment of the
Performance Measurement Framework and the Risk Management Framework for the project.
This RBM approach was used throughout the design mission. In both states, the state AIDS
societies participated fully in designing their project components. In addition to ongoing
consultations during field trips and meetings with local institutions and NGOs, three workshops
were held, one at each state and one at the national level. Due to time constraints, the PMF and
the RMF could not be completed in the field, and it is therefore proposed that the draft
documents developed the Design Team be further refined through a participatory process in the
field at the outset of project implementation.
During the implementation phase and throughout the project, stakeholders (such as the state
AIDS societies and NGOs involved in project activities) will participate in the process of
reviewing and refining outcomes, outputs and indicators for various components of the project.
Experience indicates that projects are better able to adapt to local conditions, leverage resources,
and enhance program impact through processes that enable stakeholders to meet and articulate
expected results and indicators. There is also a good deal of evidence that better results are
achieved through a once-a-year strategic planning process (workshop) involving all stakeholders.
It is therefore proposed that such strategic planning workshops be held on an annual basis.
11.4 Logical Framework Analysis
At the final workshop of the Design Mission, the stakeholders were presented with the
conceptual outcomes, outputs and activities of the project components. The discussions during
that workshop and the workshops held at the state level in Rajasthan and Karnataka provided
-102-
r
inputs to the development of the LFA which is included in this report in Section 6. Because of
the iterative nature of the project, this LFA should be viewed as a dynamic document, to be
revised as the Performance Measurement Framework is revised.
11.5 Performance Measurement Framework
For purposes of monitoring and reporting to CIDA and other partners, the main tool will be the
Performance Measurement Framework (PMF). The PMF not only identifies the performance
indicators for achievement of each result, it also provides information on the method and
frequency of collecting data on each indicator and the assumptions and risks associated with the
realization of each result. The effectiveness of this RBM tool depends on the extent to which it
incorporates the full range of stakeholder views. As mentioned above, due to shortage of time
during the Design Mission, the PMF could not be completed in India with participation of all the
stakeholders. Therefore, at this stage, a preliminary PMF has been developed and is available,
but is not included in the Project Implementation Plan at this stage. The PMF will be completed
with the participation of all stakeholders in India at the outset of when the detailed activities will
be designed.
11.6 Risk Management Framework
Based on the assumptions and risks identified in the PMF, a risk analysis will be conducted and a
Risk Management Framework (RMF) established. For each assumption, the RMF identifies risk
indicators, i.e. data which will be collected on a regular basis to provide advance warning that an
assumption may not be not holding true. Activities may then be redirected to avoid any adverse
results. As with the PMF, the RMF will also provides information on the method, source and
frequency of collecting data on each risk indicator. Stakeholder participation is essential in
identifying assumptions, assessing risks and establishing risk indicators. An RMF format has
been developed and is available, but like the draft PMF, has not been included in the Project
Implementation Plan at this stage.
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12.
PROJECT MANAGEMENT DETAILS
12.1 Project Management Strategy
As per results-based management principles, the CEA, jointly with its Indian partners, will be
responsible for ensuring that the conditions are met to produce the project outcomes, thereby
achieving the project purpose. The Indian partners are the National AIDS Control Organization
at the national level, and the Karnataka State AIDS Prevention Society and the Rajasthan State
AIDS Control Society (RSACS). The project has been designed by the CEA in collaboration
with the Indian partners and will be implemented jointly.
In keeping with the project's underlying philosophy of capacity building for the state AIDS
societies, an organizational structure for project implementation has been developed which
represents integration of the CEA inputs with that of the two societies. This is depicted in the
Project Organization Chart below.
In Canada, the Project Director from the University of Manitoba will be accountable to CIDA,
on behalf of the CEA, for overall project management, as well as the efficient and effective use
of CIDA’s inputs to the project. To provide on-going technical assistance and to coordinate
project activities jointly with the directors of the state AIDS societies, a full-time Resident
Canadian Coordinator (RCC) will be deployed in each state. In addition to her/his responsibility
to coordinate CEA input and activities in the state, the RCA will be available to the society
director and her/his team for technical assistance and support. To integrate the project within the
state systems, each RCC will participate in state AIDS society meetings. The RCCs and the
society directors will have authority to jointly manage activities funded wholly or partly by
CIDA. Integration of the RCCs into the societies' activities will not only obviate the need for a
Project Management Committee, but will strengthen the spirit of working together within the
existing system, rather than establishing a parallel system for the CIDA-funded activities only.
In addition, the RCCs will communicate regularly with the Canadian High Commission in New
Delhi, on technical, financial and administrative issues.
At the overall project level, a Project Steering Committee (PSC) will make policy decisions and
review annual workplans for project activities in both states and at the national level. The
membership of the PSC will include representatives from NACO, the directors of the two state
AIDS societies, the RCCs from the two states, representatives of CIDA and the Canadian High
Commission in India, the CEA’s Project Director from Canada and other partners. NACO will
convey important PSC decisions to the governing bodies of the state societies through its regular
channels of communication.
To provide technical assistance on project activities in each state, each RCC will be supported by
a pool of technical specialists from Canada and India, and a technical support unit. The pool of
Indian specialists will be contracted as required on a full-time or part-time basis. The expertise
of the RCCs and the technical specialists in each state will be complementary to their
counterparts in the other state, to ensure that as wide a range as possible of technical expertise is
available to support activities.
-104-
12.2 Project Organization Chart
The Project Organization Chart is graphically depicted on the following page, as per the
relationships described above.
*
- 105 -
PROJECT ORGANIZATION CHART
CIDA
Project Manager
GOI
NACO
CIDA/CHC
Selected
TRGs
UNAIDS
<
Canadian
Executing
Agency (CEA)
Project Steering
Committee
KSAPS & RSACS
Governing Bodies
and
Executive
Committees
Project Director .
University of
Manitoba
(Winnipeg)
KSAPS & RSACS
Project Directors
(Bangalore & Jaipur)
Resident Canadian
Technical Program
Coordinators
(Bangalore and
Jaipur)
Short Term
Specialists
HIV Surveillance ;
Targeted Interventions
STD Control
Community Development
HRD
Gender
RBM
M&E
Other
CEA
Technical Support
Units
(Bangalore & Jaipur)
I
I
I
I
1
Project
Implementation Partners
(Karnataka & Rajasthan)
■
•
Legend
Reporting
Communication
Selective Contracting
Administered directly
by CEA
Committee Membership
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r
12.3 Project Staffing
The Canadian Executing Agency (CEA) is led by the University of Manitoba, with Mascen
Consultants Inc. and ProAction: Partners for Community Health as partners. The University of
Manitoba has been contracted by CIDA and will provide the following short and long-term
professional consultants to carry out the India-Canada Collaborative HIV/AIDS Project.
Canada-Based Project Staff
• Project Director
• Internal Monitoring Coordinator
• Administrative Support
Long-Term Canadian Coordinators
• Resident Canadian Coordinator - Karnataka
• Resident Canadian Coordinator - Rajasthan
In order to meet the requirements as outlined in the Work Breakdown Structures of the various •
project components, the project will require substantial inputs of technical assistance. The CEA
has already identified part of the Canadian technical assistance team in its proposal which has
been accepted by CIDA. Additional Canadian and Indian resources may be recruited as
required. The following areas are the ones which been identified during the project design as
requiring Canadian, international or Indian technical assistance.
•
•
•
•
•
•
•
•
•
•
•
HIV surveillance systems
targeted interventions
STI Control for HIV prevention
community health and development
training
human resource development
gender and development
results - based management
research and evaluation
communications
HIV-related care and support
12.4 Project Offices
As mentioned earlier in this document, a project office will be established in each project state.
To ensure close liaison and to establish close working relationships between the two project
partners (the CEA and the State AIDS Control/Prevention Society), one of the major criteria for
location will be close proximity to, if not in the same location as, the state society. For project
administration, the project office in each state will have an Office/Finance Manager and a
Secretary/Logistics Coordinator. The office will also house the Technical Support Unit of the
project and that will require working space for a maximum of five professionals.
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12.5 Financial Management
The CEA will open a project account in each of the two states in India. Funds will be transferred
to this account by the CEA from Canada for project purposes, as approved by CIDA and the
Project Steering Committee through the annual workplan. Records of all project-related
expenditures will be kept up-to-date in the project office. Financial management guidelines will
be established by the RCC and the Office/Financial Manager. A University of Manitoba
accountant and the Canada-based Project Director in Winnipeg will review all financial reports
submitted by the project office and prepare semi-annual financial reports for submission to
CIDA. The CEA will submit invoices to CIDA on a monthly basis. Requests for advances will
be submitted as needed. The project’s financial records will be subject to a financial audit if
CIDA requests one.
The CEA will receive funds from CIDA on a reimbursement basis, except for allowed advances,
and will be accountable to CIDA for all expenditures. Expenditure of funds will be governed by
annual and quarterly project workplans approved by the Project Steering Committee, with
agreement by CIDA, the CEA, NACO and state AIDS societies.
Funds for CEA management costs and technical assistance, including the RCCs and associated
technical support units, will be administered by the CEA. Funds for activities at state or national
level will be managed by NACO on a reimbursement basis, as per Department of Economic
Affairs (DEA) guidelines. NACO will provide funds for activities to the two state AIDS
societies on an annual or quarterly basis, as per the approved annual and quarterly workplans,
and will be reimbursed by the CEA upon presentation of accounts of expenditures. To facilitate
timely disbursement and accounting, a financial officer position will be budgeted for the project
at NACO level and at each of the two state levels.
12.6 Roles and Responsibilities
12.6.1 Government of India
The Government of India (GOI), through its Department of Economic Affairs (DEA) of the
Ministry of Finance, will have the following responsibilities:
•
Obtain all necessary project approval.
•
Negotiate and sign a Memorandum of Understanding (MOU) with the Government of
Canada (represented by the Canadian High Commissioner in India) for implementation of
the project.
•
Provide and obtain from the appropriate GOI department all necessary approvals and
documentation to facilitate ease of entry to and exit from India of Canadian personnel
assigned to the project on long-term or short-term basis, their personal effects as well as
equipment and material required for the project.
•
Arrange approvals for all work permits necessary and duty-free exemptions and
privileges for Canadian project personnel resident in India.
•
Nominate NACO to be the Indian agency responsible for project implementation.
-108-
12.6.2 Government of Canada (CHC, New Delhi)
The Canadian High Commission in New Delhi will represent the Government of Canada on
project-related issues at government to government level, will represent CIDA on all project
related matters in India and will be responsible for on-going liaison with the GOI and NACO.
Without limiting the generality of the above, the CHC will be responsible for the following:
’
•
Negotiating and signing the Memorandum of Understanding with the DEA.
•
Liaising with NACO on project-related matters.
•
Liaising with the CEA through its representatives in India on project matters.
•
Keeping CIDA headquarters informed and up-to-date on any significant activities or
problems which may affect the successful implementation of the project.
•
Participating in Project Steering Committee meetings.
12.6.3 Government of Canada (CIDA)
' The overall responsibility of managing the Government of Canada's inputs rests with CIDA's
headquarters in Hull, with Project Team led by a Project Manager. The Project Team's
responsibilities include:
•
Approving the Project Implementation Plan and obtaining all necessary GOC approvals for
project funding.
•
Preparing the Memorandum of Understanding (MOU) for signing with the DEA, GOI.
•
Amending CEA’s contract to include implementation activities as per to this PIP.
- •
Monitoring project activities, and reviewing and commenting on progress and financial
reports.
•
Timely disbursement of Project funds.
•
Participation in the Project Steering Committee.
12.6.4 National AIDS Control Organization of India (NACO)
NACO, along with the state AIDS societies of Karnataka and Rajasthan, will be responsible for
the achievement of the project purpose. In particular, its responsibilities will include:
-
•
Obtaining the necessary project approvals from the appropriate GOI authority and
ensuring that project funding is approved and allocated.
•
Signing the necessary implementation agreement with the CEA.
•
Providing KSAPS and RSACS with sufficient funds to implement project activities.
These funds will consist of project funds derived from CIDA through the CEA, and other
program funds supplied by NACO which will complement project funds. The mix of
funding modalities will be specified for specific project activities in the annual
workplans.
•
Facilitating and expediting project activities in case of any problem at the national or
state level.
-109-
•
Participating in the design and implementation of project activities.
•
Collecting and analyzing data for on-going performance measurement of the project as
stipulated in the performance measurement framework.
•
Coordinating and chairing the Project Steering Committee;
12.6.5 State AIDS Societies
The state AIDS societies of Karnataka and Rajasthan (KSAPS and RS ACS), along with NACO,
will be responsible for the achievement of the project purpose. In particular, their
responsibilities will include:
•
Obtaining the necessary project approvals from the appropriate state authorities and
ensuring that the project funding is approved and allocated.
•
Signing the necessary implementation agreement with the CEA.
•
Allocating sufficient funds to implement project activities. These funds will consist of
project funds derived from CIDA through the CEA and NACO, and other program funds
which will complement project funds. The mix of funding modalities will be specified
for specific project activities in the annual workplans.
•
Facilitating project activities in the event of any problems at the national or state level.
•
With the RCC and other project personnel, carrying out the detailed project
implementation.
•
Providing sufficient and appropriate human and financial resources to the project.
•
Collecting and analyzing data for on-going performance measurement of the project as
stipulated in the performance measurement framework.
•
Nominating the Project Director to be the counterpart of the RCC and to sit on the Project
Steering Committee.
12.6.6 Canadian Executing Agency
Once the PIP is accepted by CIDA and the project approved by CIDA, a contract amendment
will be signed between CIDA and the University of Manitoba for the implementation of the
approved project.
During project implementation, the CEA will be responsible for the following activities:
•
Providing project management services.
•
Within the first six months of the project, preparing a detailed Inception Report to include
updated procedures, activity packages, schedules and budgets.
•
Regular internal performance measurement and reporting to CIDA.
•
Taking remedial actions to correct deviations and resolve problems.
•
Providing the technical assistance required by the project by using Canadian,
international and Indian technical specialists.
-110-
•
Providing two full-time Canadian coordinators to be resident in India, one in Bangalore
and one in Jaipur (the Resident Canadian Coordinators).
•
Establishing a Project Office in each state.
•
Staffing the offices and technical support units with the necessary human resources.
•
Administering the provision of all Canadian inputs.
•
Preparing and submitting project reports on schedule.
•
Procuring all CIDA-funded equipment and material in accordance with CIDA guidelines
on procurement.
•
Cooperating with and providing support to any project monitoring, evaluation or other
missions arranged by CIDA.
•
Providing general administrative and support services to the project in Canada and India.
12.6.7 Project Steering Committee (PSC)
The Project Steering Committee (PSC) will be the key policy body for the project and will be
responsible for providing overall project coordination and decisions on policy issues.
The membership of the PSC will be as follows:
NACO:
KSAPS:
RSACS:
CIDA :
CEA:
Ex Officio'.
Director (Chair)
Project Director
Project Director
Representative based at the Canadian High Commission in New Delhi
Representative based at CIDA headquarters in Canada
Project Director (Canada)
Resident Canadian Coordinator - Karnataka (Alternate Secretary)
Resident Canadian Coordinator - Rajasthan (Alternate Secretary)
Selected TRG representatives
UNAIDS representative
The committee will meet at least once a year in India and may meet more frequently, if required.
The CEA will be the Secretariat for the Committee. The two RCCs will alternatively act as the
Secretary for the committee. The PSC will:
•
Provide policy guidelines and direction.
•
Review and approve workplans and budgets.
•
Make adjustments to project targets, if necessary, on the basis of field experience and
periodic review.
•
Discuss and act upon any implementation problems.
The decisions taken by the PSC with respect to activities in the states will be conveyed by
NACO to the state societies for appropriate action.
-Ill -
13.
PROPOSED BUDGET
13.1
Budget by component
-4
I
I
The budget by component is presented in the Table below. Budget notes follow. All figures are in constant Canadian dollars (CAD).
Item
Component
Year 1
Year 2
Year 3
Year 4
Year 5
Total
1.0
Management in Canada
167,000
167,000
167,000
167,000
167,000
835,000
2.0
Management and Operations in India
165,000
165,000
165,000
165,000
165,000
825,000
3.0
Procurement
247,000
4.0
Technical Assistance and Support
896,100
942,900
942,900
942,900
942,900
4,667,700
5.0
5.1
5.2
Karnataka Programming______________
Component K1000 - Capacity Building
Component K2000 - Demonstration project
Sub-Total
34,000
402,500
436,500
43,500
501,000
544,500
43,500
501,000
544,500
43,500
501,000
544,500
43,500
501,000
544,500
208,000
2,406,500
2,614,500
Sub-total
34,000
402,500
436,500
43,500
501,000
544,500
43,500
501,000
544,500
43,500
501,000
544,500
43,500
501,000
544,500
208,000
2,406,500
2,614,500
Sub-total
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
25,000
125,000
125,000
2,373,100
2,388,900
2,465,900
2,388,900
2,388,900
12,005,700
71,600
150,100
221,500
299,800
743,000
2,460,500
2,616,000
2,610,400
2,688,700
12,748,700
6.0
6.1
6.2
7.0
7.1
Rajasthan Programming_______________
Component K1000 - Capacity Building_____
Component K2000 - Demonstration projects
National Programming
Operations research
GRAND TOTAL BEFORE INFLATION
8.0
Inflation (3% per year from Year 2)
GRAND TOTAL AFTER INFLATION
2,373,100
-112-
77,000
324,000
13.2 Budget Notes
1. Management in Canada
This budget category includes:
•
•
•
Fees for the Canada-based Project Director, internal monitoring and reporting, and project
administration support. All fees are inclusive of benefits and overhead.
Travel costs within Canada and to India for management and monitoring project activities..
Office expenses, communications and printing costs in Canada.
2. Management and Operations in India
This category includes:
•
•
•
•
Project accountant salaries for central (NACO) and state (Karnataka and Rajasthan)
accounting activities.
Support staff for the project office.
Office rental, utility and supply costs.
Local transportation costs.
3. Procurement
This category includes the purchase of capital equipment for the Karnataka and Rajasthan project
offices in Year 1 of the project:
•
•
•
•
Project vehicles (including partial replacement in Year 3, midway through the project).
Office furniture and set-up of utilities.
Computer equipment and software (including partial replacement/upgrade in Year 3, midway
through the project).
Photocopiers and fax machines.
4. Technical Assistance and Support
This component covers expenses to support the resident Canadian coordinators in their capacity
building roles in various project activities, as well as expenses to support Canadian, Indian and
international technical advisors in various project activities.
5. Karnataka, Rajasthan and National Component Programming
These components describe the costs for the activity streams for the outputs in each component
of the project. For each activity stream there are costs for technical assistance and programming
costs. See the Budget by Activity below for more details.
-113-
>
I
13.3 BUDGET BY ACTIVITY
The Budget by Activity is exclusive of management costs in Canada and India, procurement costs and inflation. These latter items are
included in the Budget by Component. All figures are in constant Canadian dollars (CAD).
Item
Component
Year 1
Year 2
Year 3
Year 4
Year 5
Total
1.0
Karnataka Component Activities_______
Output K1100___________________
• Technical Assistance and Support
•
Programming Support__________
31,000
8,000
32,500
11,000
32,500
11,000
32,500
11,000
32,500
11,000
161,000
52,000
71,000
18,000
75,000
21,500
75,000
21,500
75,000
21,500
75,000
21,500
371,000
104,000
31,000
8,000
32,500
11,000
32,500
11,000
32,500
11,000
32,500
11,000
161,000
52,000
70,000
100,000
72,500
125,000
72,500
125,000
72,500
125,000
72,500
125,000
360,000
600,000
89,000
127,000
95,000
160,000
95,000
160,000
95,000
160,000
95,000
160,000
469.000
767,000
70,000
100,000
73,500
125,000
73,500
125,000
73,500
125.000
73,500
125,000
364,000
600,000
57,000
75,500
60,000
91,000
60,000
91,000
60,000
91,000
60,000
91,000
297,000
439,500
855,500
985,500
985,500
985,500
985,500
4,797,500
Output K1200___________________
• Technical Assistance and Support
•
Programming Support__________
Output K1300___________________
• Technical Assistance and Support
•
Programming Support
Output K2100___________________
• Technical Assistance and Support
•
Programming Support__________
Output K2200___________________
• Technical Assistance and Support
•
Programming Support__________
Output K2300___________________
•
Technical Assistance and Support
•
Programming Support
Output K2400___________________
• Technical Assistance and Support
•
Programming Support
Sub-total
-114-
Item
2.0
Component
Rajasthan Component Activities
Output R1100___________________
•
Technical Assistance and Support
•
Programming Support
Output R1200___________________
•
Technical Assistance and Support
•
Programming Support
Output R1300___________________
•
Technical Assistance and Support
•
Programming Support__________
Output R2100___________________
•
Technical Assistance and Support
•
Programming Support__________
Output R2200___________________
•
Technical Assistance and Support
•
Programming Support_________
Output R2300___________________
•
Technical Assistance and Support
•
Programming Support__________
3.2
National Component Activities
Output N1100___________________
•
Technical Assistance and Support
•
Programming Support__________
Output N1200 __________________
•
Technical Assistance and Support
•
Programming Support
Sub-total
Grand
Total
Year 2
Year3
Year 4
Year 5
Total
31,000
32,500
11,000
32,500
11,000
32,500
11,000
32,500
11,000
161,000
52,000
8,000
Sub-total
3.0
3.1
Year 1
71,000
75,000
75,000
18,000
21,500
21,500
75,000
21,500
75,000
21,500
371,000
104,000
31,000
8,000
32,500
11,000
32,500
11,000
32,500
11,000
32,500
11,000
161,000
52,000
95,500
134,500
100,500
167,000
100,500
100,500
167,000
100,500
167,000
497,500
802,500
95,500
134,500
100,500
100,500
167,000
167,000
100,500
167,000
100,500
167,000
497,500
802,500
95,000
133,500
100,000
167,000
100,000
167,000
100,000
167,000
100,000
167,000
495,000
801,500
855,500
985,500
985,500
985,500
985,500
4,797,500
31,600
12,500
34,500
12,500
34,500
12,500
34,500
12,500
34,500
12,500
169,600
62,500
24,100
27,000
27,000
12,500
12,500
27,000
12,500
27,000
12,500
12,500
132,100
62,500
80,700
86,500
86,500
86,500
86,500
426,700
1,791,700
2,057,500
2,057,500
2,057,500
2,057,500
10,021,700
-115-
167,000
>
1
14.
PROJECT IMPLEMENTATION SCHEDULE
The project implementation schedule is given in the tables below, for Year 1 by month and for subsequent years by quarter. It is
broken down into the four project components (Karnataka, Rajasthan, National and Management). These schedules will be modified
during the first year of the project at the time of the inception report and the development of the first and second annual workplans.
Project Implementation Schedule, Karnataka Component, Year 1.
Activity
^irst Quarter
1
2
3
Second Quarter
4
5
6
JThird Quarter
7
8
9
Fourth Quarter
10
11
12
X
X
Component K1000 - Capacity Building for KSAPS and implementors
Output K1100 - Capacity to gather and analyze information.
K1101 - Train in rapid epidemiologic assessment.________
K1102 - Train in collection and analysis of information.
K1103-Train in situational analysis.
K1104 - Train/assist in directed policy research.________
K1105 - Train/asslst In operational research.____________
K1106 - Train/assist in monitoring and evaluation.
K1107-Train/assist in strategic planning.
X
X
X
X
X
Output K1200 - Capacity to implement HIV/AIDS programming
K1201 - Train in best practices of targeted interventions__
K1202 - Train/assist in peer led interventions.______________
K1203 - Assist in scaling up of interventions._______________
K1204 - Train/assist in establishing VCT._________________
K1205 - Train/assist In ‘'grassroots" STI management._______
K1206 - Train/assist to integrate program activities.
X
Output K1300 - Capacity to create an enabling environment for HIV/AIDS
programming.___________________________________________________
K1301 - Increasing awareness of policy makers.
K1302 - Involve vulnerable groups in programming._______
K1303 - Incorporate HIV into social change initiatives._______
K1304 - Train/assist in occupational health safety.___________________
K1305 - Train/assist in programming along a continuum
K1306 - Develop training materials and methods.
X
X
-116-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
|
_First Quarter
________________________________Activity_______________
Component K2000 - Implementation of Demonstration Project
Output K2100 - Enhanced information base for programming, evaluation and
monitoring______________________________________________
K2101 - Select Project Area and build partnerships.
K2102 - Zone and map the Project Area.
K2103 - Review and document information base.
2
3
4
5
6
771 ird Quarter
7
8
9
X
X
X
X
X
X
X
X
K2104 - Strengthen selected laboratories.
K2105 - Conduct baseline surveys and assessments.
K2106 - Analyze and disseminate information.
K2107 - Develop a strategic plan for Project Area.
K2108 - Develop mechanisms for monitoring.
Output K2200 - Development of community based participatory interventions.
K2201 - Identify vulnerable groups and NGO partners.
K2202 - Train/mobilize NGOs and other implementers.
K2203 - Conduct assessment of vulnerable groups.
K2204 - Train peer educators and supervisors.
K2205 - Implement interventions.
K2206 - Evaluate outcomes and impacts.
K2207 - Disseminate lessons learned and innovations.
K2208 - Provide training resources/opportunities.
X
X
Fourth Quarter
10
12
11
X
X
X
X
X
X
X
2L
2£
X
Output K2300 - Development of a model for STI management at the
“grassroots” level.__________________
K2301 - Baseline assessment of STI services.
K2302 - Select and partner with providers.__________
K2303 - Train providers.
K2304 - Develop a strategy for services to women.
K2305 - Upgrade selected laboratory facilities.
Output K2400 - Improved availability of high quality care and support.
K2401 - Review current practices and resources.
K2402 - Identify priorities for improving care/support.
K2403 - Train care providers.
K2404 - Strengthen VCT services in selected sites.
K2405 - Support the development of PLWHA groups.
K2406 - Assist NGOs to develop plans and proposals.
*
Second_Quarter
1
-117
i
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
*
Project Implementation Schedule, Rajasthan Component, Year 1.
Activity
First Quarter
1
2
3
SecondQuarter
4
5
6
Third Quarter
7
8
X
X
9
Fourth Quarter
11
12
10
Component R1000 - Capacity Building for RSACS and implementers
Output R1100 - Capacity to gather and analyze information.
R1101 - Train in rapid epidemiologic assessment.________
R1102 - Train in collection and analysis of information.
R1103 - Train in situational analysis.___________________
R1104 -Train/assist in directed policy research.__________
R1105 - Train/assist in operational research.____________
R1106 - Train/assist in monitoring and evaluation.________
R1107 - Train/assist in strategic planning.
X
X
X
X
X
Output R1200 - Capacity to implement HIV/AIDS programming
R1201 - Train in best practices of targeted interventions
R1202 - Train/assist in peer led interventions.______________
R1203 - Assist in scaling up of interventions.
R1204 - Train/assist in establishing VCT.__________________
R1205 - Train/assist in ‘‘grassroots" STI management.
R1206 - Train/assist to integrate program activities.
X
Output R1300 - Capacity to create an enabling environment for HIV/AIDS
programming.
______________________________________________
R1301 - Increasing awareness of policy makers._____________________
R1302 - Involve vulnerable groups in programming.__________________
R1303 - Incorporate HIV into social change initiatives.________________
R1304 - Train/assist in occupational health safety.___________________
R1305 - Train/assist in programming along a continuum_______________
R1306 - Develop training materials and methods.____________________
X
X
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X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
♦
Activity
Component R2000 - Implementation of DemonstrationProjects
*
First Quarter
2
3
1
Output R2100 - Development of a community-based participatory intervention
for rural migrant men____________________________
R2101 - Identify community of rural migrant men for intervention
R2102 - Train and mobilize NGOs and other implementing partners
R2103 - Conduct baseline assessments of migrant population
Second Quarter
4
5
6
7
X
X
X
Third Quarter
8
9
X
X
R2104 - Train peer educators and supervisors
R2105 - Implement interventions using an iterative approach
R2106 - Evaluate outcomes and impacts and disseminate innovations, lessons
learned and best practices
R2107 - Provide resources and opportunities for hands on training for other
implementers in interventions
R2108 - Expand intervention to networked communities
Output R2200 - Development of a community based participatory intervention
for rural caste-based sex work
_________________
R2101 - Identify community or area for intervention
R2102 - Train and mobilize NGOs and other implementing partners
R2103 - Conduct baseline assessments of interve ntionpopulation
R2104 - Train peer educators and supervisors
~
~
R2105 - Implement interventions using an iterative approach
R2106 - Evaluate outcomes and impacts and disseminate innovations, lessons
learned and best practices
_____ __
R2107 - Provide resources and opportunities for hands on training for other
implementers in interventions
R2108 - Expand intervention to networked communities
X
Output R2300 - Development of a Rajasthan model of the prevention-care
continuum______________________
R2301 - Conduct a needs assessment and determine model site
R2302 - Identify and review best practice models that could be adapted
R2303 - Design and implement the model project using a participatory approach
R2304 - Develop mechanisms for the ongoing evaluation of the model
R2305 - Document and disseminate lessons learned and project impacts
R2306 - Provide resources and opportunities for hands-on training
R2406 - Assist NGOs to develop plans and proposals.
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X
X
X
Fourth Quarter
10
77
72
X
X
X
X
X
X
X
X
X
X
_x
X
X
X
X
X
X
X
X
*
Project Implementation Schedule, Karnataka Component, Years 2-5.
Activity
Q1
Year2
Q3
Q2
Q4
Q1
Year 3
Q3
Q2
Q4
Year 5
Q3
Q2
Year 4
Q3
Q2
Q4
Q1
X
X
X
X
X
X
X
X
X
x_
x_
X
X
X
X
X
X
X
X
X
X
X
X
Q1
3
Component K1QOO - Capacity Building for KSAPS and implemented
Output K1100 - Capacity to gather and analyze information.
Ki 101 - Train in rapid epidemiologic assessment.
K1102 - Train in collection and analysis of information.
K1103 - Train in situational analysis.___________________
K1104 - Train/assist in directed policy research.__________
K1105 - Train/assist in operational research.____________
K1106 - Train/assist in monitoring and evaluation.
K1107 - Train/assist in strategic planning.______________
Output K1200-Capacity to implement HIV/AIDS programming
KI 201 - Train in best practices of targeted interventions.
K1202 - Train/assist in peer led interventions.____________
K1203 - Assist in scaling up of interventions._______________
K1204 - Train/assist in establishing VCT.______________
K1205 - Train/assist in ‘‘grassroots’’ STI management._______
K1206 - Train/assist to integrate program activities.
Output K1300 - Capacity to create an enabling environment for
HIV/AIDS programming.
K1301 - Increasing awareness of policy makers.______
K1302 - Involve vulnerable groups in programming.
K1303 - Incorporate HIV into social change initiatives.
K1304 - Train/assist in occupational health safety.
K1305 - Train/assist in programming along a continuum
K1306 - Develop training materials and methods._____
X
X
X
X
X
X
X
X
X_
X
X
X
X
X
X
X
X
X
x
x
x
X
JC
X
X
2<
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-120-
X
X
X
X
2<
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
—
X
X
X
4
4
Activity
Q1
Year 2
Q2
Q3
Q4
Component K2000 - Implementation of Demonstration Project
Output K2100 - Enhanced information base for programming,
evaluation and monitoring
_____ ___________
K2101 - Select Project Area and build partnerships.
K2102 - Zone and map the Project Area.
K2103 - Review and document information base.
K2104 - Strengthen selected laboratories.
K2105 - Conduct baseline surveys and assessments.
K2106 - Analyze and disseminate information.
K2107 - Develop a strategic plan for Project Area._________
K2108 - Develop mechanisms for monitoring.
Output K2200 - Development of community based participatory
interventions._________________
K2201 - Identify vulnerable groups and NGO partners.
K2202 - Train/mobilize NGOs and other implementers.______
K2203 - Conduct assessment of vulnerable groups.
K2204 - Train peer educators and supervisors.
K2205 - Implement interventions.
K2206 - Evaluate outcomes and impacts.
K2207 - Disseminate lessons learned and innovations.
K2208 - Provide training resources/opportunities.
X
X
X
Year 3
Q2
Q3
Q4
X
X
X
X
Q1
Year 4
Q2
Q3
X
X
X
X
X
X
X
X
X
X
X
X
X
A
Year 5
Q2
Q3
Q4
X
X
X
X
X
X
X
X
2<
2£
2L_ X
X
X
X
X
X
X
X
X
E
Q1
X
X
X
Q4
X
Output K2300 - Development of a model for STI management at
the “grassroots” level.
K2301 - Baseline assessment of STI services.
K2302 - Select and partner with providers.
K2303 - Train providers.
“
K2304 - Develop a strategy for services to women.
K2305 - Upgrade selected laboratory facilities^
Output K2400 - Improved availability of high quality care/support.
K2401 - Review current practices and resources.
K2402 - Identify priorities for improving care/support.
K2403 - Train care providers.
K2404 - Strengthen VCT services in selected sites.
K2405 - Support the development of PLWHA groups.
K2406 - Assist NGOs to develop plans and proposals.
Q1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
zz
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
2£
X
X
-121-
X
X
X
X
X
X
X
w
Project Implementation Schedule, Rajasthan Component, Years 2-5.
Activity
Q1
Year 2
Q2 Q3
Q4
Q1
Year 3
Q2
Q3
Q4
Year 4
Q2
Q3
Q4
Q1
Year 5
Q2 Q3
Q4
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Q1
Component R1000 - Capacity Building for RSACS and
implementers
Output R1100 - Capacity to gather and analyze information.
R1101 - Train in rapid epidemiologic assessment.
R1102 - Train in collection and analysis of information.
R1103 - Train in situational analysis.__________
R1104 - Train/assist in directed policy research.
R1105 - Train/assist in operational research.
R1106 - Train/assist in monitoring and evaluation.
R1107 - Train/assist in strategic planning.
Output R1200 - Capacity to implement HIV/AIDS programming
R1201 - Train in best practices of targeted interventions
R1202 - Train/assist in peer led interventions.
R1203 - Assist in scaling up of interventions.
R1204 - Train/assist in establishing VCT._________________
R1205 - Train/assist in "grassroots” STI management.
R1206 - Train/assist to integrate program activities.
Output R1300 - Capacity to create an enabling environment for
HIV/AIDS programming.__________________________________
R1301 - Increasing awareness of policy makers.
R1302 - Involve vulnerable groups in programming.
R1303 - Incorporate HIV into social change initiatives.
R1304 - Train/assist in occupational health safety.
R1305 - Train/assist in programming along a continuum.
R1306 - Develop training materials and methods.
X
X
X
X
X
2<
x
X
X
X
X
X
X
X
X
X
X
X
X
X
X
2£
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
-122-
X
X
X
X
tz
X
X
■
Activity
Q1
Year 2
Q2
Q3
X
X
Q4
Q1
Year 3
Q2
Q3
X
X
X
X
X
X
X
X
Component R2000 - Implementation of Demonstration Projects
Output R2100 - Development of a community-based participatory
intervention for rural migrant men_____________________________
R2101 - Identify community of rural migrant men for intervention.
R2102 - Train and mobilize NGOs and other implementing partners.
R2103 - Conduct baseline assessments of migrant population.
R2104 - Train peer educators and supervisors._________________
R2105 - Implement interventions using an iterative approach.
R2106 - Evaluate outcomes and impacts and disseminate
innovations, lessons learned and best practices._________________
R2107 - Provide resources and opportunities for hands on training
for other implementers in interventions.________________________
R2108 - Expand intervention to networked communities.
Output R2200 - Development of a community based participatory
intervention for rural caste-based sex work_____________________
R2201 - Identify community or area for intervention.
R2202 - Train and mobilize NGOs and other implementing partners.
R2203 - Conduct baseline assessments of intervention population.
R2204 - Train peer educators and supervisors.
R2205 - Implement interventions using an iterative approach.
R2206 - Evaluate outcomes and impacts and disseminate
innovations, lessons learned and best practices._________________
R2207 - Provide resources and opportunities for hands on training
for other implementers in interventions.________________________
R2208 - Expand intervention to networked communities.
Output R2300 - Development of a Rajasthan model of the
prevention-care continuum___________________________________
R2301 - Conduct a needs assessment and determine model site.
R2302 - Identify and review best practice models that could be
adapted.________________________________________________
R2303 - Design and implement the model project using a
participatory approach.____________________________________
R2304 - Develop mechanisms for the ongoing evaluation of the
model.__________________________________________________
R2305 - Document and disseminate lessons learned and project
impact._________________________________________________
R2306 - Provide resources and opportunities for hands-on training.
R2406 - Assist NGOs to develop plans and proposals.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
a
X
X
Q1
Year 4
Q2
Q3
Q4
Q1
Year 5
Q2 Q3
Q4
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
x_
X
X
X
X
X
X
X
X
X
X
-123-
X
X
X
X
X
X
X
X
X
X
X
X
X
X
J
Project Implementation Schedule, National Component, Year 1.
First Quarter
1
2
3
____________________________ Activity_______________________
Component N1000 - Capacity Building for NACO and Selected TRGs
Second Quarter
4
5
6
Output N1100 - Incorporation of international experience and expertise into
national HIV/AIDS policy and programming by NACO and TRGs
N1101 - Documentation of best practices
N1102 - Increase the utilization of best practices by NACO and TRGs
N1103 - Conduct directed research to inform decision-making
N1104 - Increase the use of evidence-based advocacy and policy formulation
X
X
X
X
X
Tliird Quarter
7
8
9
Fourth Quarter
10
11
12
X
X
X
X
X
X
Year 4
Q2
Q3
Q4~
I
)(
X
X
X
X
X
Output N1200 - Incorporation of innovations from state and local level
demonstration projects into national HIV/AIDS programming by TRGs/NACO
N1101 - Quantify impacts and costs of HIV/AIDS interventions in Rajasthan and
Karnataka____________
N1102 - Disseminate innovations and best practices to other state and local
programs__________
N1103 - Disseminate innovations and best practices nationally and
internationally
Project Implementation Schedule, National Component, Years 2-5.
Activity
Q1
Year 2
Q2
Q3
qTT QI
Year 3
Q2
Q3
Q4
Component N1000 - Capacity Building for NACO and Selected TRGs
Output N1100 - Incorporation of international experience and
expertise into national HIV/AIDS policy and programming_______
N1101 - Documentation of best practices
N1102 - Increase the utilization of best practices
N1103 - Conduct directed research to inform decision-making
N1104 - Increase the use of evidence-based advocacy and policy
X
X
X
X
X
X
X
X
X
—
X
X
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Year 5
Q2
Q3
X
X
Q4
X
X
X
X
X
QI
X
X
X
Output N1200 - Incorporation of innovations from state and local
level demonstration projects into national HIV/AIDS programming
N1101 - Quantify impacts and costs of HIV/AIDS interventions in
Rajasthan and Karnataka _____________________________
N1102 - Disseminate innovations and best practices to other state
and local programs______________________________________
N1103 - Disseminate innovations and best practices nationally and
internationally
Q1
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
PROJECT REPORTING
15.
15.1 General
The Project Director in Winnipeg will have overall responsibility for liaison with and reporting
to CIDA on the project’s technical and financial progress. Reports will focus on progress
towards achievement of results. It is proposed to provide progress reports on a semi-annual
basis. While monthly expenditure accounting will be provided with monthly invoicing to CIDA,
the financial reports will also be semi-annual.
1
Reporting will be linked with CIDA’s fiscal year as follows:
•
The annual workplan will be for the period between April 1 of one year and March 31 of
the next.
•
A semi-annual report will cover the period April to September of each fiscal year.
•
An annual report will cover the entire fiscal year (April to March).
5
15.2 Annual Workplan and Budget
i
Since this Project Implementation Plan (PIP) has been prepared following the Design Mission,
only a preliminary design framework for the project could be developed with project partners in
India. The project design will be reviewed and revised within the first three to six months after
implementation, including in particular a revised first year workplan.
•
All subsequent annual workplans will cover a fiscal year, and will be prepared in the
month of February prior to the beginning of the fiscal year and submitted to CID A at the
beginning of March each year for finalization by the end of March. The annual workplan
will include:
•
A listing and detailed description of each activity to be carried out during the year, as per
the WBS, and a schedule of implementation.
•
The planned achievements for the year - the expected outputs and progress towards
achievements of the outcomes.
•
The resources required to carry out the activities - list of materials and professional
services required.
•
A procurement plan.
•
A personnel deployment plan.
a
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•
Planned expenditures for project activities, including actual disbursement for previous
years and an updated budget for the remaining years of the project.
15.3 Semi-Annual Progress and Financial Status Report
t
This report will be prepared on the basis of the data collected on the indicators identified in the
PMF. This report will be submitted at the end of October for the period April-September. It will
include:
•
For each activity, progress in achieving results and deviation from the original plan.
•
For each activity, financial status and deviation from the original plan.
•
Explanation of deviations, in results and expenditures, from what were planned.
•
Discussion of contextual changes, issues, problems, assumptions, risks and associated
implementation challenges, and how they will deal with.
•
Minutes of PSC or any other important meetings held during the period and actions
taken.
*
15.4 Annual Report
The Annual Report will also be prepared on the basis of data collected on the indicators
identified in the PMF. This report will be submitted once a year, at the end of May, and will
cover the fiscal year just completed. It will include:
•
Progress towards achievement of each outcome against the original plan and a discussion
of deviations from the plan, with explanations.
•
Technical progress since the beginning of the Project.
•
For each activity, progress in achieving results and deviation from the original plan.
•
For each activity, financial status and deviation from the original plan.
•
Explanation of deviations, in results and expenditures, from what were planned.
•
Discussion of contextual changes, issues, problems, assumptions, risks and associated
implementation challenges, and how they will deal with.
•
Minutes of PSC or any other important meetings held during the period and actions
taken.
•
How the overall project, its results, beneficiaries and budget may be changing from what
was envisioned.
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15.5 End-of-Project Report
An end-of-project report will be produced within three months of project completion. In
addition to including the points addressed in the annual reports, it will focus particularly on
progress towards achieving the project impact.
15.6 Other Reports
In addition to the above-mentioned regular reports, the following reports will be submitted to
CIDA, as and when they are produced.
•
Consultant reports on special assignments.
•
Training workshop reports and evaluations conducted by the project and, where relevant,
by NACO, KSAPS, RSACS and other donors.
i
*
*
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16.
PROCUREMENT PLAN
Procurement for the project will consist primarily of project vehicles, office furniture, equipment
and accessories. All of these items are manufactured and are readily available in India. It is
therefore recommended that for cost-effective procurement and maintenance, as well as for
system compatibility, they all be procured in India. Procurement of most of the major items will
be effected during the first year of the project. Some minor ongoing procurement will be
necessary, particularly partial replacement of vehicles and partial replacement or upgrades of
computer equipment. These items will be identified in the semi-annual and annual reports. The
project office in each state will carry out the procurement in accordance with CIDA procurement
guidelines. At the end of the project, CIDA will be provided with a list of the all the equipment
purchased with project funds and will recommend to CIDA a method for disposal of these assets
in accordance with CIDA guidelines.
t
The following table represents the planned procurement for the first year.
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PROCUREMENT TABLE
Item
No.
Unit Cost
Can $
Total
Quantit
Description
1. Project Vehicles
Vehicles: 4x4
1.1
$19,000
6 in
Year 1,
3 in
______________ Year 3
Total Project Vehicles
2. Office Furniture and Equipment, and Furnishings
$20,000
2 sets
Office furniture and renovations for
2.1
project offices___________
$5,000
8 in
Computer stations, including printers
2.2
Year 1,
4 in
Year 3
$3,500
2
Photocopiers________________
2.3
$1,500
2
Fax Machines________________
2.4
$1,000
8
Office Air-conditioners________
2.5
$1,000
2
Telephone systems____________
2.6
$1,500
2
Television/VCR______________
2.7
$5,000
2 sets
Audio-visual systems for training
2.8
$1,000
2 sets
Miscellaneous kitchen equipment
2.9
2.10 Furnishings__________________
Total Office Furniture and Equipment, and Furnishings
'■
x
ft
I
I
Total Cost
Can $
Intended Time
of Purchase
$171,000.00
Commencement,
with partial
replacement in
Year 3
$171,000.00
$44,000.00
Commencement
$60,000.00
Commencement,
with partial
replacement/
Upgrade, Year 3
Commencement
Commencement
Commencement
Commencement
Commencement
Commencement
Commencement
Commencement
$7,000.00
$3,000.00
$8,000.00
$2,000.00
$3,000.00
$10,000.00
$2,000.00
$14,000.00
$153,000.00
$324,000.00
Total Project Procurement____________
ft
>
*
*<
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17.
FIRST ANNUAL WORKPLAN
The basic elements of the first year workplan are contained in this Project Implementation Plan.
A detailed workplan will be provided at the time of the inception report, within the first six
months of project implementation. The project's work breakdown structure and description of
outputs and activities are described in Sections 7 to 10 above, and the planned activities for the
first year appear in the project implementation schedule in Section 14. The planned first year
budget is given in Section 13, with first year procurement in Section 16. The planned first year
achievements are described below.
17.1 Planned First Year Achievements
17.1.1 Karnataka Component
Component KI 000 - Capacity Building for KSAPS and implementers
1
Within the first year, initial training and support will have been provided for KSAPS and
implementers in the following areas:
•
•
•
•
•
•
•
Rapid epidemiologic assessment (K1101).
Collection and analysis of information (KI 102).
Preparation of situational analyses (KI 103).
Population-based strategic planning (KI 107).
Best practices of targeted interventions (KI 201).
Design and implementation of participatory peer-led HIV prevention interventions
(KI 202).
Principles and strategies for the establishment of voluntary counselling and testing
programs (KI204).
In addition, a number of activities to increase the capacity to create an enabling environment for
HIV/AIDS programming (Output KI300) will have been undertaken. These include:
•
•
•
A
<
Activities to increase the awareness of policy makers.
Training in strategies for incorporating HIV issues into social change initiatives.
Development of high quality training materials and methods.
Component K2000 - Implementation of the Demonstration Project
Within the first year, a number of initial activities will be conducted in support of the
implementation of the district level demonstration project. These include:
•
•
•
Selection of the project area and the establishment of partnerships with implementers and
community members (K2101).
An initial exercise in the zoning and mapping of the project area (K2102).
A review and documentation of the information base (K2103).
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**
?
•
•
•
•
f
w
•
•
•
•
I
*
«
The conduct of preliminary baseline surveys and assessments (K2105).
Analysis and dissemination of information from preliminary baseline surveys and
assessments (K2106).
Identification of vulnerable groups and potential NGO implementing partners (K2201).
Initial training and support for implementing partners in the development of community
based interventions (K2202).
An initial assessment of vulnerable population groups (K2203).
A baseline assessment of STI services (K2301).
A review of current care and support practices and resources (K2401).
An initial identification of priorities for improving care and support services (K2402).
17.1.2 Rajasthan Component
Component KI 000 - Capacity Building for KSAPS and implementers
1
The first year achievements in this component will be similar to those in Karnataka (see above).
They include training and support in:
•<
•
•
•
•
•
•
•
Rapid epidemiologic assessment (R1101).
Collection and analysis of information (R1102).
Preparation of situational analyses (R1103).
Population-based strategic planning (R1107).
Best practices of targeted interventions (R1201).
Design and implementation of participatory peer-led HIV prevention interventions
(R1202).
Principles and strategies for the establishment of voluntary HIV counselling and testing
programs (R1204).
The planned first year achievements in creating an enabling environment in Rajasthan (Output
R1300) are also the same as those in Karnataka and include:
•
•
•
Activities to increase the awareness of policy makers.
Training in strategies for incorporating HIV issues into social change initiatives.
Development of high quality training, materials and methods.
Component R2000 - Implementation of Demonstration Projects
For the implementation of the community-based interventions for rural migrant men (Output
R2100) and rural caste-based sex work (R2200), the following activities will be conducted in the
first year.
. <■
•
•
•
Identification of communities for the implementation of interventions (R2101 and
R2201).
Initial training and mobilization of NGOs and other implementing partners (R2102 and
R2202).
Conduct of initial assessments of the intervention populations (R2103 and R2203).
-131 -
For the development of a Rajasthan model of the prevention-care continuum, the following
activities will be conducted in the first year:
•
•
A needs assessment and selection of a model site (R2301).
Initial identification and review of best practice models that could be adapted
(R2302).
t
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17.1.3 National Component
At the national level, the following activities will be conducted during the first year:
•
•
•
•
Documentation of best practices from India and elsewhere (Nl 101).
Work with NACO and TRGs to support the utilization of best practices (N1102).
The conduct of selected policy-relevant operations research to inform decision-making
(N1103).
Activities to increase the use of evidence in advocacy and policy formulation (N1104).
*
I
17.1.4 Project Management Component
The following activities will be conducted in the first year in relation to project management:
•
•
•
•
•
•
Development of systems for internal project monitoring.
Establishment of financial systems for disbursement of funds and funds flow.
Mobilization and relocation of Resident Canadian Coordinators to India.
Establishment of project offices and procurement of equipment in Rajasthan and
Karnataka.
Hiring of Indian support staff and technical advisors.
Establishment of the Canadian management office and support services.
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