OTHER ACTIVITIES /ACHIEVMENTS Treatment of Sexually Transmitted Infections (STI) National Centre of Dermatology and Venereal Diseases provides STI treatment for migrants and vulnerable women via 45 FCs; Trained doctors/consultants in 28 Trust points for IDUs and 16 Friendly Cabinets for SWs and MSM provide STI treatment for at-risk groups; 18 Youth-friendly Clinics provide STI treatment for vulnerable youth; STI treatment is provided to prisoners either. Cross-cutting issues: Stigma and Discrimination Islamic Institute of Tajikistan: 2- and 3-year students are lectured on HIV prevention and S&D; State Committee on Women and Family Affairs: HIV prevention and S&D issues for women-leaders and community activists; Tajik Medical Institute of Postgraduate Studies: training on S&D among health care providers and medical students (a designed module incorporated in curriculum). Blood safety Republican Scientific Blood Centre is supplied with ELISA screening tests for HIV/AIDS and HCV detection/confirmation; 4 blood collector vehicles delivered to reach distant regions; 69 computers and 2 laptops provided to set-up IT database in all blood centers; HIV/AIDS Project: Key Achievements as of 1 January 2012 Impact 16.3% IDUs who are HIV infected; (BSS 2010) 8.5% HIV prevalence among prisoners (BSS 2010). 7% in 2007 8% in 2008 9% in 2009 - 53% of HIV positive people infected through injecting way (report of National AIDS center, December 2011) Outcome 69% IDUs reported the use of sterile injecting equipment the last time they injected (BSS 2010); 46% IDUs had voluntary and counseling testing in the last 12 months (BSS 2010); - 64.5% health professionals demonstrated readiness to provide health services to PLHIV at the same quality level with the same attitude as to all other people (S&D 2010).
Includes: 1 Information, Education and Communication and Behaviour Change Communication (IEC an BCC); 2 NSEP 3. Condom promotion and distribution; 4. OST; 5. Stigma reduction associated with drug use and HIV;
HIV Service Mapping is a critical and first step of optimizing service deliver to ensure effective collaboration, integration and cordination. Lists of the services are generalized as below: TPs (Trust Points) for IDUs (NAC) – 21 FCs (Friendly Cabinets) for SWs (NAC) – 10 FCs for migrants (Dermatology Centre) – 10 Youth friendly centre (UNICEF) – 18 TPs for IDUs (NGO) – 4 Youth Voluntary Clubs in rural areas (Youth Com) – 51 OST sites (Narcological Centre) - 3
We don’t do only: “Vaccination, diagnosis and treatment of viral hepatitis” Source: WHO, UNODC, UNAIDS, http://www.unodc.org/documents/hiv-aids/idu_target_setting_guide.pdf NSP- we are currently supporting 21 NAC’s NSP centers, 4 through local NGOs and 1 in the prison setting. In addition, we provide commodities for NSP of other donor projects (CARHAP- DFID and PSI- USAID). Overall, yearly HIV project distributes around 5 mln needles and syringes. OST has been launched in 2010 in Dushanbe and expanded to 2 more regions (Khujand and Khorog) in 2011. Currently, we are supporting approximately 230 IDUs (as of April, 2012). The main purpose of the OST program is reduce burden of injective way of HIV transmission, and increase adherence to ARV treatment; There are 35 AIDS centers in Tajikistan providing Voluntary Testing and Counseling. The dynamic of VCT is increasing. In the 1 st quarter of 2012 - 117,696 people undergone VCT. As of april, 2012 – 832 people are on ARV treatment. About 95% are on the 1 st line drugs, 5% are on the 2 nd line drugs; STI treatment is provided for migrant population through 45 Friendly cabinets and through Youth Friendly Cabinets for young people. Syndromic treatment according to WHO standards is used. Condom distribution: for quarter 1 of 2012- more than 1 mln condoms were distributed; IEC materials are available and are printed for all vulnerable and most-at risk population groups (throughout all HIV grant components); We don’t do Hep vaccination, but support diagnosis, and treatment of only HIV + people through NAC. 35 patients received treatment in quarter 1 of 2012 in ARV clinics; TB diagnosis and treatment for HIV+ people are free.
*psychologists, skin and venereal disease doctors, TB doctors, surgeons, etc
Governmental entities box: Social support : escort to VCT/other medical points, counseling, referral, services of lawyer/psychologist; Civil society/NGO box: Engagement and referral of clients : CBOs encourage clients to have VCT, referral coupons developed and successfully is being implemented since 2010 to boost VCT among IDUs; Low threshold services : shelter, laundry, cooking/meal, shower, counseling, training and info sessions, IEC materials;
*Provision of irreplaceable government services to IDUs : provision of OST, VCT, BSS, blood screening for HIV/STI, HIV prevention in penitentiary, peer education among uniformed staff (five law enforcement agencies: MoD, National Guard, MoIA, Committee on emergencies, Committee on border patrol), STI treatment; *Provision of regulatory acts and norms: elaboration, testing and approval of standards, norms and guidelines on various services (previous point). * Legitimacy of the services – working on the GoT level provides services with legitimate basis, corresponding to laws/regulations/guidelines approved. Due to what the services provided are considered ‘irreplaceable’ and legal (example will be National program on HIV/AIDS, Law on HIV/AIDS stipulating the rules of working with MARP- confidentiality, free services, etc.).
OST : Dushanbe – 120 IDUs, Khujand – 58 IDUs, Khorog – 52 clients. After opening the 1 st centre in 2010, it was found that selection criteria quite rigid, after simplifying selection criteria it has resulted into drastic increase (64%) of OST patients in 2011. Nonetheless, the co-infected IDUs with TB, HIV, HCV are prioritized to provide OST. Also, it is anticipated to conduct research/assessment in summer 2012 to find out the impact of this initiative to IDUs; NSEP: The rapid assessment conducted in November 2009 revealed that less than 50% prison-inmates use drugs; 50-75% prisoners (75-83% prison staff) state the transfer of HIV happens via common syringes; 28.6% prison staff confirms the overdose among IDUs; 51.7% prison staff do not know how to help in case of over-dose; 57% prisoners and 50% prison staff assert that HIV spread could be reduced by using single-use/sterile syringe. Based on findings of assessment, a regulations “About conditions and procedure of NSEP among IDUs in penitentiaries of MoJ of RT” has been developed; study tour to Switzerland for penitentiary staff was organized in 2010; advocacy and awareness program on basics of HR was developed; trainers and volunteers were trained; unified M&E system implemented.
High stigma and discrimination: Czech Trust Fund initiative : It consisted of 2 steps: Study tour to the Czech republic and a workshop in Tajikistan. This initiative brought together a mu lti-disciplinary team of law enforcement and public health agencies to discuss urgent problems, and achieving a consensus with regards to a variety of problems surrounding programs for IDUs. One of the most important one was stigma and discrimination. The Czech organization has conducted a situation analysis regarding S&D and released a report on tackling S&D towards IDUs in Tajikistan. The report is on the stage of translation and dissemination among local partners. Also, the Tajik Medical Institute of Postgraduate Studies was contracted betw. Jul’10-Sept’11 with the purpose of S&D reduction towards HIV+ patients via preparing trainers in health care sector nationwide for them to further train medical students/doctors; module “S&D towards PLHIV and creation of favorable environment in health care sector” was incorporated into curriculum. For example, overall, 2711 physicians and middle level medical personnel were taught in 2011. The aim of the training is to contribute in reduction of S&D among medical personnel countrywide. Assessments conducted every two year (2008-2010-2012-2014) to analyze the situation and take appropriate measures and plan accordingly. Distribution of pharmaceuticals challenged by the law: UNDP’s proactive role: 1. review, analysis and facilitation of further revision of current legislation regarding pharmaceutical (hiring consultant); 2. Lobbying&advocacy on the level of MoH; 3. Promotion of interests of NGOs as key player in this issue; 4. involvement of GF into this issue (meeting with deputy prime minister). CCM as a mediation : As a coordination mechanism, CCM was involved in tackling the issue of pharmaceuticals distribution. By intervention of CCM the meeting was held betw. MoH and NGOs to clarify the issue and come to mutual settlement/agreement. Late detection of HIV status and acceptance of treatment : Linkage betw. GoT and NGOs : Coordination of work between the GoT, partners and CBOs will considerably impact the earlier HIV detection and project/forecast the needs of the county. Build trust and effective collaborative relationships between 3 parties: donor-GoT-civil society. Relevant and effective mechanisms to be enhanced/streamlined and implemented (e.g. referral, awareness campaigns, access to VCT in remote places, etc)
Harm Reduction program sustainability: one of the important strategies of UNDP is to gradually hand the program over to the GoT (full ownership). However, there are perceived risks (according to various assessments, evaluations, weak national mechanisms). Drug situation in T-n : Tajikistan is situated in the south-eastern part of Central Asia, bordering with Uzbekistan, Kyrgyzstan, China and Afghanistan. With its long boarder (1344km) shared with Afghanistan the main regional drug producer, Tajikistan serves as a shield for the trafficking of drugs from Afghanistan to the Central Asian countries, Russia and further to Europe, but also faces the threat of national drug abuse and the long term social consequences thereof. Against this background the government of the Republic of Tajikistan approved the “Universal state target programme of prevention of drug abuse and control of illicit drug turnover in the Republic of Tajikistan for the years of 2008-2012” on 30th November 2007. Though required measures for the prevention of drug addiction have been taken considering the danger of the spread of drug abuse and crimes related specifically to drug trafficking, the current situation is far from satisfactory: The number of drug addicts in Tajikistan has steadily grown during the course of the past decades. According to official statistics of the Ministry of Health, there were 8018 registered drug users, including 4583 injecting drug users(57,4% of total drug users), in 2009. In 2008 1,422 people were infected with HIV were registered. The HIV prevalence among drug users was 10.2%, the prevalence of Hepatitis C was 29.9%. 55.6% of the drug users were injecting. (http://cadap.eu/en/node/11)
Following strict UNDP recruitment and tender rules on subcontracting CSOs: NGOs have to follow minimum standards of HR programming while applying; the cost effectiveness per client is used (UNFPA standard); panel of recruitment commission integrates UNDP, other international org-s, and GoT entities’ representatives; Consistency of capacity building of GoT and civil society organizations – on job coaching and trainings from UNDP/GFATM side as well as inviting international experts. All the training and capacity building activities are conducted within the frame of international standards. Liaison of relationships between GoT and civil society organizations- MoUs exist between AIDS centers and NGOs; between skin-venereal disease hospitals and NGOs, etc. Establishment and strengthening horizontal and vertical partnerships in HIV programs- UNDP plays a key role in Establishment and strengthening horizontal and vertical partnerships in HIV programs. Horizontal- NGO-GoT; and vertical: donor – GoT - NGO;
Tajikistan: Optimizing service delivery: promoting linkages, integration and collaboration
Tajikistan: Optimizing service delivery: Promoting linkages, integration and collaboration Dr. Tedla Mezemir Programme Manager , UNDP Tajikistan
Presentation Outline• Background Information• Approaches of optimizing service delivery through promoting linkages, integration and coordination• Challenges and perceived risks• Resolving challenges• Lessons Learnt
GENERAL HIV PROJECT INFORMATION Strengthening the supportive environment andProject title scaling up prevention, treatment and care to(Round 8) contain HIV epidemic in TajikistanPrincipal United Nations Development ProgrammeRecepient Phase 1: 01/10/2009 to 30/09/2011Period covered Phase 2: 01/10/2011 to 30/09/2014 Phase 1: $ 20,028,139.45Budget Phase 2: € 17,050,694 8 Governmental StructuresPartners /SRs 14 Local Non-governmental Organizations 5 International Organizations
HIV/AIDS Project: Key Achievements as of 1 January 2012 - Reached cumulatively 10 223 IDUs (denominator - 25,000)At-risk groups reached - Reached cumulatively 9 420 SWs (denominator - 12,500)by HIV prevention - Reached cumulatively 2 732 MSM (denominator - 30,000) - Reached yearly 4 580 prison inmatesVulnerable groups - Covered cumulatively 618 724 youth aged 15-24covered by peer - Covered cumulatively 1 154 033 labor migrants andeducation on HIV vulnerable womenprevention - Covered cumulatively 17 718 uniformed staff - Cumulatively 121 pregnant women received ARVTARVT received - Cumulatively 769 PLHIV currently on ARVT - Counseled and tested 5 114 IDUs yearlyVoluntary counseling - Counseled and tested 4 247 SWs yearlyand testing - Counseled and tested 181 789 pregnant women yearlyCondoms - Distributed cumulatively 15 804 358Opiod Substitution - Received cumulatively 296 IDUs in three sitesTherapy
Business model of Harm Reduction programNine components of Harm Reduction program:• Needle and syringe programmes (NSPs)• Opioid substitution therapy (OST) and other drug dependence treatment• HIV testing and counselling (T&C)• Antiretroviral therapy (ART)• Prevention and treatment of sexually transmitted infections (STIs)• Condom programmes for IDUs and their sexual partners• Targeted information, education and communication (IEC) for IDUs and their sexual partners• Vaccination, diagnosis and treatment of viral hepatitis• Prevention, diagnosis and treatment of tuberculosis (TB).
Service flow for IDUs – from client prospect Outreach Low work: peer threshold support services and referral Provision of Socialcommodities for support safe sexual behavior and care Awareness raising Consultations (trainings, of varioussessions, IEC specialists* materials)
Technical collaboration and integration of Services for IDUs – Provider prospect Donors Prevention, Treatment,Governmental care and entities Civil society/ NGOs support for IDUs
Linkages between key players of HIV programs working with IDUs
National collaborative essentials on HIV/AIDS (Roles and responsibilities) Governmental entities DonorsCivil society/ NGOs
BREAKTHROUGH HIV IMPLEMENTED INTERVENTIONSOpiod Substitution Dushanbe-based site opened in June 2010;Therapy launch Khujand-based site opened in February 2011;(authorized by the Khorog-based site opened in June 2011;Government in 2009) As of April 2012, 230 IDUs/PLHIV under OST In March 2010 a pilot NSE point was opened inNeedle/Syringe prison to supply with sterile equipment for IDU-Exchange program prisoners; it is anticipated to open another NSElaunch in prison point in summer 2012;(authorized As of 1 April 2012, 35 prisoners use the servicesby MoJ in 2009) of NSE
Other Challenges•Time-sensitive procurement of life-saving anddiagnostic health products such as test kits inextremely difficult circumstances (budget deficit,difficulties with delivery to final destination due todifferent reasons such as geographical location,changes of specifications, inadequate planning andprojection of country needs, fluctuation of theprices on global market)•Lack and frequent turn over of qualified humanresources.•Inadequate regular coordination among donorsand national stakeholders
Perceived risks• Harm Reduction program sustainability: Huge infrastructure development such as building labs, hospitals will need sustainable maintenance, HR and running cost in the future… This is perceived as risk beyond constructions• Reliance on external funding to HIV/AIDS programs : All commodities, drugs, lab supplies and major HR cost covered by GF project which …• Long term risks: Narcotic drug – market situation in the country (Possibility of abrupt increase of IDUs; outburst of HIV epidemics)
UNDP’s approach in enhancing HR program • Following strict UNDP recruitment and tender rules on subcontracting CSOs; • Consistency of capacity building of GoT and civil society organizations; • Promote positive relationships between GoT and civil society organizations; • Establishment and strengthening horizontal and vertical partnerships in HIV programs; • M&E: Advance planning, joint M&E with partners, collaborative approach in addressing obstacles;
Lessons Learnt• To optimize service delivery it is important to ensures coordinations at donors level, at implementers level as well as integration of services at service delivery points• Identifying challenges and risks through monitoring , regular surveillance and studies to institute timely risk mitigation plans and customized approach to the situation