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STANDARD CONCEPT NOTE In Investing for impact against HIV, tuberculosis or malaria A concept note outlines
STANDARD CONCEPT NOTE In Investing for impact against HIV, tuberculosis or malaria A concept note outlines

STANDARD CONCEPT NOTE

In

Investing for impact against HIV, tuberculosis or malaria

A concept note outlines the reasons for Global Fund investment. Each concept note should describe

a strategy, supported by technical data that shows why this approach will be effective. Guided by a

national health strategy and a national disease strategic plan, it prioritizes a country’s needs within

a broader context. Further, it describes how implementation of the resulting grants can maximize the impact of the investment, by reaching the greatest number of people and by achieving the greatest possible effect on their health.

A concept note is divided into the following sections:

Section 1:

A description of the country’s epidemiological situation, including health systems and barriers to access, as well as the national response.

Section 2: Information on the national funding landscape and sustainability.

Section 3:

A funding request to the Global Fund, including a programmatic gap analysis, rationale and description, and modular template.

Section 4: Implementation arrangements and risk assessment.

SUMMARY INFORMATION

 

Applicant Information

Country

Philippines

Component

Choose an item.

Funding Request Start Date

01 July 2015

Funding Request End Date

31 December 2017

Principal

Save the Children (SC)

 

Recipient(s)

Funding Request Summary Table

SUMMARY INFORMATION Applicant Information Country Philippines Component Choose an item. Funding Request Start Date 01 July

A funding request summary table will be automatically generated in the online grant management platform based on the information presented in the programmatic gap table and modular templates.

SECTION 1: COUNTRY CONTEXT

This section requests information on the country context, including the disease epidemiology, the health systems and community systems setting, and the human rights situation. This description is critical for justifying the choice of appropriate interventions.

1.1 Country Disease, Health and Community Systems Context

With reference to the latest available epidemiological information, in addition to the portfolio analysis provided by the Global Fund, highlight:

  • d. The health systems and community systems context in the country, including any constraints.

  • b. Key populations that may have disproportionately low access to prevention and treatment services (and for HIV and TB, the availability of care and support services), and the contributing factors to this inequality.

  • c. Key human rights barriers and gender inequalities that may impede access to health services.

  • a. The current and evolving epidemiology of the disease(s) and any significant geographic variations in disease risk or prevalence.

The HIV prevalence in the country remains low at less than one percent. But the Philippines has been identified in the 2012 United Nations Global Report as one of nine countries to have registered more than 25% increase in HIV incidence between 2001 and 2011 despite the declining trend of HIV epidemic in the world. 1 As of April 2014, there was one new case reported every 1.5 hours compared to one case per 24 hours in 2007. 2 Figure 1 shows the trend of HIV and AIDS cases at the national level since the first HIV case surfaced in 1984.

From 1984-2014, males comprised 90% (16,412) of the cumulative HIV cases while females were only 10%. The age groups with the most number of cases were: 20-24 years (23%), 25-29 (31%),

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Figure 1. Trends in HIV and AIDS Cases at the National Level , 1984-2014

  • a. Current and evolving epidemiology

1 Department of Health (2014), AIDS Epidemic Model Impact, Modeling and Analysis, Philippine Case Study, p.5. Annex 1. 2 Department of Health (April 2014), Philippine HIV and AIDS Registry. Annex 2.

and 30-34 years (19%). Ninety-three percent (17,051) were infected through sexual contact and 5% (829) through needle sharing among injecting drug users (IDUs). Males having sex with males (MSM) was the predominant mode of transmission at 84%. Of the total 1,680 AIDS cases, 83% were male and 17% were female. There were 981 reported deaths among people with HIV and the majority was male at 81%. There were 116 reported deaths among youth aged 15-24 years old and 15 among children below 15 years.

The geographic distribution of the cumulative HIV cases shows that five regions comprised 85% of the total, while the remaining 14% came from the rest of the country (ROTC). Half (8,401) of the cases came from the National Capital Region (NCR). Figure 2 shows the percentage by region, 1984-2014. 3

and 30-34 years (19%). Ninety-three percent (17,051) were infected through sexual contact and 5% (829) through

Figure 2. Percentage of HIV cases by region, 1984-2014

There was a significant decrease in HIV prevalence among registered female sex workers (RFSW) from 0.13% in 2011 to 0.07% in 2013, but the prevalence among freelance female sex workers (FFSW) had increased from 0.68% in 2011 to 1.03% in 2013 4 . However, a shift in the predominant mode of transmission from heterosexual contact to MSM was observed in 2008. The transmission of HIV among People Who Inject Drugs (PWID) was also detected in Cebu City in 2010. Due to changes in epidemiological evidence and the drivers of the epidemic, the National Epidemiological Center (NEC) of the Department of Health (DOH) decided to include the most-at- risk-populations (MARPs) e.g. MSM, Female Sex Workers or FSW and IDU) in the 2011 Integrated HIV Behavioral and Serological Surveillance (IHBSS). The surveillance findings confirmed that the concentrated epidemic among MSM and IDU/PWID is evolving in certain geographic sites. 5

In 2013, the NEC-DOH conducted the IHBSS in 21 sites among MSM, and two sites among IDU (See Table 1). The results of the 2013 IHBSS further confirmed that HIV transmissions are now mostly concentrated among these two key populations. Findings indicated that the national HIV prevalence among MSM increased from 1.68% in 2011 to 2.93% in 2013. In six cities, MSM prevalence is >4% (See Table 2). There was a significant increase in HIV prevalence among IDU in Cebu and Mandaue from 2005-2013 as shown in Figure 3. 6

Table 1. HIV Prevalence among MSM, IDU and Transgender (TG)

  • 3 See Annex 1.

  • 4 2014 Global AIDS Response Progress Reporting | Philippines, p.8. Annex 3.

  • 5 Philippines Health Sector Strategic Plan on HIV and STI 2015-2020 (HSSP), p.14. Annex 4.

  • 6 2013 IHBSS Briefer MSM and Male IDU. Annex 5.

 

Geographic

                   

Sites/Cities

MSM

IDU

TG

         

HIV

       

N

HIV

N

HIV

MSM

MSM

%

IDU

IDU

%

N TG

IDU

%

Bacoor

300

10

3.33%

           

San Jose Del Monte

300

 
  • 3 1.00%

           

Butuan

300

 
  • 3 1.00%

           

Puerto

                 

Princesa

300

  • 6 2.00%

Batangas

300

 
  • 3 1.00%

           

Bacolod

301

 
  • 2 0.66%

           

Mandaue

305

 
  • 0 0.00%

 

98

  • 260 37.69%

     

Cebu IDU male

       

239

  • 457 52.30%

     

Cebu IDU

                 

female

31

  • 102 30.39%

Angeles

300

 
  • 7 2.33%

           

Baguio

299

 
  • 5 1.67%

           

Iloilo

300

 
  • 2 0.67%

           

Cebu

300

 
  • 23 7.67%

     

300

11

3.67%

Davao

300

 
  • 15 5.00%

           

General Santos

301

2

0.66%

           

Cagayan De

                 

Oro

300

14

4.67%

Zamboanga

300

 
  • 8 2.67%

           

Pasay

300

 
  • 9 3.00%

           

Quezon City

304

 
  • 20 6.58%

           

Makati

300

 
  • 11 3.67%

           
 

Table 2. Cities with the Highest HIV Prevalence among MSM, 2009-2013

Cities

2009

2011

2013

Quezon

1.4%

5.6%

6.6%

Manila

3.7%

4.3%

6.7%

Caloocan

0.7%

0.3%

5.3%

Cebu

1.0%

4.7%

7.7%

Davao

3.7%

3.0%

5.0%

Cagayan De Oro

n/a

1.9%

4.7%

Table 2. Cities with the Highest HIV Prevalence among MSM, 2009-2013 Cities 2009 2011 2013 Quezon

Figure 3. HIV prevalence among IDU, 2005-2013

The geographic sites discussed above belong to the C45 Priority Sites (See Map 1 in Annex 6) which have been identified in the Health Sector Strategic Plan (HSSP) for HIV and Sexually Transmitted Infections (STI) 2015-2020 as the focus of interventions. These priority sites contribute to more than half of the epidemic due to multiple risks and high prevalence.

According to the AIDS Epidemic Model (AEM) baseline scenario, if the current level and coverage of interventions will be maintained, infections will continue to increase. There will be around 57,236 People Living with HIV and AIDS (PLHIV) by 2017, and this will increase to 336,181 by 2030. MSM will continue to be the most affected population. In 2017, there will be 10,273 new infections among MSM, accounting for 90% of all new HIV infections. This proportion will continue to increase and reach 91% (38,643) by 2030.

To avert the rapid rise in HIV infections and contribute to systems strengthening, the AEM recommends that the Philippines adopts a policy scenario that is focused on: Scale-up Prevention Coverage to 80% of MSM and PWID, Sustain Prevention Coverage among FSW, and Scale-up Treatment Coverage to 90% of PLHIV with CD4 of 350 and below.

b. Key populations

Based on the epidemiological evidence, the HSSP for HIV and STI 2015-2020 included MSM, FFSW, RFSW, PWID, TG women and Young People (high risk) as key populations and focus of prevention, care and treatment interventions. As shown by the current and evolving epidemiology, the main drivers are MSM and PWID. In the HIV Concept Note under the New Funding Model (NFM) of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the target groups are MSM, PWID and TG women. Although there is no population estimate on TG at the national level, this key population is included in the Concept Note on the basis of the preliminary data collected in Cebu, the observation that HIV prevalence in transgender communities is estimated to be as high

as 68% worldwide 7 , and the recommendations gathered from the Key Affected Population (KAP) consultations with MSM and TG. 8

Both the External Mid-Term Review of the 5 th AIDS Medium Term Plan (AMTP5) conducted in October-November 2013 and Global Fund (GF) Portfolio Analysis of the Philippines HIV and AIDS grant (June 2014) pointed out key issues that are cross-cutting among the MSM, PWID and TG, namely: low condom use, low health seeking behaviors and low prevention coverage and uptake of prevention services. Although prevalence is high, only a few PWID, MSM and TG know their HIV status. Stigma and discrimination, legal barriers and the inadequate package of comprehensive services are the key factors preventing them from accessing care and treatment.

Males who have Sex with Males (MSM). As of 2014, there are 685,416 MSM in the country and according to the population size estimates of AEM, 40.20% (276,583) came from Category A sites 9 . Survey results from the 2013 IHBSS showed that 34% of MSM belong to the 20-24 year old age group, majority (84%) of them are living with a partner, 50% graduated from high school and 45% are bisexual. Findings further showed that as they grow older or when they are between the ages of 18-24, they engage in more risky sex or the anal positions. High-risk behavior exists among MSM as evidenced by the very low condom use during their last anal sex (36%). Only 35% of them have correct knowledge of HIV, and less than half (31%) among the 15 years old and above had accessed the Social Hygiene Clinic (SHC) for consultation and treatment in the past 12 months before the conduct of the 2013 IHBSS. Only 23% of MSMs were reached with prevention interventions. Linkages between peer outreach and HIV testing, STI and other services are weak. The External Review of AMTP5 found out that only 15% of MSM have ever had an HIV test, and in 2011, only 5% of those tested know the result. 10 The 2013 IHBSS found out that there was no significant increase because only 8% of MSM had received an HIV test and knew the results in the last year. This was mainly attributed to the poor quality of peer education, stigma and discrimination.

People Who Inject Drugs (PWID). As of 2014, the AEM estimates that the number of PWIDs in the country is 9,380, 66% (6,140) of which are from Category A sites. The HIV prevalence among male PWID in Cebu City reached 52.3% in 2013. The HIV prevalence among female PWIDs in Cebu City is also high at 30.39%. The median age of first drug use among males was 16 years old, while the median age of first injected drug use among males was 19 years old. Ninety-eight percent of them injected nalbuphine, with an average of three injections per day. HIV knowledge is low among PWID (only 35% correctly answered 5 questions about HIV) and 35% had shared needles during their last injection. 11 The shooting gallery in Cebu City was the place where 70% of male IDU usually injected drugs while 10% do it at home. At least 31% of them got needles from a clean source and did not share needles in their last injection. Many of them (53%) knew that there were STI services at the SHCs and stated that they were comfortable to go to the SHC for STI consultation. However, the level of knowledge did not translate into actual access of services as shown by the low access of SHC services (only 10%). There was a decrease in the percentage of male IDU who got their HIV test result in the past 12 months from 9% in 2011 to 6% in 2013. Most of them (43) cited that they forgot to get the results. Moreover, there was an increased risky sexual behavior among them as indicated by the decrease in condom use with their permanent female partners from 27% in 2011 to 17% in 2013.

Like MSM, the current HIV prevention program among PWID is minimal and the coverage is low. In antiretroviral therapy (ART) enrolment, lost-to-follow-up among PWID is a major problem. Overall, the scale of harm reduction interventions particularly the needle and syringe program is insufficient to generate any measurable impact on the spread of HIV in this KAP. This situation requires an enabling environment that promotes health-seeking behaviors, that is supported by national laws or local ordinances that will allow the implementation of a harm reduction program.

Transgender (TG). Except for the 2013 IHBSS data in Cebu City, there is no official estimate on the total number of TGs in the country. There is no current surveillance data in the Philippines to

  • 7 International AIDS Society: Key Affected Populations Fact Sheet, March 2014. Annex 7.

  • 8 Compiled Reports on Recommendations from KAP Consultations. Annex 8.

  • 9 Category A, B and C sites are part of the DOH’s priority areas for HIV intervention which shows the cities and municipalities that have been identified as the highest priority for intervention. Category A sites are those cities requiring the highest priority followed by Categories B and C.

    • 10 Philippine National AIDS Council (2014) External Mid-Term Review of the 5 th AIDS Medium Term, p. 54. Annex 9.

    • 11 See Annex 5.

show the magnitude of HIV among TGs. Neither is there any official definition of transgender in the Philippines, although almost exclusively when the term transgender is used, it refers to transgender women. A 2011 survey of TG women in three sites showed differing definitions of transgender among the group, but most frequently, TG people define TG as someone who was born male, had taken female hormones and/or someone who looked and acted like a woman (although this is subjective). Further, there is a perception that TGs are engaged in sex work in big cities, such as Metro Manila and other highly urbanized areas 12 . One of the hindering factors determining HIV prevalence among TGs is the lack of effective and quality intervention services that are customized to their needs.

Fifty percent of the 300 respondents in the 2013 IHBSS for TG in Cebu City belong to the young age group of 18-24 while 31.7% came from the older age group. Majority are single (97.3%), 60% said that they were TG while 39.7% identified themselves as female. Majority of them (97.3%) graduated from high school. Of the 300 TG sex workers sampled, 60% were engaged in full-time sex work (sex worker without other occupation) while 40% were sex workers with other occupation. In the youngest age group 15-17 years old, almost 87% were sex workers without other occupation.

In terms of their sexual behavior, most had an early initiation to sex with the youngest at 11 years old. The median age for oral sex was 13 while first anal sex was at the age of 17. The average number of male sex partners in the past 30 days prior to the interview was nine (9). The median age for first condom use was 18 and some did not know how to use a condom (19.7%). Older TGs have higher number of sexual activities which ranged from oral to anal sex.

It is evident from the responses that information and communication technology (ICT) tools were popular among TGs as a channel for social interaction and sexual activities. Majority of the TG (97.0%) have an account in a chat messenger, website, online social network, or mobile application. Male partners or sex clients were met through these Internet sites. More than a third (35.7%) of the respondents reported having oral sex partners met through online accounts and 35.5% reported having anal sex partners met through online accounts. Of those who reported having had oral sex with partners met through online accounts, the average is 11 oral sex partners. The same average number is computed for those who had anal sex with partners whom they met from online accounts.

Facebook has the highest proportion of membership (86.9%) followed by Ladyboy Kisses (44.3%). Yahoo, Twitter, Skype and Date in Asia and person.com were also identified as popular venues for TG.

Apart from risky sexual behavior, at least 20% of them reported to have used drugs in the past 12 months, and four of them have used needle and syringe already used by another IDU. Of the respondents, 20% reported to have used drugs in the past 12 months. A third (32.6 percent) of those in the 25 years and older age bracket were highly engaged in drug use. Knowledge of HIV transmission is also low with only 50% able to answer correctly all five knowledge questions. Less than half (46%) were aware that SHC in Cebu offers HIV testing and other services

TGs are a neglected population, which makes them particularly vulnerable to HIV and STI infection; tailored prevention interventions are not available. Even though the needs of TGs are different from MSM, no customized prevention, care and treatment services have been developed for them. Systematic implementation of prevention services for these populations has focused on stand-alone behavioral change communication (BCC), which did not demonstrate effectiveness in changing behaviors among the TG people. There is a plan to address this data gap on TG population size estimation in the 2015 IHBSS.

  • c. Human rights and gender constraints

The Philippines has signed and ratified core human rights instruments, including the International Covenant on Civil and Political Rights (ICPR), International Covenant on Economic, Social and Cultural Rights (ICESCR), Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW), Convention on the Rights of the Child (CRC), Convention on the Rights of People with Disabilities (CRPD), Convention on the Elimination of all Forms of Racial

12 2013 IHBSS among Transgender people in Cebu City, Philippines, Statistical Report, February 3, 2013. Annex 10.

Discrimination (CERD) and other human rights treaties. However, prejudice towards the lesbians, gay, bi-sexual and transgender (LGBT) people continues to exist in Philippine society and culture 13 . This situation is indicated by the following:

Lack of basic sensitivity and recognition of the LGBT rights

The Constitution states that the State guarantees full respect for human rights and every person has the right to equal protection of the laws, but sexual orientation and gender identity are not explicitly mentioned. The Revised Penal Code of the Philippines, as well as other criminal laws, does not have provisions punishing hate crimes.

The Philippines has no comprehensive anti-discrimination law. At the LGU level, there are only three (3) cities that have enacted anti-discrimination ordinances. These are Quezon City, Cebu City and Davao City. Quezon City’s local ordinance specifically focused on anti-discrimination in the workplace based on sexual orientation and gender identity. While there are specific anti-discrimination provisions in the Philippine National Police (PNP) Code and the Magna Carta of Social Workers, these are not fully enforced.

Stigma and discrimination among MSM continue to be a major obstacle to improving public health interventions among MSM and increasing service coverage. The AMTP5 External Review noted that the weak uptake of HIV testing and counseling is the most obvious result of the fear of LGBT populations to face the results of HIV testing.

In the case of PWID, drug use in the Philippines is strictly treated as a criminal offense rather than a social or health issue. Hence, harm reduction for HIV prevention among PWID is very difficult to scale up at the national level.

The climate of religious conservatism which prohibits condom use and the open education on issues such as sexual orientation and sexual reproductive health and rights also hinders MSM and TGs, particularly the young sub-populations from accessing information and services from SHCs and health facilities.

Gender bias against TG people is perceived as existing in health care settings and viewed as one of the reasons for the vacuum in TG-specific services. Gender disaggregation of services for MSM, PWID and their female partners, including the integration of reproductive health has not yet been sufficiently addressed. This includes the lack of orientation of women to reproductive choices; safe pregnancy; abortion and post-abortion care; and reproductive tract cancer screening. Counseling on hormone use and referral to other gender enhancement practices for TGs is still lacking in the current continuum of HIV prevention, care and treatment services.

Efforts are now being made to address the issue of stigma and discrimination. In 2010, the Commission on Human Rights (CHR) has signed memorandums with civil society organizations (CSOs) that would start projects aimed at educating and strengthening protection programs on human rights based sexual orientation and gender identity. On 8 October 2014, the Dangerous Drugs Board (DDB) approved a resolution authorizing the conduct of an operations research on needle syringe distribution. The research will hopefully provide the needed evidence that will inform policy and programming work on harm reduction for PWID.

  • d. Health systems and community systems

The Philippine health system is decentralized. With the passage of the 1991 Local Government Code, the Local Government Units (LGUs) were granted autonomy and responsibility to provide for their own health services while the DOH is mandated to provide national policy direction and develop national plans, technical standards and guidelines on health. LGUs make up the political subdivisions of the country covering 81 provinces, 138 cities, 1,496 municipalities and 42,025 barangays or villages. Under the devolved structure, the provincial governments are given the responsibility to provide secondary hospital care, while city and municipal administrations are charged with providing primary care. The DOH guides the LGUs through the Regional Centers for

13 Cited from “The Status of LGBT Rights in the Philippines Submission to the Human Rights Council for Universal Periodic Review, 13 th Session”, Rainbow Rights Project (R-Rights) and Philippine LGBT Hate Crime Watch, pp.1-2. Annex 11.

Health Development (CHDs). The private sector which is composed of for-profit and non-profit providers caters to 30% of the population. The DOH and the Philippine Health Insurance Corporation (PhilHealth) perform regulatory functions over this sector.

The DOH leads the country response to HIV and AIDS through the National AIDS STI Prevention and Control Program (NASPCP) while the NEC monitors and evaluates the HIV programs. 14 The NEC is in charge of generating three strategic pieces of information: the National HIV and AIDS Registry, the IHBSS and special studies. The Philippine National AIDS Council (PNAC) is the national multi-sectoral policy making body for HIV and AIDS and its counterpart at the LGUs are the Local HIV and AIDS Councils (LACs).

Major reforms in the health sector were implemented through the Decentralization Law, the National Health Insurance Act of 1995, the 1998 Health Sector Reform Agenda (HSRA) and the 2005 FOURmula ONE for Health (F1). These reforms resulted to two significant improvements: i) increase in health insurance coverage from around 30% of the population in 1995 to almost 70% or 65.44 million Filipinos in 2013. The PhilHealth reported that 32% of coverage went to the Sponsored Program (SP) for indigent households; 15 and ii) slight increase in public spending on health from 3.3% of the Gross Domestic Product (GDP) to 4.4% in 2012. 16 The Philippine National Health Accounts reported that government health spending in 2012 was PhP 86,423 million compared to PhP 84,139 million in 2011. 17 Government spending on HIV and AIDS also increased by 118.48% in 2014 or PhP 227,451,764 from PhP191,974,886 in 2013. 18

The overarching intent of the devolution of health services to LGUs was to make primary care accessible to the people and improve health outcomes, but the process had also resulted to the fragmentation of the health system. Hence, despite the succeeding reforms, there are still remaining gaps in the health system. The referral system for example, is still very limited and lacks systematic evaluation of its utilization by the clients. 19 Health information management system is disjointed as shown by the weak integration of national and local health information and the lack of health informatics standards. 20

Currently, Kalusugan Pangkalahatan/Universal Health Care (KP/UHC) is being implemented to accelerate and scale up health sector reforms through the F1 of the DOH. 21 Its intent is to continue the process of resolving the gaps in the health system and strengthen its overall capacity to provide equitable access to care. Its main goal is to provide every Filipino with quality health care that is accessible, efficiently delivered and affordable. However, the implementation of the three strategic thrusts of the UHC reform program has been affected by several challenges and constraints: 22

1)

Financial Risk Protection (FRP) has been minimally addressed by PhilHealth spending. In 2012, PhilHealth’s total health expenditures (THE) was only 12%. Even though PhilHealth insurance coverage has increased, it has not substantially reduced the private Out-of-Pocket (OOP). In 2012, the THE reached 57.6% as compared to 48% in 2008. It has been noted that despite PhilHealth’s progress in promoting coverage among the enrolled SP members, the reach is still low. This is attributed to their limited knowledge of health insurance benefits and the LGUs’ weak understanding of the procedures for enrollment. Given that LGUs are dependent on the internal revenue allotment (IRA), those with limited financial resources cannot afford the subsidized contribution requirements under the PhilHealth SP, hence the gap in the enrollment coverage for poor urban and rural households. Among the PLHIV patients, only 645 Outpatient HIV/AIDS Treatment (OHAT) filed claims in 2011 and 1,009 patients in 2012. The utilization rate of PhilHealth among PLHIV in 2011 was low at 19.48% and 17.08% in the last quarter of 2012. 23

  • 14 DOH-NASPCP: Philippine Health Sector Strategic Plan on HIV and STI 2015-2020, p.4. Annex 4.

  • 15 ECORYS Health Consortium: Annual Health Sector-wide Performance Assessment, April 2014, p. 12. Annex 12.

  • 16 Health Sector Reform Agenda (HRSA) Monograph No. 10: “Financial Risk Protection: National Health Care Financing Strategy of the Philippines 2010-2020, 15 July 2010. Annex 13.

  • 17 Philippine Statistics Authority Press Release posted on11 August 2014, pp.1-2. Annex 14.

  • 18 See Annex 3.

  • 19 Philippine Health Systems Review, 2011. Annex 15.

  • 20 The International Bank for Reconstruction and Development / World Bank (2011): Philippine Health Sector Review. Transforming the Philippine Health Sector: Challenges and Future Directions. Annex 16.

  • 21 PhilHealth: Annual Report 2013, pp. 6-7. Annex 17.

  • 22 ECORYS Health Consortium: Annual Health Sector-wide Performance Assessment, April 2014. Annex 12.

  • 23 Philippine Institute for Development Studies, Discussion Paper Series 2013-38, July 2013. Annex 18.

2)

Improved access to quality health care facilities is focused on upgrading primary level and other facilities to improve emergency obstetric care and neonatal care and ensuring availability of drugs and medicines and health personnel in underserved areas. 24 The infrastructure investments of DOH through the Health Facilities Enhancement Program (HFEP) have significantly increased from 10% in 2008-2009 to 22% during the budget period of 2010-2013. Availability and access to essential drugs has also improved from 2010 to 2012. However, procurement issues have affected this KP/UHC strategic thrust which resulted to delayed construction and upgrading of provincial facilities. There were also incidences of stock-outs on drugs and vaccines due to the lack of systematic procurement planning at DOH.

The Annual Sector-Wide Performance Assessment 25 noted that, “figures on specific stock- outs are not maintained at the facility or LGU level, but a field visit in one site revealed stock- outs of several pharmaceuticals and contraceptives at the district hospital and primary care

facilities level”. To address this constraint, procurement reforms were undertaken by the DOH

such as the development of Customized Procurement Manuals (CPM); creation of a Procurement Oversight Committee, the Central Office Bids and Awards Committee (COBAC), Procurement Monitoring Teams (PMT); and the incorporation of the Agency Procurement Performance Indicators in the monitoring tool. Technical Assistance is also being proposed for systematic improvement of the HIV Procurement and Supply Chain Management.

3)

Attainment of health-related Millennium Development Goals (MDG) showed progress in lowering infant and child mortality and reducing the prevalence of malaria and tuberculosis (TB). MDG 6 which includes HIV has yet to be achieved as shown by the rapidly growing prevalence as discussed in Section 1.1a. The strengthening of the LGUs’ HIV-response capacity and implementation of community-based strategies are seen as key factors in the attainment of health-related MDGs, particularly HIV through a comprehensive and scaled up prevention care and treatment programs for KAP and PLHIV. 26

Community systems context

CSOs can support the health sector in meeting these challenges. Health systems could be strengthened through a process of collaboration, making use of civil society’s expertise and access to communities. They have played a big role in the country’s response to HIV and AIDS such as: a) participation in planning and budgeting for the HSSP on HIV and STI; b) assisting national agencies and LGUs in the implementation of sector-specific responses in focus geographical sites; c) contributing to behavior change needed for HIV prevention; d) PLHIV participation in the treatment model to implement ART with hospital-based treatment facilities under the Global Fund-Round 6 and GFATM-Transition Funding Model (TFM) grants; e) facilitating a strong referral network between treatment hubs and the PLHIV/MSM support groups resulting to increased ART enrollment; f) participation in governance of HIV/AIDS; and g) psycho- social support to PLHIV.

However, non-government organizations (NGOs), community-based organizations (CBOs), PLHIV and the KAP community can only be effectively utilized in strengthening the health systems when their engagement is contracted in the context of partnership building. It should be noted that in the 1970’s and 1980’s, the CSOs in the Philippines were used as alternative channels for the delivery of primary care or community based health programs due to the limited capacity of the government to provide health care in rural or hard-to-reach areas. They have proven that they were effective in delivering primary care services to poor communities. However, this approach was not sustained because the CSOs have limitations in capacity, resources and referral networks. Furthermore, the parallel structures further reinforced the fragmentation and non- integrated delivery of health care services. Hence, there is a need to link the community systems and health systems in an integrated and sustainable framework. In this way, the interest and voices of all stakeholders in the health systems, especially the individuals, families and communities that are in need of health services are mainstreamed in the policy process and in governance structures. Although Local Health Boards, LACs and other mechanisms have been created to ensure participation, more effort needs to be done at the community level where financial, legal and socio-cultural barriers hinder access to quality care.

  • 24 Annex 12, pp.18-19.

  • 25 Annex 12, p.19.

  • 26 Annex 14.

Community System is not a parallel mechanism but a necessary base for reaching the KAP. In this Concept Note, the community-based prevention interventions, which will be KAP and/or community-led is considered as a vital strategic game changer in the country’s HIV response. Central to this framework is the strengthening of community systems to ensure their proactive engagement in the various processes of the interventions. This will entail leadership development, innovative capacity building for peer education, community-based rapid testing, advocacy and social mobilization, skills upgrading on project management, and skills enhancement for negotiation and policy development for the MSM, PWID and TG communities.

1.2 National Disease Strategic Plans

With clear references to the current national disease strategic plan(s) and supporting documentation (include the name of the document and specific page reference), briefly summarize:

 
  • a. The key goals, objectives and priority program areas.

  • b. Implementation to date, including the main outcomes and impact achieved.

  • c. Limitations to implementation and any lessons learned that will inform future implementation. In particular, highlight how the inequalities and key constraints described in question 1.1 are being addressed.

  • d. The main areas of linkage to the national health strategy, including how implementation of this strategy impacts relevant disease outcomes.

  • e. For standard HIV or TB funding requests 27 , describe existing TB/HIV collaborative activities, including linkages between the respective national TB and HIV programs in areas such as: diagnostics, service delivery, information systems and monitoring and evaluation, capacity building, policy development and coordination processes.

  • f. Country processes for reviewing and revising the national disease strategic plan(s) and results of these assessments. Explain the process and timeline for the development of a new plan (if current one is valid for 18 months or less from funding request start date), including how key populations will be meaningfully engaged.

a.

The key goals, objectives and priority program areas

The goal of the HSSP 2020 is for the country to maintain a prevalence of less than 66 HIV cases per 100,000 population (0.66%) in 2020 by preventing the further spread of HIV infection and reducing the impact of the disease on individuals, families, sectors and communities. The HSSP has identified four strategies and objectives to guide the country response to the HIV epidemic.

 
  • 1. Continuum of HIV and STI prevention, diagnosis, treatment and care services to KAP.

This strategy will ensure that the Cascade for the Continuum of Care is implemented, and that any leaks in each phase will be addressed in order to reduce new HIV infections and improve the quality of life among PLHIV.

  • 2. Health promotion and communication on HIV and STI prevention and care services. This strategy hinges on accelerating appropriate community-based information and education to prevent and reduce risky practices among KAP, and the vulnerable and general population. The assumption is that access to strengthened and quality prevention, treatment and care packages can be accelerated through demand generation from the community.

  • 3. Enhanced strategic information systems. This strategy will ensure the systematic collection of strategic information on HIV and other STIs among KAP that could guide health policy, planning, resource allocation, program management and service delivery and accountability.

27 Countries with high co-infection rates of HIV and TB must submit a TB and HIV concept note. Countries with high burden of TB/HIV are considered to have a high estimated TB/HIV incidence (in numbers) as well as high HIV positivity rate among people infected with TB.

  • 4. Strengthened health system platform for broader health outcomes. This strategy will focus on strengthening the key areas of health systems: a) leadership/governance; b) health financing; c) human resource; d) medical products and technologies; e) information systems; and f) service delivery.

Based on the strategies, the objectives are:

  • 1. To improve the coverage and linkage of services from prevention and diagnosis among KAP to treatment and care for PLHIV through an intensifies delivery of quality and evidence based services;

  • 2. To raise the awareness of key populations and the public on HIV and STI prevention and care services;

  • 3. To increase demand and access to available HIV and STI services;

  • 4. To provide timely evidence-based information for planning, monitoring, evaluation and quality assurance of HIV and STI programs; and

  • 5. To intensify delivery of quality HIV and STI services through a strengthened support system by addressing barriers, improving linkages and ensuring delivery of critical enablers.

Given the 2013 IHBSS findings, a re-classification of the priority areas for a targeted and calibrated HIV and AIDS intervention was done using these three parameters: a) KAP identified to be highly affected by HIV; b) characteristics; and c) presence in these geographic areas. Category A contributes to almost half of the epidemic, with multiple risks and high prevalence while Category B contributes to 30 to 40% of the epidemic, with multiple risks. According to the HSSP, these are the high priority sites in the next three years with maximum target of interventions expected for KAP. These are selected from the previous Category A and B sites with 80% of full investment for prevention intervention (see Table below).

   

Table 3. Category A and B Sites. Category A (cities, except*) = 26

Category B (cities/municipalities) = 19

Paranaque

1.

  • 1. Danao

Muntinlupa

2.

  • 2. Olongapo

3.

Taguig

  • 3. Antipolo

4.

Pasay

  • 4. Dasmarinas

5.

Makati

  • 5. Batangas

Mandaluyong

6.

  • 6. Cainta, Rizal

7.

Marikina

  • 7. Imus, Cavite

8.

Quezon

  • 8. Lipa, Batangas

9.

Caloocan

  • 9. Iloilo

10.

Navotas

  • 10. Bacolod, Negros Occidental

11.

Las Pinas

  • 11. Lapu-lapu, Cebu

12.

Manila

  • 12. Talisay, Cebu

13.

Pasig

  • 13. General Santos city

14.

San Juan

  • 14. Butuan

15.

Malabon

  • 15. San Fernando, Pampanga

16.

Valenzuela

  • 16. Mabalacat, Pampanga

17.

Pateros*

  • 17. San Jose del Monte

18.

Angeles

  • 18. Meycauyan, Bulacan

19.

Davao

  • 19. Sta Rosa, Laguna

20.

Cebu

21.

Mandaue

22.

Baguio

23.

Cebu City

24.

Cagayan de Oro

25.

Puerto Princesa

26.

Bacoor, Cavite

An operational plan and budget for the period 2015-2017 were developed in line with these four strategies and five objectives to respond to the current needs and priority interventions. The Operational Plan budget is shown in the table below.

Table 4. Budget of the HSSP Operational Plan

 

Year

PhP

USD

% of Total

2015

2,933,529,906.16

66,671,134

32%

2016

2,919,540,218.42

66,353,187

31%

2017

3,448,159,631.81

78,367,264

37%

Total

9,301,229,756.38

211,391,585

100%

b. Implementation to date, including the main outcomes and impact achieved

The country response to the HIV epidemic started in 1984 after the disclosure of the first HIV case in the Philippines. Development partners such as the United Nations Joint Program on HIV and AIDS (UNAIDS), World Health Organization (WHO), Asian Development Bank (ADB), European Union (EU), USAID and Global Fund provided funding and technical support to HIV and AIDS programs implemented by the DOH, LGUs, NGOs and CBOs. Since 2004, the Global Fund has invested a total of USD 32,404,783 in the Philippines to accelerate and scale up HIV prevention, care and treatment of PLHIV and strengthen the health and community systems. Currently, the Rolling Continuation Channel (RCC) Extension TFM-HIV with a grant of USD 21,776,057 is being implemented and will end in June 2015.

Overall, the gains in HIV prevention, care and treatment that were achieved in the last 26 years and the critical gaps that require actions have been consolidated in the AMTP5. The goal of the AMTP5 is to prevent the further spread of HIV infection and reduce the impact of AIDS on individuals. An External Mid-Term Review of the AMTP5 was conducted in October-November 2013 to assess the progress achieved and constraints encountered in the implementation. The results of the mid-term review acknowledged that the Philippines had maintained the national prevalence of below one percent of the adult population.

Program/project-specific evaluations were also conducted to assess the accomplishments and gaps, namely: Evaluation of GF-Round 6 HIV Grant; External Evaluation of the Health Sector’s Response to HIV and STI in the Philippines; Evaluation of the HIV and STI Programs and Strategies for MSM, TG and PWID; and program review of donor funded programs for KAPs.

Key achievements at the governance level

Enabling Policies/Legal Environment. Since 2010, PNAC has worked for the institutionalization of HIV and AIDS response at the national and local levels. As of 2014, considerable progress has been achieved in the policy environment that has direct bearing on treatment, care and support area:

o

Implementation of an OHAT package in 2010. This benefit aims to increase the

o

proportion of the population having access to effective AIDS treatment package in PhilHealth, which is a critical step in guaranteeing the sustainability of access to ART treatment package; Access to Cheaper Medicines Act ensures lower prices for antiretroviral

o

medicines (ARVs) and gives access to Trade-Related Aspects of Intellectual Property Rights (TRIPS) flexibilities; Lobbying for proposed amendments in the Philippine HIV and AIDS Policy and Program Act of 2012, amending the Republic Act (RA) 8504 or the Philippine AIDS Prevention and Control Act of 1998 which is now on its Second Reading in the House of Representatives. The new law will restructure the legal framework on HIV and AIDS by harmonizing it with evidence-informed strategies and approaches (e.g. opt out HIV counseling and testing, positive prevention). The revision of the National AIDS Law, if passed, will remove many non-supportive

o

HIV policies that are barriers to the current efforts in HIV prevention such as the Comprehensive Dangerous Drugs Act (Republic Act or RA 9165) which prohibits the distribution of clean needles and injecting equipment; Other important national policies and laws are: a) HIV in the workplace policy of the Civil Service Commission; b) Memorandum of the Department of Interior and

Local Government (DILG) on “Strengthening Local Responses Towards More Effective and Sustained Responses to HIV and AIDS” which enjoins all cities and

o

provinces to create the LACs; c) Referral System for the Care and Support Services for PLHIV, a tool which was developed by the Department of Social Welfare and Development (DSWD) to facilitate the collaboration of service providers and LGUs in providing care and support for PLHIV; and d) The Responsible Parenthood and Reproductive Health Act which facilitates the education on sexuality, reproductive and sexual health, including HIV, for young people; At the LGU level, the Quezon City Government has passed the first anti- discrimination ordinance that specifically tackles the issues confronting the LGBT community.

Investment Plan for HIV and AIDS. The investment plan is necessary for planning and programming of resources and can be used as an advocacy tool for mobilizing resources. The preparation of the LGU investment plan used the Investment Case Framework which

was adopted by UNAIDS in 2011. The framework is “designed to maximize the benefits of

the AIDS response by supporting a more focused and strategic allocation of resources, based on country/local epidemiology and context. 28 Health departments in six high priority cities (Quezon City, Manila, Caloocan, Pasay, Cebu City and Davao City) have worked with the UNAIDS to develop local AIDS investment plans.

Civil Society Participation in Governance. Some CSOs were able to integrate their HIV core work in the LGUs’ HIV programs, and have provided management assistance. Examples of these LGU-CSO partnerships 29 are: a) League of Angeles City Entertainers and Managers (LACEM), which is an organization composed of ‘mamasans’ (pimps) that work closely with the City Health Office (CHO); b) Quezon City Pride Council, that oversees programs and projects for LGBT; c) Batang Laging Umiiwas sa Tiyak na Impeksyon (BALUTI), a youth-led organization composed of volunteer educators who are former MARPS; d) Barangay Gender and Development (GAD) Focal Leaders; e) Klinika Bernardo, LGU-owned and managed MSM clinic in Quezon City.

Strategic Information. The Philippines has developed a robust system for risk assessment. Both the HIV and STI reporting systems capture data that allow disaggregation by age, sex and the most-at-risk groups. The IHBSS is conducted every two years and has produced data trends that proved instrumental in allowing the timely detection of the recent rapid increases in HIV prevalence among PWID, MSM and FSW beginning in 2007. On the other hand, the HIV and AIDS Registry captures initial CD4 and symptomatic and asymptomatic cases to allow for disaggregation of cases diagnosed as advanced HIV infection.

Key achievements at the program level

There were four major HIV programs which are focused on FSW, MSM, PWID and TG implemented by the DOH and CSOs with funding from donors. These programs include: GF Round 6, NFM-TFM, the ADB-funded Big Cities Project (BCP) and the USAID-funded Reaching Out to Most-at-Risk Populations (ROMP).

Overall, the key outcomes in prevention, care and treatment are:

Decrease in HIV prevalence among registered female sex workers, which is attributed to

increased condom use with every client from 60 to 75%; Coverage goals for HIV prevention services for KAP was reached under TFM

implementation; Rapid increase in ART enrolment from 56 patients in 2005 to 1,274 in 2012. As of April

2014, there are 6,437 PLHIV currently enrolled and accessing ART in the 18 treatment hubs. ART eligibility is becoming increasingly more inclusive, moving from a threshold of CD4 count ≤ 200 in 2005 to ≤ 350 in 2012; Establishment and operations of 522 HIV testing facilities including 29 SHCs, which despite their limitations have contributed to increased HIV tests in the Philippines which totaled 1.3 million in 2012;

28 Developing a Local HIV Investment Plan: The Experience of Quezon City Health Department’s AIDS Program. 29 External Review of AMTP5, November 2013 p.90.

The needle and syringe program for PWID in Cebu City is considered as a policy breakthrough. With the ‘One-stop Shop’ comprehensive harm reduction in the Cebu SHC, a total of 115 PWID were provided with needle/syringes in 2013 and 87 in 2014.

c. Limitations to implementation and any lessons learned

Despite these achievements, there are still gaps and weaknesses that hinder the effective implementation of the country’s response to HIV and AIDS. This discussion examines key areas in governance such as i) stigma and discrimination policies; ii) KAP participation in HIV and AIDS governance; iii) strategic information; and iv) procurement. At the program level, the gaps are analyzed in the areas of prevention and care and treatment.

Governance level

Lack of Stigma and Discrimination Policies. Policies addressing discrimination and social stigma are yet to be enacted at the national and local levels.

Insufficient engagement and participation of KAP in leadership/governance bodies. MSM, PWID and TG have yet to be elected in LACs and participate in strategic planning, policy making and coordinating mechanisms for HIV and AIDS response at the national and local levels.

Strategic Information 30 . The following weaknesses were observed: a) IHBSS data analysis, dissemination and utilization are limited; b) PWID sites are few considering that needle/syringe sharing is one of the main drivers of the epidemic, and guidance on how to assess PWID is limited; c) Mapping of most-at-risk behaviors e.g. condom use, number of partners, needle/syringe sharing, to guide local prevention is limited; d) HIV data from antenatal women to detect an increase in HIV prevalence is weak; e) No systematic screening or surveillance of behaviors or HIV in prisons; f) Monitoring data of health services is limited in analysis and dissemination due to limited number of staff. There is limited strategic information for quality improvement; and, g) Epidemiological surveillance and the application of new laboratory technologies along with greater dispersion of existing technologies (e.g. rapid tests for HIV, STI, CD4 count, Viral load).

Procurement. In Section 1.1, the issues concerning procurement that caused delays in the construction/upgrading of primary care facilities and stock-outs of pharmaceutical products have been identified as affecting the attainment of KP/UHC strategic thrusts. The country response, especially program implementation has also experienced challenges concerning procurement. A major challenge in the procurement and supply chain management (PSM) of commodities and pharmaceutical products is the process of procurement mandated by the government. Government procurement happens on a yearly basis where all procurement requests are consolidated and go through the different levels of bureaucracy. The whole procurement process takes eight (8) months to complete. Based on past experience, orders for the current year usually arrive and are received only in the following year. This poses a risk in terms of addressing the increasing needs for ARVs and other commodities where the orders being received will no longer match the current needs. This can be addressed if there is a change in the procurement system specifically for medicines. The lead times for procuring such commodities will pose a problem on project implementation if certain treatment cycles are missed due to the stock-out. During the second quarter of 2014, there was an issue when one of the treatment centers ran out of stocks because the ARV drugs were not delivered on time. Because of this, some patients had to return to the Southern Philippines Medical Center (SPMC) every day to check on the availability of the medicines. In some cases, the site implementation officers had to borrow medicines from other patients. The DOH had acknowledged that there is indeed a need to improve the forecasting of ART needs of PLHIV.

There are also some weaknesses in the warehousing. The current warehouse for ARVs has very limited space. The warehouse space for ARV stocks is shared with other equipment and commodities of the other projects. Without an overall physical visibility of

30 Philippine Health Sector Strategic Plan on HIV and STI, 2015-2020, DOH-NASPCP, pp. 20-21

the stocks on hand there could be a risk of overlooking the current stockscondition and physical management of the stocks.

Linked to the above point is the need for an effective monitoring and reporting of the commodities. Even with the automated online stock inventory system, i.e. National Online Stock Inventory Reporting System (NOSIRS), efficient tracking of stocks is still a challenge. Not all of the sites have access to this system; not all are trained and have the capacity and equipment to use this. As shown in the example above, this situation has led to inefficiencies, i.e. urgent calls for replenishment from the main warehouse which required unscheduled deliveries. In addition, the limited budget and staffing of the government on the procurement and supply management side prevents the relevant DOH unit from visiting the sites and conducting assessments. Visibility of the entire supply chain is very crucial in effective service delivery to the beneficiary. To address these, Save the Children will provide support in terms of staff training on handling and managing commodities with DOH experts.

Key challenges/issues at the program level

The HSSP for HIV and STI 2015-2020 31 cited the 2012 Global AIDS Response Progress Reporting (GARPR) which stated that despite vigorous interventions, there is a) consistently low HIV knowledge among populations surveyed (FSW, RFSW, PWID, MSM). Proportions of these populations who correctly identified ways of prevention and rejected major myths and misconceptions remained below 45%; and b) Use of condoms among populations surveyed is <30%, which was very low, especially among MSM and PWID (IHBSS, 2013).

Peer Education (PE). Among the issues identified in the conduct of peer education are:

a) Need for innovative PE strategies, which is linked to the lack of local research to inform a segmented and targeted PE strategy; b) Retention of peer volunteers which affects the continuity of services. Linked to this is the lack of standard operating procedures, standard criteria for recruitment and engagement of PE and measures for retention of staff. Role uncertainty and confusion also affect retention. There are no written work contracts and agreements with the PEs, the project or clinical facility. Lack of uniformity in stipends paid across agencies contributes to demoralization; c) PEs’ lack skills in communications, to explore whether individuals had a test or to uptake treatment and care. Many of them are not knowledgeable about handling gender-specific issues. Overall, there is lack of segmentation in the response to PE service delivery to key populations. IEC, Multimedia and Online Content. The main gaps in IEC which affect advocacy and social mobilization campaigns are: a) Availability of media. There are limited stocks of brochures and pamphlets and many services did not retain a master copy of the approved leaflets and brochures for reproduction; b) Content Analysis. Media and information materials are inadequate to address the real issues that confront clients in reducing transmission or the risk of acquisition of HIV and STI. Because of this, basic issues regarding condom negotiation and the common reasons why people do not like using condoms remain unaddressed; c) Online web-chat and web interactive information services failed to provide sufficient or adequate information to sufficiently motivate the client to attend a service to get information face to face; and d) Many of the materials contained graphics that did not reflect the profile and needs of the population that are most at risk.

The Implementation of Cascade for Continuum of Care under the TFM implementation shows that overall the coverage goals for HIV prevention for KAP were achieved. However, high-risk behaviors have not significantly changed resulting to low condom use among MSM at last anal sex (36.7%) and needle/syringe sharing among PWID at their last injection (35%). The results for HIV and testing are low or only 20-30% of the KAP population in TFM sites. The External Evaluation of AMTP5 noted that the waiting period for HIV test results hinders access to timely treatment and care. The long turnaround time for provision of results ranging from 10 days up to 5 weeks or longer is a major factor related to poor rates of return for results, and delayed entry into treatment among MSM and PWID.

31 Annex 4, HSSP.

Other programs like the ADB-BCP identified human resources and procurement-related challenges in the implementation of the interventions, such as: a) Product required by the project does not exist or has shortage locally; b) Philippines has no registered condom and lubricant co- pack. The concept of co-packing condoms with water based lubricant is very new to Philippines; c) Terumo Gauge 27 needle in 1 cc syringe has shortage as expressed by invited suppliers; and d) Lack of human resources on the ground.

The Cebu program experience among PWID in particular highlighted the following lessons in the implementation of the harm reduction program:

SHC-based needle and syringe program (NSP) is a model that fits well in the Philippines.

Dedicated manager/staff is essential, and more trained staff are needed to ensure quality

of services and use of data. Strong support from DOH, PWID community, NGOs from HIV-positive groups and faith-

based organizations has facilitated implementation Working with the police is possible. Increased police understanding of public health solution to HIV crisis contributes to public security.

It was also pointed out in the AMTP5 review that there are legal barriers to service delivery among MSM, PWID and TG such as access to treatment and counseling for minors. The Philippine AIDS Law restricts access to testing to individuals below the age of 18 years old except when consent is provided by a parent or guardian.

d. The main areas of linkage to the national health strategy

The HSSP for HIV and STI 2015-2020 is guided by the goal of the KP/UHC and its three strategic thrusts which include financial risk protection, access to quality healthcare facilities and attainment of health-related MDGs. It is linked with the National Objectives for Health 2011-2016 where all

the health program goals, strategies, performance indicators and targets are defined to make sure that the health sector could achieve Universal Health Care by 2016. The overall direction of the HSSP is to contribute to the attainment of MDG 6 which is focused on HIV and AIDS, Malaria and TB. The goal of HSSP and its four strategies as discussed in Section 1.2a of this Concept Note clearly described how this national HIV strategy will contribute to KP/UHC and in particular, MDG

  • 6. Strategy 1 and 2 align with the thrusts to provide quality care in healthcare facilities by

strengthening the capacity of SHCs and treatment hubs and make sure that services are accessible through facility and community based providers. Strategy 3 and 4 are focused on strengthening health systems which include initiatives to support the objectives of PhilHealth in ensuring financial risk protection among the poor, in particular the PLHIV. The NASPCP is mandated by the DOH to lead the implementation of these strategies in partnership with CSOs, private sector and development partners.

e. TB-HIV collaboration

The Philippines still ranks ninth among the 22 high-burden countries for TB. Based on the national TB prevalence survey in 2007, the prevalence rate of smear positive TB was 2 per 100,000 while culture-positive was 4.7 per 100,000. Bacteriologically positive TB cases in the Philippines was estimated to be around 430,000 in 2009. Twelve million (13% of the population) were estimated to be TB symptomatics. 32 For HIV, the current epidemiological situation was discussed in Section 1.1a of this Concept Note.

The DOH considers TB-HIV co-infection as a serious challenge to HIV and TB programs in the Philippines. Because HIV weakens the immune system, the risk for people with HIV to develop TB as a disease is very high. It is estimated that HIV infected persons have 5% to 10% annual risk and 30% lifetime risk of developing TB. According to the WHO 33 , there is a probability that people with both HIV and TB could die far earlier than those HIV patients without TB. Also, it was observed that TB patients with HIV infection are more likely to die earlier than TB patients who do not have an HIV infection.

  • 32 PhilPACT Sub-Plan on TB-HIV Collaboration 2014-2016. Annex 19.

  • 33 A revised framework to address TB-HIV co-infection in the Western Pacific Region, WPRO 2008.

However, data about TB-HIV co-infection in the Philippines is limited. An institutionalized recording and reporting system to capture co-morbidity cases has not yet been developed in the country. Only the Metro Manila CHD was able to document TB-HIV cases. In 2011, out of the 9,331 registered TB cases of the 118 Directly-Observed Treatment, Short Course or DOTS facilities in NCR, 3,917 were tested for HIV. Only nine (9) TB patients turned out reactive. 34 Data from the NCR HIV Treatment Hubs showed that TB is the most common opportunistic infection (OI) among PLHIV, and about 40-50% of them are TB infected. 35

As a response to the TB-HIV epidemiology, the Administrative Order (AO) 2008-0022 otherwise known as the “Policies and Guidelines in the Collaborative Approach of TB and HIV Prevention and Control” was signed and disseminated in 2008. This was revised and signed into AO no. 2014-0005 on 3 February 2014. 36 The NASPCP and National TB Program (NTP) collaboration is guided by this AO.

The Philippine Plan of Action to Control Tuberculosis (PhilPACT) Sub-Plan on TB-HIV Collaboration for 2014-2016 supports the 12-point agenda set by the WHO. The three main points of the agenda are focused on the following: 1) Establish and strengthen the mechanisms for delivering integrated TB and HIV services, 2) Reduce the burden of TB among PLHIV and initiate early ART, and 3) Reduce the burden of HIV in patients with presumptive and diagnosed TB.

The key programmatic gaps that will be addressed by this Subplan are:

  • 1. Weak carrying out or execution of NTP policies and guidelines in the provision of TB services among PLHIV, including Isoniazid Preventive Therapy (IPT) implementation

  • 2. Ineffective referral mechanism for TB and HIV services

  • 3. Limited access to centralized HIV services

  • 4. Inadequate logistics such as HIV testing kits

  • 5. Fast turn-over of staff especially medical technoligists providing HIV testing (not all health centers have medical technologists)

  • 6. Uninstitutionalized recording and reporting system

The indicators for TB-HIV collaboration are:

TB-HIV Indicators

# and % of TB patients who had an HIV

80% of Cat A and B Registered TB cases and MDR TB cases

test result recorded in the TB register # and % of HIV-positive registered TB patients given an anti-retroviral theraphy

100% of HIV and TB cases

during TB treatment # and % of HIV-positive patients who were screened for TB in HIV care or treatment

90% of PLHIV accessing HIV Thubs care

settings # and % of new HIV-positive patients started IPT during the reporting period

50% of new PLHIV with inactive TB

The scope of TB-HIV collaboration would be: a) All public and private TB DOTS facilities in Category A and B sites; b) All Programmatic Management of Drug-Resistant TB (PMDT) treatment centers and satellite treatment centers nationwide; and c) All SHCs and HIV treatment hubs nationwide.

To date, Provider Initiated Counseling and and Testing was conducted in Category A and B DOTS facilities for 16 batches and 3 batches in PMDT Treatment Centers and Satellites. HIV Profiency Training was also conducted in 3 batches at the Research Institute of Tropical Medicine (RITM), with 13 participants in Cagayan de Oro in partnership with the Philippine Association of Medical Technologists (PAMET), and with the Mindanao DOTS in partnership again with the PAMET for another 30 participants.

  • 34 PhilPACT Sub-Plan on TB-HIV Collaboration 2014-2016. Annex 19

  • 35 GF-TB Grant PR/PBSP Presentation on TB-HIV Collaboration. Annex 20

  • 36 Administrative Order no. 2014-0005. Annex 21

Such initiatives need to be sustained by complementing them with other strategies such as human resource augmentation in facilities, upgrading of SHCs and treatment facilities, improving data recording and reporting on TB-HIV, procurement of diagnostic equipment and development of information and education materials on TB-HIV for use in SHCs and DOTS facilities. (Please refer to Section 3.2: Addressing TB-HIV for the interventions.)

 

f.

Country processes and timelines for the development of the HSSP for HIV and STI 2015-2020 and the operational plan for 2015-2017

The DOH, through the NASPCP, engaged national, sub-national and local stakeholders including KAP in the formulation of the HSSP Plan for HIV and AIDS and STI. This is to ensure that the process is inclusive, participatory and that the HSSP is collectively owned. In doing this, a series of consultations, workshops and Focus Group Discussions (FGD) were conducted which included representatives from government agencies, LGUs, civil society and KAP communities. Presented below is an outline of the key processes that transpired from October 2013 until September 2014.

November 2013

Dissemination of the 5 th AMTP Mid-Term review findings and recommendations participated in by DOH, LGU/SHC representatives, CSOs/NGOs, PLHIV community and representatives from MSM, PWID, TG and sex workers

 

March & April 2014

HIV Technical Working Group Consultation meeting to:

 

Discuss of the

AMTP5 review findings and recommendations

Develop the log frame for the HSSP

18

March to 15 April

Consultation meetings and FGD with the target population among the KAP

 

2014

24

April 2014

National Stakeholders Meeting to discuss the proposed key interventions for the HSSP for the period 2015-2017.

 

16

May 2014

Technical Working Group Sub-team Meeting on the HSSP

 

28

May 2014

Costing of Health Sector Plan utilizing the AEM developed primarily by DOH NEC and UNAIDS

 

June 2014

Dissemination of the external evaluation of the HIV and STI Programs and

 

3-5 June 2014

Strategies for MSM, TG and PWID Validation writeshop on the Updated HSSP for HIV and STI

 

6

June 2014

Presentation of the draft HSSP to the Country Coordinating Mechanism

 

10-11 June 2014

(CCM) in preparation for the GFATM NFM Concept Note development First Country Dialogue on HIV and AIDS to present and discuss the HSSP 2015-2017 and the priorities that will be included in the GF NFM Concept Note

 

15-17 July 2014

Conduct of a workshop for the development of the Detailed Operational Plan for the HSSP

 

31

July to 1 August

Conduct of a workshop on the costing of the HSSP Operational Plan

 

2014

13

August 2014

Presentation of HSSP and Scope of the GF NFM Concept Note to the CCM

 

1

   

September 2014 2-3 September 2014

Validation Workshop on the Costed Operational Plan for the HSSP Presentation of the HSSP and the GF NFM Concept Note at the Second Country Dialogue

 
  • 13 September 2014

Community-initiated National Consultation/Discussion on the HSSP and GF NFM Concept Note participated in by LGBT and MSM organizations

 
  • 22 September 2014

Submission of the final documentation of the HSSP by the technical writer to DOH for approval

 
   

SECTION 2: FUNDING LANDSCAPE, ADDITIONALITY AND SUSTAINABILITY

To achieve lasting impact against the three diseases, financial commitments from domestic sources must play a key role in a national strategy. Global Fund allocates resources which are far from sufficient to address the full cost of a technically sound program. It is therefore critical to assess how the funding requested fits within the overall funding landscape and how the national government plans to commit increased resources to the national disease program and health sector each year.

2.1 Overall Funding Landscape for Upcoming Implementation Period

In order to understand the overall funding landscape of the national program and how this funding request fits within this, briefly describe:

  • a. The availability of funds for each program area and the source of such funding (government and/or donor). Highlight any program areas that are adequately resourced (and are therefore not included in the request to the Global Fund).

  • c. For program areas that have significant funding gaps, planned actions to address these gaps.

  • b. How the proposed Global Fund investment has leveraged other donor resources.

The HSSP on HIV and STI 2015-2020 sets the national direction for HIV response. Part of it is the Operational Plan 2015-2017 which contains the cost estimates for the initial 3-year implementation. A total of USD 211,391,585 is the estimated cost of operations for HIV/STI for 2015-2017. There are four major strategies, each one of which has specific activities with the corresponding budget for each year starting from 2015 until 2017. The strategies and activities are further categorized as to the program areas, cost categories and fund source as reflected in the following tables:

Based on the National AIDS Spending Assessment (NASA), total government AIDS spending for 2012 (USD 4.656 million) increased by 84.09% in 2013 (USD 8.579 million). The government percentage share in the overall AIDS spending from 2012-2013 ranged from 48.41% (2012) to a high of 59.18% (2013). Private sector domestic contributions were below 1% at 0.24% (2012) and 0.12% (2013). The biggest contributors were the external sources at 51.35% (2012) and 40.10% (2013). Among the external sources, the largest contribution came from the Global Fund at 44.91% in 2012 (USD 4.343 million) and 22.07% in 2013 (USD 3.181 million).

The annual national health budget is part of the “Social Services Expenditure Program” of the government’s general appropriations. A sub-category of the health budget is the “Other Infectious Diseases and Emerging and Re-Emerging Disease” which includes HIV and AIDS together with dengue, food and water-borne diseases.

Program Area

Amount (US $)

Percent to Total

Prevention

120,020,979

56.8%

Care and Treatment

66,216,383

31.3%

Advocacy, Communication and Social Mobilization

2,738,620

1.3%

Health Systems

20,991,933

9.9%

M&E

1,423,670

0.7%

GRAND TOTAL INDICATIVE BUDGET

211,391,585

100.0%

Table 5. Operational Costs as to Program Areas for 2015 to 2017

  • a. Funding for program areas

The GARPR identified the abovementioned Program Areas to be considered in the preparation of the Operational Plan. Among the five (5) areas, Prevention will be prioritized at 56.8% and Care and Treatment at 31.3%. Health Systems will be 9.9% while Advocacy, Communications and Social Mobilization and Monitoring and Evaluation will be at 1.3% and 0.70%, respectively.

The Operational Plan 2015-2017 also contains the costs of each strategy and activities. Table 6 below lists down the different cost items in the Operational Plan 2015-2017 and the percentage to total of each cost category.

Human Resources get the highest allocation at 44.5% followed by Health Products at 20.3%. Pharmaceutical Products is at 18.3%, Training is at 5.8% while the other nine budget line items have percentages of less than 5% each.

Table 6. Operational Plan as to Cost Category for 2015-2017

   

Percent

Cost Category

Amount (US $)

to Total

Human Resources

94,135,444.45

44.5%

Health Products- Prophylactic

10,364,123.37

4.9%

Health Products- Reagents

21,001,814.51

9.9%

Health Products- Testing

11,644,909.16

5.5%

Pharmaceutical Products (ARV Drugs/Medicines)

24,539,144.10

11.6%

Pharmaceutical Products (Drugs/Medicines)

14,233,891.74

6.7%

Training

12,242,617.12

5.8%

Systems Strengthening and Program Coordination

5,177,720.55

2.4%

Planning and Administration

4,639,661.74

2.2%

Advocacy, Communication and Social Mobilization

3,351,517.54

1.6%

Research and Surveillance

3,075,694.36

1.5%

Infrastructure

3,029,545.45

1.4%

Monitoring and Evaluation

1,454,286.36

0.7%

Health Equipment

949,545.45

0.4%

Living Support to Clients/Target Population / Human Resources

887,082.27

0.4%

Technical Assistance

664,587.18

0.3%

GRAND TOTAL INDICATIVE BUDGET

211,391,585

100.00%

Table 7. Operational Plan as to Fund Source for 2015-2017

Fund Source

Amount (US $)

Percent to Total

DOH- CENTRAL OFFICE (GOP)

65,068,176

30.8%

DOH- HFEP (GOP)

1,784,091

0.8%

DOH- REGIONAL OFFICE (GOP)

3,429,150

1.6%

LOCAL GOVERNMENT UNIT (LGU)

85,207,837

40.3%

PHIC (GOP)

19,612,713

9.3%

DEVELOPMENTAL PARTNERS (ODA)

1,344,374

0.6%

GF TB HIV PROJECT (GF-TB HIV)

168,397

0.1%

UNFUNDED

34,776,848

16.5%

GRAND TOTAL INDICATIVE BUDGET

211,391,585

100.0%

Overall, the Operational Plan 37 indicates that the total government share is about 82.8%.

As

shown in the table above, the biggest share among the government sector will come from the

37 HSSP Operational Plan 2015-2017. See Annex 35.

LGUs at 40.3%. The Department of Health (Central & Regional Office & Health Facilities Enhancement Program) at 33.2% will be the second source while PhilHealth contributions will be

9.3%.

The non-government fund source (development partners and Global Fund TB HIV Project) will only be 0.7%. The unfunded portion of the Operational Plan 2015-2017 is estimated at 16.5%.

Financial Gap Analysis

Considering the data mentioned above in the Operational Plan for 2015-2017, Table 8 below links the resource need contained in the Operational Plan 2015-2017 as well as that of the current year 2014 with the anticipated resources from 2014 to 2017. This table shows the matching of the resource requirement with the potential sources that will be available for each year. Any unmatched amount will be considered as the financial gap or the unfunded areas that will still require resourcing.

The resource requirement from 2014-2017 is about $291.632 million ($80.240M for 2014; $66.671M for 2015; $66.353M for 2016; $78.367M for 2017) while the total resources that will be possibly available for the same 4-year period is $193.419 million ($15.837M for 2014; $57.327M for 2015; $59.075M for 2016; $61.180M for 2017). There will be a financial gap totaling $98.213 million from 2014 to 2017.

Table 8. Financial Gap Analysis

 

HIV SPENDING (in US Dollar)

   

Proposed Investment (in US Dollar)

Fund Source

2012

2013

2014

2015

2016

2017

Domestic:

           

National

& Sub-

4,655,901

8,579,180

9,514,102

49,721,459

51,777,854

53,989,941

National

Social

Security

24,647

37,418

1,197,273

6,131,466

6,798,106

6,683,141

Insurance

Total Gov’t

4,680,548

8,616,597

10,711,375

55,852,925

58,575,960

60,673,082

Private

22,919

17,185

-

-

-

-

Total

           

Domestic

4,703,467

8,633,782

10,711,375

55,852,925

58,575,960

60,673,082

External:

           

UN

agencies,

Bilaterals &

623,120

2,598,419

2,552,927

506,774

499,427

506,570

other multi-

laterals

Global

4,342,676

3,181,203

2,572,330

967,662

0

Fund

0

Total

           

External

4,965,796

5,779,622

5,125,257

1,474,436

499,427

506,570

Total

           

Resources

9,669,263

14,413,404

15,836,632

57,327,361

59,075,387

61,179,651

Resource

           

Need 2014-

80,240,452

66,671,134

66,353,187

78,367,264

2017

Resource

       

GAP

(64,403,820)

(9,343,773)

(7,277,800)

(17,187,613)

b.

How

the

proposed

Global

Fund

investment

has

leveraged

other

donor

resources

 

This discussion was not yet undertaken at the time of the Concept Note development, but the Philippine Country Coordinating Mechanism (CCM) plans to facilitate a buy-in exercise among donors for potential resource contribution to the GF-NFM funding request.

  • c. Planned actions to address funding gaps

As shown in Table 8 Financial Gap Analysis, a total amount of US$98.213 million ($64.403M in 2014; $9.344M in 2015; $7.278M in 2016 and $17.188M in 2017) will be the financial gap in resources.

While the Operational Plan 2015-2017 has initially identified possible fund sources, of which the government through the DOH, PhilHealth and LGUs will have the biggest share, the government will still have to exert its best effort to mobilize the resources of the identified government units. In addition to this, the following initiatives will be undertaken to address the financial gap:

Efforts will be made to attain higher levels of efficiency, economy and effectiveness in productivity and managing operational costs within government;

With the infusion of fresh funds, the government is expecting the favorable action by lawmakers on the amendment of the National AIDS Law which advocates for the

appropriation of “sin taxes” to the HIV budget;

Conduct of Partnership Forums on HIV can be made where buy-in on contributions to the

different interventions included in the HSSP will be initiated with the participation of the private sector and other donor agencies; Fundraising campaign for HIV will be done through the use of media and volunteers;

The GF under the NFM and the possible above allocation funding as well as savings from other disease programs, e.g. Malaria, are considered as possible sources in reducing the financial gap.

2.2 Counterpart Financing Requirements

 

Complete the Financial Gap Analysis and Counterpart Financing Table (Table 1). The counterpart financing requirements are set forth in the Global Fund Eligibility and Counterpart Financing Policy.

a.

Indicate below whether the counterpart financing requirements have been met. If not, provide a justification that includes actions planned during implementation to reach compliance.

Counterpart Financing Requirements

Compliant?

If not, provide a brief justification and planned actions

i. Availability of reliable data to assess compliance

Yes

No

The National AIDS Spending Assessment (NASA) report; DOH reports

ii. Minimum threshold government contribution to disease program (low income-5%, lower lower- middle income-20%, upper lower-middle income-40%, upper middle income-60%)

Yes

No

Minimum threshold on government contribution complied. Per financial gap analysis table template, 64% is the computed threshold.

   

Total government contribution to the HIV program:

iii. Increasing government contribution to disease program

Yes

No

2014: $10.711M 2015: $55.853M - (421% increase from 2014) 2016: $58.576M - (4.8% increase from 2015) 2017: $60.673M - (3.6% increase from 2016)

  • b. Compared to previous years, what additional government investments are committed to the national programs in the next implementation period that counts towards accessing the willingness-to-pay allocation from the Global Fund. Clearly specify the interventions or activities that are expected to be financed by the additional government resources and indicate how realization of these commitments will be tracked and reported.

  • c. Provide an assessment of the completeness and reliability of financial data reported, including any assumptions and caveats associated with the figures.

Counterpart financing

Government investments in HIV and AIDS will be increasing compared to previous years (See Table 8). The projected investments for 2015-2017 of the national government include the PhilHealth which targets 100% enrollment, coverage and utilization. Resources from the LGUs will still have to be mobilized to ensure budget allocation for HIV and AIDS programs.

The Financial Gap Analysis and Counterpart Financing Table template reflect the computed counterpart of 64% which is way above the minimum 20% threshold requirement for government.

The Operational Plan for 2015-2017 includes focused interventions of the government on the HIV and AIDS program. The 2015 national budget already provides for the appropriation for the Health Facilities Enhancement Program (HFEP) which will be allocated for health equipment and physical improvement of the SHCs and treatment hubs. The commitment of assuming the costs of health products and pharmaceuticals as well as the procurement thereof indicates that the government will exert all possible efforts in preventing HIV infection and strengthening access to treatment.

The financial data for the funding landscape came from the NASA, Summary Budget of Global Fund Existing Round 6 Grant, Operational Plan 2015-2017 and data provided by the DOH and UNAIDS as well as the national budget prepared by the Department of Budget and Management (DBM).

SECTION 3: FUNDING REQUEST TO THE GLOBAL FUND

This section details the request for funding and how the investment is strategically targeted to achieve greater impact on the disease and health systems. It requests an analysis of the key programmatic gaps, which forms the basis upon which the request is prioritized. The modular template (Table 3) organizes the request to clearly link the selected modules of interventions to the goals and objectives of the program, and associates these with indicators, targets, and costs.

3.1 Programmatic Gap Analysis

A programmatic gap analysis needs to be conducted for the three to six priority

modules within the applicant’s funding request.

Complete a programmatic gap table (Table 2) detailing the quantifiable priority modules within the applicant’s funding request. Ensure that the coverage levels for the priority modules selected are consistent with the coverage targets in section D of the modular template (Table 3).

For any selected priority modules that are difficult to quantify (i.e. not service delivery modules), explain the gaps, the types of activities in place, the populations or groups involved, and the current funding sources and gaps.

The programmatic gap table includes seven (7) sections: treatment and care; HIV prevention for MSM, HIV prevention for TG, HIV prevention for PWID, HIV testing and counseling for MSM, HIV testing and counseling for TG and HIV testing and counseling for PWID.

To calculate the MSM+TG population (denominator) used in both the programmatic gap table and the modular template, the estimated MSM+TG population in the Category A sites 38 plus the estimated MSM+TG population in Bacoor, Puerto Princesa, Zamboanga and Cagayan De Oro cities (cities with estimated HIV prevalence in MSM above 2%). To estimate the population in need of HIV prevention and testing services, this is multiplied by the percent of MSM who had anal sex in the last 12 months (67% based on the IHBSS 2013), a proxy for risk.

The TG population size in the Philippines is not known and in general, data is not disaggregated from MSM data. However, available data suggests that about 12-15% of individuals reached by MSM services are actually transgender. This matches closely with regional estimates that 0.3% of the population above 15 years old is transgender 39 . For the purposes of developing separate denominators, baseline values and targets for TG we have assumed that 15% of the MSM+TG population is TG. Population size estimates for all KAP will be conducted in 2015; after this, targets for TG reached and tested in the NFM may need to be adjusted. Further, we have used the most recent working definition of TG 40 :

Would self-identify as a TG woman, but may also identify/label themselves using various

o

o

o

terms/labels more common in their locality Whose birth assigned sex is male (AND)

Whose gender identity is more female/woman (AND)

Whose gender expression (appearance, behaviour, attitude) is more feminine

(accepted: sometimes masculine) May or may not have injected/taken female hormones

May or may have not undergone any body modifications (for breasts and/or hips, surgical

or non-surgical) May have varying sexual orientations (hetero, homo, bi, poly, etc.)

The denominator used for PWID in the programmatic gap table and the modular template is the estimated PWID population in all Category A sites. The Category A sites include the majority of Cebu province, where injecting drug use is concentrated.

  • 38 Category A sites contribute to almost half of the epidemic with multiple risks and high prevalence.

  • 39 UNDP and Asia Pacific Transgender Network (2012), Lost in Transition: Transgender people, rights and HIV vulnerability in the Asia Pacific Region. Annex 22.

  • 40 Power Point Presentation of Raine Cortes, Understanding the Localized Transgender Definition, 18 December 2012. Annex 23.

HIV prevention for MSM

Selected indicator: % MSM reached with HIV prevention package - defined package of services

The IHBSS 2013 (see Annex 5) found that only 12% of MSM surveyed had accessed a SHC in the last 12 months and while slightly more (17%) had received HIV information from a Peer Educator (PE), this is a serious gap in the national program whose prevention efforts focus on the SHCs. This contributes to ongoing high risk behaviors in MSM, with only 37% of MSM and TG people reporting condom use at last anal sex (IHBSS, 2013).

The 2013 IHBSS found that MSM in older age groups had riskier sexual practices: in the 15 to 17 year age group 10% practiced anal versatile sex and 22% reported anal receptive sex compared to 26% reporting anal versatile and 31% anal receptive sex in the 25 and older age group. Older MSM are known to meet online and also at venues such as bars, saunas and other on-site sex establishments. Outreach proposed in the Concept Note will focus on reaching MSM at these sites and providing HIV testing and counselling on-site. A comprehensive internet based communication strategy is also proposed with links between sites where MSM meet and information about HIV testing.

The current TFM program of the Global Fund provides HIV prevention interventions for MSM and TG in 12 cities (see Table 1). In the first half of 2015, two donor-funded programs (Big Cities and ROMP) will reach MSM in the same cities as the TFM plus an additional 4 cities in Greater Metro Manila (GMM) and Cebu (see Table 1), although funding for both of these will end in June 2015 and end of year targets are not possible. The TFM, too, will end in June 2015. The RITM program through the DOH operates in GMM and employs MSM peer educators as “change agents” who reach peers and serve as role models; this program will run for the foreseeable future.

In cities other than those covered by the TFM, RITM, ROMP or the Big Cities projects, MSM specific programs do not exist, although the DOH is committed to providing MSM prevention

services in existing SHCs. They set a target for 80% of MSM to be reached in Category A sites by

2017.

Selected indicator: % MSM who had an HIV test in the last 12 months and know the results

The 2013 IHBSS also found extremely low rates of HIV testing among MSM at 8% and this negatively impacts on the epidemic. The majority of HIV positive MSM are unaware of their status, with ongoing risk behaviors and no access to treatment and care. Those that are tested and found positive are often lost to follow up, unaware of their CD4 count and not linked to treatment and care.

In general, while HIV testing in the Philippines is available, the focus of testing may be on the wrong groups. For example, many overseas Filipino workers (OFWs) receive HIV testing as a pre- employment requirement, but few of these are MSM. Another example, data from Manila SHC showed that in one (1) year 1,765 people were tested for HIV for the purposes of health certificates for work, but none of these were reactive. In contrast, only 328 were referred by friends, mainly MSM and 21% of these were reactive 41 .

Few services are MSM friendly, specifically target MSM or employ MSM peers and the geographic coverage of services is low. Further, testing services are available mostly at the SHCs which may have restricted opening hours and be located far from MSM communities 42 . It should also be noted that the IHBSS 2013 found that 59% of MSM surveyed did not know where to get an HIV test indicating the need for effective demand generation campaign.

41 WHO, NEC, DOH (2012), Health Sector Models to increase access to HIV counselling and testing for males who have sex with males in the Philippines. Annex 24. 42 WHO, NEC, DOH (2012), Health Sector Models to increase access to HIV counselling and testing for males who have sex with males in the Philippines. Annex 24.

A barrier to HIV testing is the testing protocol. The current guidelines state that results can only be given to someone after confirmatory testing by Western Blot at the reference laboratory. This means that confirmed results are only available about one (1) month after the test is performed. Further, only registered medical technologists are allowed to perform the test (see Annex 25). Apart from pilots running in a few sites in GMM, rapid testing is not available, and even in those

sites where rapid diagnostic tests are used, MSM, TG and PWID are often asked to return in two to

three days to the SHC for results 43 .

Many people are lost to follow-up after initial testing.

The RITM 3S Program: Smart, Safe and Sexy aims to decrease the waiting time for HIV testing results by piloting a same day testing algorithm in certain cities in Metro Manila targeting MSM. After two (2) positive rapid tests, patients are linked to the treatment hubs where they receive baseline CD4 and have blood drawn for confirmatory testing at the reference laboratory using Western blot 44 . This promising pilot has yet to be evaluated.

While the efforts of the TFM, Big Cities project and ROMP have improved the availability of HIV testing services for MSM in certain Category A and B cities, including piloting the use of rapid testing (see Table 9), all of these are unfunded from mid-2015.

HIV prevention for TG

Selected indicator: % TG reached with HIV prevention package - defined package of services

As above, the national program sets a target of 80% of TG reached with HIV prevention interventions by 2017 with a package that includes: outreach, information, education, condoms+lubricant and referral to other health services. In the NFM sites (13 sites with allocated funding and 3 with above allocated funding) a target of 80% coverage is also set. In other cities, although most are served by SHC, TG specific programs do not exist. The DOH is committed to providing HIV prevention services to TG through the SHCs in cities outside of the NFM sites.

Selected indicator: % of TG who receive an HIV test in the last 12 months and know the results

An IHBSS of TG people in Cebu found that only 4.3% had been tested for HIV in the last 12 months and knew the result. Further, few were aware that they could receive testing for HIV at the SHC (see Annex 26). There are no specific services for TG people which offer HIV testing in almost all parts of the country.

HIV prevention for PWID

Selected indicator: % PWID who receive sterile needle syringe in the last year

The 2013 IHBSS found that 29% of PWID received needle/syringes from an SHC or PE in the last 12 months, which is far from both the national target and the percentage coverage which would impact on the epidemic in this population. As a result 61% reported ever sharing injecting equipment and 35% shared during their last injection.

The HSSP operational plan sets a target for PWID to be reached with an HIV prevention intervention which includes: HIV information and education, condoms and lubricant, needles/syringes and information about other health services. The targets are 55% in 2015, 68% in 2016 and 80% in 2017 in Category A sites.

The USAID-funded ROMP project and the ADB-funded Big Cities project both target PWID in Cebu province (Cebu, Mandaue, Danao and Lapu Lapu cities), likewise the Global Fund TFM grant (in Cebu, Mandaue, and Danao; see Table 9). However, all of these will be unfunded from June 2015 and do not have yearend targets. Apart from these, there are no other specific services for PWID, although the DOH is committed to providing HIV prevention services for PWID through SHCs in the cities outside of the NFM sites.

43 UNDP and Asia Pacific Transgender Network (2012), Lost in Transition: Transgender people, rights and HIV vulnerability in the Asia Pacific Region. Annex 22. 44 3S program: Smart, Safe and Sexy (2013,) Research Institute for Tropical Medicine. Annex 27.

Selected indicator: % of PWID who received an HIV test in the last 12 months and know the result

Only 6% of PWID have received an HIV test in the last 12 months and know their results (IHBSS, 2013), an extremely low rate particularly in a setting where the estimated HIV prevalence in this population is 48%. It is imperative that more PWID are aware of their status, given the knowledge and tools to prevent the further spread of HIV. Program managers also note that male PWID who are diagnosed positive with HIV are often reluctant to disclose their status to their female partners who may or may not also be PWID.

As above, the TFM, Big Cities and ROMP projects offer HIV testing and counseling for PWID in

Cebu Province (see Table 9) but as mentioned above, all of these are unfunded from the middle of

2015.

Table 9. Category A and B sites and Current HIV and AIDS Programs (See Annex 6 Map of New C45 Sites)

   

Category

TFM

Other programs

 

Angeles City

Cat A

TFM

 

Cagayan de Oro City

Cat A

TFM

 

Cebu City

Cat A

TFM

ROMP + Big Cities

Mandaue City

Cat A

TFM

ROMP + Big Cities

Manila City (GMM)

Cat A

TFM

RITM

Marikina City (GMM)

Cat A

TFM

 

Pasay City (GMM)

Cat A

TFM

 

Quezon City (GMM)

Cat A

TFM

ROMP

Davao City

Cat A

TFM

 

Caloocan (GMM)

Cat A

TFM

 

Pasig City (GMM)

Cat A

TFM

 

Bacoor

Cat A

   

Puerto Princesa City

Cat A

   

Zamboanga City

Cat A

   

Makati City (GMM)

Cat A

   

Baguio City

Cat A

   

Las Pinas City (GMM)

Cat A

   

Mandaluyong City (GMM)

Cat A

 

Big Cities

Muntinlupa City (GMM)

Cat A

 

RITM

Paranaque City (GMM)

Cat A

 

Big Cities

Pateros City (GMM)

Cat A

   

San Juan City (GMM)

Cat A

   

Taguig City (GMM)

Cat A

 

Big Cities

Valenzuela City (GMM)

Cat A

   

Danao

Cat B

TFM

 

Lapu Lapu City

Cat B

 

ROMP

Talisay

Cat B

   

Antipolo

Cat B

   

Bacolod City

Cat B

   

Batangas City

Cat B

   

Butuan City

Cat B

   

Cainta, Rizal

Cat B

   

Dasmarinas

Cat B

   

General Santos City

Cat B

   

Iloilo City

Cat B

   

Imus, Cavite

Cat B

   
 

Lipa City

Cat B

     

Mabalacat

Cat B

   

Meycauayan

Cat B

   

Olongapo

Cat B

   

San Fernando City

Cat B

   

San Jose City

Cat B

   

Sta. Rosa

Cat B

   

HIV treatment and care

 

Selected indicator: % eligible adults and children receiving ART

 

In early 2015 new national guidelines for ART will be implemented, shifting treatment eligibility from a CD4 count of 350 or less to a CD4 count of 500 or less. This will increase the number of people who are treatment eligible; in 2015, it is estimated that 24,729 adults and children will be eligible for treatment, an increase from 18,679 under the old guidelines. The NASPCP budget request to the DOH will grow over the years to cover this additional need; however they anticipate that their request will not be able to increase in line with forecasted needs. As such, the DOH will procure 70% of required drugs in 2015, 80% in 2016 and 90% in 2017. This leaves a gap of 30% in 2015, 20% in 2016 and 10% in 2017.

Overall issues with HIV prevention services

 

A 2013 review of peer educators and HIV prevention services in the Philippines noted weaknesses in the current system which may contribute to ongoing risk behaviors in KAP and inadequate reach of programs. The review made recommendations to address this including increasing coverage of PEs, ensure that PEs are able to be gender responsive, hire female and TG peer educators, the development of standard operating procedures and training curriculum for PEs, consistency in the provision of stipends to PEs, reducing the case load for each PE and investment in infrastructure improvements that allow services to grow at local level (See Annex 28).

The review also noted the importance of empowering communities to be involved in planning and provision of services. While some TFM sites work through NGOs, in others the involvement of CBOs and NGOs in the delivery of services is limited or non-existent.

There are also legal, regulatory and police barriers to access by KAP to HIV prevention services. These include lack of a regulatory framework which allows the operation of needle/syringes programs, mistreatment by police of KAP, lack of mandated representation by KAP in local government structures and poor understanding of KAP and HIV in local government units and law enforcement agencies.

Recently a resolution from the DDB on 8 October 2014 paved the way for the implementation of needle/syringe programs as part of the National HIV program, but only as an operational research project. There is still a need to translate this into local level ordinances which will allow for the inclusion of needle/syringe programs in local government planning and budgeting.

Analysis of gaps in the HIV cascade

 

The design of this concept note was guided by an analysis of what had worked and not worked during the TFM grant and other projects. Formal evaluations of the TFM, ROMP, Big Cities and RITM projects were not available at the time of writing. However, service data from the TFM, discussions with program managers, a 2013 evaluation of HIV prevention services in the Philippines and a review of HIV testing options for MSM were used to identify gaps, leakage points and issues in the HIV cascade.

It was particularly important to understand how to improve and build on the successes of the TFM for the design of the NFM.

The analysis identified several gaps:

 
  • 1. Reach While the TFM overall met its coverage goals for HIV prevention services for KAP, the

IHBSS shows that high risk behaviors still occur, with only 36.7% of MSM and TG using a condom at last anal sex and 35% of PWID sharing needle/syringes at their last injection. This is likely related to the quality of Behavioral Change Communication (BCC) messaging, peer education and outreach. Program managers noted that the PEs stated that they could not reach anymore KAP (they had reached “saturation”) and that there were sub-populations of MSM, TG and PWID that they were not finding. The TFM set a target for each PE to reach 17 new individuals a month, but there were concerns that PEs were not able to effectively engage with these many people. Further, there are legal barriers to KAP accessing services, including changing legislation around needle/syringe programming. Transgender people and MSM also report police injustice and mistreatment.

The TFM PEs currently aim to reach 17 new individuals each month and provide information, skills, condoms and lubricant and advice on how to access SHCs; additionally for PWID they provide needle/syringe and advice on safe injection. It was felt that the PEs were rushing to provide services in order to meet their targets and not engaging effectively at each service contact. Also, the PEs who were working on the program had reached saturation, that is, they had reached all KAP in their network and were failing to identify new subsets of KAP.

  • 2. HIV testing and results While the TFM met its targets for prevention coverage, it did not meet

targets for MSM, TG or PWID who were tested for HIV and knew the results. Only 20-30% of the

KAP population in the TFM sites received an HIV test and knew the results. The reasons for this include long waiting times for confirmed test results (as described above); poor coverage of testing services which are usually only performed at SHCs, which may be inaccessible due to geographical distance to the community or unavailable due to limited opening hours or uninviting for MSM, TG and PWID. The pilot of rapid testing protocols is only in limited sites, and confirmatory testing at the reference laboratory is still required for confirmation of HIV.

  • 3. Linked to care The TFM set a target for 50% of those testing positive to receive a baseline

CD4 test and they achieved this target. However, program managers felt this target was too low and cited a lack of availability of CD4 machines as a limiting factor in high numbers of newly diagnosed PLHIV knowing their status. It was also noted that many PLHIV were not aware of the importance of CD4 testing nor that their CD4 count determined their eligibility for treatment.

  • 4. Enrolled on treatment The TFM did not collect data on how many of those tested and with

baseline CD4 were then enrolled on treatment. However, the National ART registry shows that in the Philippines the average CD4 count at treatment initiation is 165 cell/mm 3 . It is likely that most KAP

in the TFM sites are also late initiators to treatment due to loss to follow-up, being unaware of their CD4 count early in the disease or altogether unaware of their status until they are at a more advanced disease stage.

1. Reach – While the TFM overall met its coverage goals for HIV prevention services for

Figure 4. Gaps in the current TFM program HIV cascade

3.2 Applicant Funding Request

Provide a strategic overview of the applicant’s funding request to the Global Fund, including both the proposed investment of the allocation amount and the request above this amount. Describe how it addresses the gaps and constraints described in questions 1, 2 and 3.1. If the Global Fund is supporting existing programs, explain how they will be adapted to maximize impact.

In the Philippines, MSM, TG and PWID all have extremely low rates of access to a continuum of HIV services and as such, the HIV epidemic in this population continues to grow unabated. Barriers to accessing these services prevent key populations from having the knowledge, tools, care, support and treatment which would allow them to improve their health and adopt new behaviors which would decrease transmission of HIV in their communities.

As described above, an analysis of what worked and what did not work during the implementation of the TFM and other programs guided the design of this concept note. The main strategy is to increase the number of KAP who enter into each stage of the HIV cascade: reached by HIV prevention interventions; received HIV testing, counseling and results; linked to care; enrolled in treatment program and retained in treatment.

Reached by HIV prevention services

In terms of reach, the concept note includes strategies and interventions which will increase the number of PWID, TG and MSM who will be reached by HIV prevention interventions, the first stage of the cascade:

1. Increase coverage

The NFM coverage targets for HIV prevention are 80% each year of MSM and TG in 13 cities and an additional three (3) cities with above allocated funding (see Table 10), an increase from TFM targets. By the end of the NFM grant, the coverage in Category A cities (plus Bacoor, Puerto Princesa, Cagayan De Oro and Zamboanga) will be 42% with allocated funding and 47% with above allocated funding. Including domestic sources, 80% of MSM will be reached by 2017 in all Category A sites (see Table 11).

For PWID, the NFM sets targets of 60% in 2015, 70% in 2016 and 80% in 2017 in three (3) cities (with allocated funding) and an additional three (3) cities with above allocated funding (see Table 11). By the end of the of the grant, the coverage of PWID HIV prevention interventions in the Category A sites will be 55% with allocated funding and 64% with above allocated funding. With domestic funding, the % of PWID reached in Category A sites will be 80% by 2017.

The NFM will continue in the TFM sites, building on the successes of this program. With the above allocated funding request, the NFM can: a) expand to other cities which have recently been identified as having an HIV epidemic in MSM (i.e. HIV prevalence above 2%; Zamboanga, Bacoor, Puerto Princesa cities); and b) Expand the PWID program to cover more of Cebu province (Lapu Lapu, Toledo and Talisay cities).

HIV prevention services will also play an important role linking KAP to other services. Referral from HIV prevention services on outreach will focus on referring to SHCs for STI testing and treatment, hepatitis B vaccination. From SHC and from outreach, KAP will be referred for Prevention of Mother-to-Child Transmission (PMTCT) and drug dependence treatment and rehabilitation. Travel costs are included in the funding request.

 
Figure 5. Referral Network 2. Provide HIV prevention services on outreach in targeted sites The IHBSS
 

Figure 5. Referral Network

 

2. Provide HIV prevention services on outreach in targeted sites

 

The IHBSS showed that about 90% of PWID injected drugs in shooting galleries and MSM are known to congregate in bars, spas and clubs with many also meeting partners online. In the TFM, it was noted that PEs were not reaching certain subsets of KAP, particularly groups of MSM and TG who may be unknown to the PEs. Currently, PEs and outreach workers do not conduct regular mapping activities and so the NFM will support the development of Standard Operating Procedures (SOPs) for outreach which will include guidelines on how to conduct micro-mapping and improve data collection in order to identify new networks of KAP and target outreach to those sites where KAP live and meet.

The HIV prevention program will focus on providing services on outreach, using micro-mapping results to identify outreach sites. Condoms, lubricant, needles and syringes will all be available at the outreach sites. The funding request includes budget for condoms, lubricant, needles and syringes.

Table 10. Target Cities under the NFM (See Annexes 29 and 30 for Maps 2 and 3 of Cities under the NFM Allocated and Above Allocation Funding)

 

City

Allocated

Above

MSM/TG

PWID

HIV

HIV

HIV

allocated

prevalence

prevalence

prevalence

MSM

PWID

TG

Cebu City(Cebu)

 
  • X X

 

X

7.67

52.3

3.7

(Male)

30.4

(Female)

Quezon City

 
  • X X

   

6.58

   

(GMM)

Manila City

 
  • X X

   

6.38

   

(GMM)

Caloocan City

 
  • X X

   

5.5

   

(GMM)

 

Davao City

X

 

X

 

5.0

     

(Region XI)

Cagayan De Oro City (Region X)

X

 

X

 

4.7

   

Makati City

X

 

X

 

3.7

   

(GMM)

Pasay City

X

 

X

 

3.0

   

(GMM)

Mandaue City

X

 

X

X

 

37.7

 

(Region VII)

Angeles City

X

 

X

 

2.3

   

Marikina City

X

 

X

 

1.9

   

(GMM)

Danao City

X

 

X

X

     

(Cebu)

Pasig City

X

 

X

 

0.33

   

(GMM)

Bacoor City,

 

X

X

 

3.3

   

Cavite (Region

IV-A)

Zamboanga City

 

X

X

 

2.7

   

(Region IX)

Puerto Princesa City (Region IV-

 

X

X

 

2.0

   

A)

Toledo City

 

X

 

X

     

(Cebu)

Lapu Lapu City (Cebu)

 

X

 

X

     

Talisay City

 

X

 

X

     

(Cebu)

3. Increase quality of outreach and peer education

 

The NFM will set the target number of KAP per PE to 100 per year with the aim of increasing quality and also engaging more PEs which will expand the networks reached through the engagement of more

PEs. In deciding to decrease the “case load” per PE the following were considered:

 
 

Peer educators at Quezon City’s Klinika Bernardo reported that they were frequently reporting

service contacts rather than individuals reached and that it would not be possible to reach the targeted number of individuals;

PE will have additional responsibilities in the NFM particularly providing counseling and other support for KP during testing, and there is an increase in targets for testing;

While coverage targets were met under the TFM, the quality of the intervention has not been proven. Indeed, high risk behaviors continue and HIV testing rates are low in TFM sites;

It was reported that current PE had reached all the KAP in their network. Employing more PEs will reach new networks of KAP;

Examples from other countries (India, Cambodia) suggest that for successful peer led behavior

change and linkage to testing and counseling services, each PE should have regular contact (i.e. at least once a month) with 50-100 of their peers

PEs are volunteers who are paid a monthly allowance and are not costly;

 

PE evaluation described the brevity and simplicity of most PE to KAP interactions and it was felt that a smaller case load will allow each PE to spend more time with KAP

All PEs are volunteers but receive a small allowance to cover travel and food costs. PE allowances will be standardized across all NFM sites. The funding request includes allowances for one PE for every 100 KAP to be reached on a regular basis. Importantly, in the TFM no targets were set for number of service contacts made per PE, the only target being to reach 17 new individuals per month. It is important that PEs have regular contact with each KAP; in the NFM this will be defined as at least once a month.

In addition the funding request includes budget for an international expert to provide support to CBOS, NGOs and SHCs to develop PE training modules, improve communication and advocacy strategies, BCC tools and effective and easy to use data collection tools for outreach.

Table 11. Baseline and Coverage Targets for HIV Prevention Interventions

 
 

Baseline

2015

2016

2017

Coverage

Coverage in

 

(TFM

in NFM

Category A

data,

sites 45 by

sites + other

first half

2017

cities 46 by

2014)

2017

MSM target prevention allocated

 

72,185

73,560

74,964

80%

80%

MSM target prevention above allocated

70,539

81,161

82,821

80%

80%

TG target prevention allocated

57,568

12,739

12,981

13,229

80%

80%

TG target prevention above allocated

14,036

14,322

14,616

80%

80%

MSM target tested allocated

 

43,311

51,491

59,971

64%

34%

MSM target tested above allocated

12,193

47,723

56,812

66,257

64%

37%

45 Thirteen (13) sites with allocated funding and an additional six (6) sites with above allocated funding. 46 Puerto Princesa City, Cagayan De Oro, Bacoor and Zamboanga for MSM and TG

 

TG target tested allocated

 

7,643

9,087

10,583

64%

34%

 

TG target tested above allocated

8,442

10,026

11,692

64%

37%

PWID target prevention allocated

 

2,575

3,054

3,547

80%

80%

PWID target prevention above allocated

1,195

3,289

3,779

4,282

80%

80%

PWID target testing allocated

388

1,545

2,137

2,838

64%

44%

PWID target testing above allocated

1,973

2,645

3,427

64%

53%

  • 4. Community systems strengthening

 

A key strategy in this concept note is the empowerment of communities to be effectively involved in and/or lead efforts to reduce the burden of HIV in their community. This means they are involved in all aspects of the response but particularly the following:

Planning how and where to reach members of their community through regular mapping and

planning exercises; Reaching other members of their community to promote safer behaviors and improve health

seeking; Either providing HIV testing and counseling, or referring members of their community to HIV

testing and counseling services; Branding and publicizing HIV prevention commodities and related information, education and

communication tools; Organizing and participating in regular training activities; and

Working with other stakeholders, including local government, to advocate for policy and legislative change to support communities, reduce stigma and increase HIV prevention efforts

The CBO role in all sites will be to identify and support PE, assist in outreach and micro-mapping activities, work in the development of SOPs, guidelines and BCC tools, conduct advocacy activities and participate in LAC, LGU and CCM meetings. In some sites, they will be directly implementing services, in others, they will support the SHC. During consultations with KAP, TG representatives stated that they would prefer a safe space to meet, other than the SHC. While this type of service does not currently exist, in select sites, the NFM will support CBOs to create such a space.

All NFM partner NGOs and CBOs will be provided with technical assistance to develop advocacy plans, strengthen communication and networking skills, financial management, monitoring and evaluation, accountability and governance systems. Key populations will be provided with training in networking and communication and advocate for their inclusion in LACs, in the CCM and in the TWG.

In NFM sites with no identified NGO or CBO, nascent CBOs will be identified and provided with technical and financial support to participate in the service network and in planning and advocacy activities.

  • 5. Enabling environment

 

Two officers will be employed to manage strategies to address stigma, legal and regulatory barriers to KAP accessing HIV prevention and testing services:

a. An advocacy and communication officer will be hired to oversee efforts spearheaded by CBOs including:

Developing and implementing advocacy and communication plans

 

Work with LACs to develop and implement stigma reduction strategies

Work to improve communication between LACs and other stakeholders

Provide onsite training to LACs to better understand HIV, gender and sexuality, M&E, PLHIV

inclusive planning, PLHIV rights and sensitive communication Advocate for legislation which will reduce the legal age for anonymous HIV testing (currently,

those under 18 years of age need parental approval ) Identify issues around workplace discrimination of MSM, TG and PWID and develop a joint strategy to address this

  • b. A police and community liaison officer will work to provide training to police and CBOs to understand

the importance of police support for HIV prevention programs

The police and community liaison officer will be employed to achieve the following:

Facilitate meetings between law enforcement agencies and CBOs/NGOs

Facilitate development of agreements between police and services providing needle/syringes, with an aspirational goal of documented memorandums of understanding between police and CBOs/NGOs

Work at the regional and national level to increase police and other stakeholders’ acceptance

of harm reduction Conduct training and sensitisation workshops with police to better understand the MSM and

TG populations Develop training modules

Work with CBOs to increase legal literacy among KAP and assist in documentation related to legal issues

6. Gender

  • a. Providing appropriate services for women - Women who inject drugs are often excluded from harm

reduction and other HIV services. This is because of several additional barriers that they face:

increased stigma associated with female injecting drug use; violence and other abuse; family commitments, and lack of ease with services which are traditionally male focused. Concrete efforts to address these are proposed in this concept note including:

Employment of female outreach workers and female peer educators at HIV prevention and

testing services; Improved data collection about female injecting drug use in the Philippines;

A women’s only room in select sites, or specific hours for female injecting drug users to visit

the drop in center Counseling to diagnosed male partners to disclose their status to their female partners;

Referral to SHC for sexual health services, family planning;

Referral to health centers for PMTCT;

Information and education about HIV tailored for women, and,

Linking women to the women’s and children’s desks in the community, as part of an enhanced

service delivery network.

  • b. Providing appropriate services for transgender people - Transgender people are often included in

data collection, planning and services for MSM but the lives and needs of transgender people remain distinctly separate from those of MSM. The concept note proposes several specific measures to address this:

Separation of services for TG and MSM, with some services designated for TG only in select

sites; Employment of TG peer educators;

Improved data collection about TG and formative research to better understand their needs

and risks; Provision of counseling and advice about the use of drugs for gender affirmation, including

possible drug interactions, safe injecting advice and sterile needle/syringes if necessary; Training and sensitization of health providers about genital examination and specimen collection for TG, and,

While it is not known how many TG in the Philippines are men, SHC, NGO and CBO staff will be sensitized to their needs, including the need for pap testing after hysterectomy 47 .

  • 7. Young people

The TFM aimed to replicate strategies initiated by UNICEF through implementation of most at risk children and youth (MARCY) intervention focusing on young MSM (aged 12 to 17). These are young males who like males but may or may not have had sex with a male. The goal was the development of preventive behaviors that reduce risk of HIV infection, including delay of sexual debut in these young men. This activity was planned for implementation under the TFM but was delayed due to problems with parental consent. Recently, consent for these activities was granted and so the MARCY intervention will commence in the last quarter of 2014. In order to capitalize on what was achieved under the TFM, the NFM will continue to support this activity. These include the following activities that will be taken on by the PR and SRs:

Collaboration with other NGO networks engaged in policy advocacy to continue to push for policy changes around the following:

Amending existing laws to remove the legal barriers on HIV testing and counselling for

o

o

those below 18 years old Developing local plans with increased budget allocations for most at-risk young people

and the prevention of mother-to-child transmission Mapping HIV and AIDS service delivery networks and making these known and available to

the most at-risk young people Improving the capacity of service providers peer educators and outreach workers so they will

understand the needs of the most at-risk young people and mainstream HIV and AIDS awareness in their daily work Ensuring the participation of the most at-risk young people in developing key messages and strategies to raise awareness and stigma

HIV testing and counseling

This stage of the HIV cascade is the main point of leakage in the Philippines response to HIV in KAP. To address these gaps and build on the successes of the TFM, the following strategies to increase the number of KAP who are tested and aware of their HIV status are included in the concept note:

  • 1. Increase targets

In the NFM, targets for HIV testing in MSM, TG and PWID will increase to 80% of all those reached with HIV prevention intervention tested and know the results. In year one, 60% of those reached with HIV prevention interventions will receive HIV testing, counselling and results; in year two, 70%; and in year three, 80%). The NFM sets an ambitious target that 100% of those tested will receive results.

The NFM will contribute to national targets in Category A sites (and other cities with high HIV prevalence) 48 for HIV testing and counseling. With the allocated funding request, by 2017 34% of MSM and TG and 44% of PWID in these cities will have received an HIV test and know the results. With above allocated funding request, 37% of MSM and TG and 53% of PWID will have received HIV testing, counselling and results (see Table 11).

  • 2. Same day testing protocol

It is believed that using rapid testing in the community is the only way that the current national targets for testing and counseling can be reached as decentralized counseling and testing models have repeatedly been shown to decrease loss to follow up and increase retention in care. In order to address the long waiting time between sample collection and receipt of test results and subsequent loss to follow-up a same day testing protocol will be implemented in the NFM sites.

In early 2015, PNAC is committed to developing new policies and guidelines for HIV testing and counseling, including allowing people other than a medical technologist to perform the test, such as

47 WHO (2014) Consolidated guidelines on HIV prevention, testing and treatment for key populations 48 Puerto Princesa, Zamboanga, Bacoor

outreach workers at HIV prevention services. NASPCP will validate a same day testing protocol for inclusion in the national guidelines. Funding for these activities is provided through the TFM.

The protocol will include the use of three (3) different rapid tests, the first as a screening test and then if the screening test is reactive a further two (2) tests will be performed in parallel. If either both of these tests are reactive this is a confirmation of HIV. If only one of these is reactive, the client will need to receive confirmatory testing using Western blot; however it is expected that this will occur rarely. After a confirmed HIV test, the client will be accompanied by the outreach worker to the Treatment Hub for baseline CD4 testing and if eligible enrollment in the ART program (see Figure 6).

The testing protocol does not match the WHO’s guidelines for rapid testing, employing an approach

that the second two tests will be given in parallel, rather than one after the other. While there is potential that the protocol could be more costly, as two additional test kits will be used for those reactive on first test, the estimated number of additional test kits to be procured is only 6600 per year and the total cost of additional test kits over the 2.5 year grant period is only USD18,810. As this is the main “leakage point” in the HIV cascade for KAP, the NFM set an ambitious target that all those tested would know their results and it was felt that the best way to do this was to provide a confirmed HIV test result in a community setting in the shortest time possible. It was felt that parallel testing was the best way to achieve this.

The funding request includes the cost of rapid test kits, training on the rapid testing protocol for outreach staff, medical technologists and SHC staff and the hiring of medical technologists for the first 18 months of the grant. It is envisaged that full implementation of the new guideline for people other than medical technologists to perform HIV testing will take at least one year. In the final year of the grant, it is assumed that outreach workers will perform all testing and counseling in the NFM sites.

outreach workers at HIV prevention services. NASPCP will validate a same day testing protocol for inclusion

Figure 6. Same day testing protocol

4. Testing on outreach

The NFM sites will perform the majority of the HIV testing and counseling on outreach; however, the ability of the SHCs to perform rapid testing will also be assured through training and support to SHC staff and KAP will still be able to receive rapid tests at the SHCs. At each site, an outreach team which includes peer educators, outreach workers and medical technologists will conduct testing on outreach at least three (3) times a week.

At certain sites, a mobile voluntary counseling and testing (VCT) van will provide same day HIV testing and counseling at outreach sites. The funding request also includes a budget for special testing events.

5. Demand creation

The results of the IHBSS showed 70% of all MSM have an online account and 24% of the MSM who have an online account met a sexual partner online. Growing evidence supports the success of social media and other online campaigns in changing behaviors and reducing HIV risk in MSM 49,50 . mHealth technology where mobile phone applications and SMS services can be used to remind people to get tested and to adhere to drug regimens have also been shown to be successful in key populations 51 . These types of campaigns are also affordable, have the potential to reach a greater number of MSM than traditional outreach methods and may be more acceptable to MSM who do not wish to publicly identify themselves as MSM. As such, it is central to the proposed communication strategy to use online technologies to contact MSM, provide information and create demand for HIV testing and counseling services.

Some good examples of the use of the Internet and social media to increase MSM demand for HIV counseling and testing (HCT) in the Philippines include one NGO whose PE enter chatrooms and engage online users in a dialogue about HIV and HCT. Other NGOs use Facebook and blogs to spread information about HCT and HCT sites. One website allows visitors to register for a test, an assigned volunteer then tracks the MSM through the entire process to make sure that they have an appointment, reach the appointment, get their results and, if necessary, are guided to treatment, care and support. However, these are not well maintained, with a recent review of HIV prevention strategies in the Philippines testing one website to find that most web contacts were unresponsive and those that did respond failed to give correct information (see Annex 26)

The PR will request proposals from local contractors who can design and monitor an Internet strategy and/or mobile phone strategy to reach MSM, drawing on the successes of the above strategies, but expanding them to reach more MSM and improving on the current system to address issues identified in evaluations. The request for proposals will call for a program design that addresses the following:

Engage and work with MSM network,