MODULE ONEHIV &TB PROGRAMME DESIGN

PRINCIPLES

1

Outline of the Module

• Basic information on HIV/AIDS, TB, Malnutrition and Food securityI • Global Perspective: role and responsibilities within UNAIDS DoLII • HIV response in Humanitarian settingsIII • WFP HIV and AIDS Policy and Programme StrategyIV • How to design an HIV and TB ProgrammeV• Overview of funding opportunity within Global FundVI• Module TestVII

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BASIC INFORMATION ON HIV/AIDS, TB, MALNUTRITION AND FOOD SECURITY

3

• Stands for Human Immunodeficiency Virus • It is a special type of virus called “retrovirus”• The virus kills white blood cells called CD4 lymphocytes that are responsible for the

immune response HIV

• Acquired because is a condition one must acquire or get infected with• Immune because it affects the immune system• Deficiency because it makes the immune system deficient• Syndrome because the person may experience a wide range of diseases and opportunist

infections

AIDS

• A person HIV positive can stay from 2 to 10-15 years before having CD4 below the threshold and thus developing symptoms

• AIDS when a) CD4 count drop below 350 cell/mm3; b) The infected person shows symptoms mainly due to opportunist infections, such as TB

HIV vs AIDS

• Only specific fluids (blood, semen, vaginal secretions, and breast milk) from an HIV-infected person can transmit HIV

• These specific fluids must come in contact with a mucous membrane or damaged tissue or be directly injected into the blood-stream for transmission to possibly occur

TRANSMISSION

• No curative treatment and no vaccine• Antiretroviral (ARV) drugs: When these drugs are given to patients, their viral load

decreases and their CD4 cell counts increase• ARV drugs are never given one at a time, but always in combination, thus “therapy”• ART stands for Antiretroviral Therapy. All patients with CD4 <350cells/mm3 should be

treated

TREATMENT

What is HIV/AIDS

4

• Tuberculosis (TB) is caused by a bacterium called Mycobacterium Tuberculosis. • The bacteria usually attack the lungsTB

• Not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions exist: latent TB infection and TB disease

• Latent infection: TB bacteria can live in the body without making you sick • Disease: TB bacteria become active because the immune system can't stop them from

multiply

DISEASE

• TB is spread through the air from one person to another trough sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infectedTRANSMISSION

• For people whose immune systems are weak, especially those with HIV infection, the risk of developing TB disease is much higher than for people with normal immune systemsTB and HIV

• TB disease can be treated by taking several drugs, usually for 6 to 9 months• Directly Observed treatment Short Course (DOTS) is an internationally recommended

comprehensive approach to TB control, used since 1995. It is five-point package to; I) Secure political commitment with adequate and sustained financing II) Ensure early case detection, and diagnosis through quality-assured bacteriology III) Provide standardized treatment with supervision, and patient support IV) Ensure effective drug supply and management and, V) Monitor and evaluate performance and impact

TREATMENT

What is TB & linkages with HIV

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Number of PLHIV

Total 34.2 million [31.8 million-35.9 million]

Adults 30.7 million [28.6 million-32.2 million]

Women 16.7 million [15.7 million-17.8 million]

Children1 3.4 million [3.1 million-3.9 million]

People newly infected with HIV in 2011

Total 2.5 million [2.2 million-2.8 million]

Adults 2.2 million [2.0 million-2.4 million]

Children1 330000 [208 000-380 000]

AIDS deaths in 2011

Total 1.7 million [1.6 million-1.9 million]

Adults 1.5 million [1.3 million-1.7 million]

Children1 230 000 [2000 000-270 000]

GLOBAL SUMMARYAIDS Epidemic

Adults and children estimated to be living with HIV |2011

UNAIDS epidemiology, 2012

1. Children < 15 years old

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GLOBAL SUMMARY ART Coverage

Eligibility for antiretroviral therapy versus coverage, low- middle-income countries, by region, 2011

UNAIDS, together we will end AIDS, 2012

What is Malnutrition

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• A state in which the physical function of an individual is impaired to the point where he or she can no longer maintain adequate bodily performance processes such as growth, pregnancy, lactation, physical work, and resisting and recovering from disease

• Malnutrition is a broad term commonly used as an alternative to undernutrition but technically it also refers to overnutrition (overweight and obesity)

MALNUTRITION

• It occurs as low body weight, short stature, micronutrient deficiencies, low birth-weight and suboptimal breastfeeding practices

• For HIV and other infections (such as TB) undernutrition is the commonest form of malnutrition observed. In particular: low body weight, weight loss, micronutrients deficiencies that affect immune system

UNDERNUTRITION

• They are used to assess low body weight• In Children are mostly used Weight for Height (W/H) & Mid-Upper Arm

Circumference (MUAC)• For PLW it is used MUAC• For Adult Man & Non-pregnant Women it used Body Mass Index (BMI) that it is

calculated by taking a person's weight and dividing by their height squared Formula: weight (kg)/ [height (m)]2

ANTHROPOMETRIC MEASUREMENT

HIV & Malnutrition Vicious cycle

9To improve treatment access and adherence

To balance nutrients loss

To increase immune system

strength

To improve treatment

outcomes & effectiveness

1

3To faster weight

gain

2

4

5

& WHY FOCUS ON NUTRITION

Tuberculosis & Malnutrition Vicious Cycle

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Tuberculosis (TB) Malnutrition

• Reduced appetite, ability to take food and increase loss of weight• Reduce ability of body to absorb nutrients• Reduced access to food due to morbidity/low productivity• Increased nutritional needs through metabolic changes

• Weakens the immune system, this increase likelihood of progression from latent infection to active disease

• Increased risk of mortality for those with low BMI (on treatment)• Impair adherence to treatment and may compromise access to treatment

& WHY FOCUS ON NUTRITION

To increase immune system

strength

To faster weight gain & balance nutrient

loss

To improve treatment effectiveness and faster treatment

success

To improve treatment access and adherence

1

2

3

4

Benefits of good nutrition for PLHIV and their families

Example of the crucial role of food and nutrition support in the success of the treatment

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What is Food Insecurity

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• A situation in which household members lack stable, secure access to sufficient amounts of safe and nutritious food for normal growth and development and an active and healthy life

• Food security comprises three elements: availability ,access and utilization

FOOD INSECURITY

• Amount of food that is physically present in a country or area through all forms of domestic production, commercial imports and food aid.AVAILABILITY

• Households' ability to regularly acquire adequate amounts of food through a combination of their own stock and home production, purchases, barter, gifts, borrowing or food aid.

ACCESS

• It refers to: (a) households’ use of the food to which they have access, and (b) individuals' ability to absorb nutrients – the conversion efficiency of food by the body

UTILIZATION

HIV, Tuberculosis & Food Insecurity Vicious Cycle

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Tuberculosis (TB)&

HIV/AIDS

Food Insecurity

• Reduced utilization of food due to loss appetite, ability to take food and reduced metabolism

• Reduced access to food due to morbidity/low productivity• Reduced productivity and out-put including non-food

• Weakens the immune system, this increase likelihood of progression from latent infection to active disease

• Increased livelihood of engage in irreversible, negative coping mechanism• Prevent people from seeking a diagnosis and/or initiating and adhering

treatment

& WHY FOCUS ON IT

Reduce coping mechanism

Mitigate the affect of HIV & TB on

households

Increase food access

Increase treatment adherence and outcomes

1

2

3

4

Availability

Accessibility

Utilization

GLOBAL PERSPECTIVEROLE AND RESPONSIBILITIES WITHIN DoL

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UNAIDS Cosponsor Joint Outcome Framework

cosponsors

Division of labour area Convener (s)

Reduce sexual transmission of HIV World BankUNFPA

Prevent mothers from dying and babies from becoming infected HIV

WHOUNICEF

Ensure that PLHIV receive treatment WHO

Prevent PLHIV from dying of tuberculosis WHO

Protect drug users from becoming infected with HIV and ensure access to comprehensive HIV sensitive for people in prisons and other closed settings

UNDOC

Empower men who have sex with man, sex workers and transgender people to protect themselves from HIV infection and fully access antiretroviral therapy

UNDPUNFPA

Remove punitive laws, policies, practices, stigma, and discrimination that block effective responses to AIDS

UNDP

Meet the HIV needs of women and girls and stop sexual and gender-based violence

UNDPUNFPA

Empower young people to protect themselves from HIV UNICEFUNFPA

Enhance social protection for people affected by HIV UNICEFWorld Bank

Address HIV in Humanitarian emergencies UNHCRWFP

Integrate food and nutrition within HIV response` WFP

Scale up HIV workplace policies and programmes and mobilize the private sector

ILO

Ensure high-quality education for a more effective HIV response UNESCO

Support strategic, prioritized and costed multisectoral national AIDS plans

World Bank15

WFP 2011 HIV/TB Operations Overview

OPERATIONS OVERVIEW

# of Countries

38with HIV/TB project# of HIV/TB project 51 # of HIV/TB project in context of:

Emergency 4 Recovery 27Development 20

BENEFICARIES OVERVIEW

Total beneficiaries: 2,259,200

C&T beneficiaries: 1 1, 406,535 HIV2:

1,196,570

TB : 209,965

M&SN beneficiaries: 852,665

HIV: 228,269TB: 260,658OVC: 363,738

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1 Under HIV are included both ART and PMTCT beneficiaries2 Under C&T are included clients and their households

Region Beneficiaries No. of Countries

ODJ/NSouth-East Africa

1,504,561 16

ODBAsia 309,899 6

ODPLAC 277,215 3

ODDWest Africa 135,870 12

ODCMiddle East 31,655 1 Beneficiaries by Region

ODJ/N67%

ODB14%

ODP12%

ODD6%

ODC1%

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WFP 2011 HIV/TB Programmes by Region

WFP Global Contribution to HIVCountries with Highest HIV prevalence rate

Rank Country HIV Prevalence

1 Swaziland 25.9

2 Botswana 24.8

3 Lesotho 23.6

4 South Africa 17.8

5 Zimbabwe 14.3

6 Zambia 13.5

7 Namibia 13.1

8 Mozambique 11.5

9 Malawi 11.0

10 Uganda 6.5

11 Kenya 6.3

12 Tanzania 5.6

13 Cameroon 5.3

Rank Country HIV Prevalence

14 Gabon 5.2

15 Equatorial Guinea 5.0

16 CAR 4.7

17 Nigeria 3.6

18 Chad 3.4

18 Rep. of Congo 3.4

18 Cote d’Ivoire 3.4

21 Burundi 3.3

22 Togo 3.2

23 Bahamas 3.1

24 Rwanda 2.9

25 Guinea-Bissau 2.5

25 Djibouti 2.5

Countries with 25 Highest HIV Prevalence Rates

Countries in blue, bold italic had WFP HIV activities in 2011

In 2011, WFP worked in 64% (16) of the 25 countries with the highest HIV prevalence rates

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WFP’s Global Contribution to UNAIDS Priorities countries

• In 2011, WFP supported HIV and TB interventions in 16 out of the 31 UNAIDS Priority Countries (52%)

• However, in 2011, WFP supported 38 countries with 51 HIV and TB projects

• WFP provided assistance to

approximately 5.8 % of the 6,650,0001 people receiving ART in low and middle income countries in 2011

Countries in blue, bold italic have HIV activities.

UNAIDS Priority Countries

Botswana

Brazil

Cambodia

Cameroon

China

Congo DR

Djibouti

Ethiopia

Guatemala

Haiti

India

Indonesia

Iran

Jamaica

Kenya

UNAIDS Priority Countries

Lesotho

Malawi

Mozambique

MyanmarNamibia

Nigeria

Russian FederationRwanda

South AfricaSwaziland

Thailand

Uganda

Ukraine

Tanzania

Zambia

Zimbabwe

31 UNAIDS Priority Countries

WFP Global Contribution to HIV UNAIDS Priority Countries

1 Global HIV/AIDS response-Progress report 2011 (WHO, UNAIDS, UNICEF) 19

WFP’s Global Contribution: TB

Rank Country TB Incidence per 100,000

14Togo

455

15Cambodia

436

16Myanmar

384

17Congo

372

18Kiribati

370

19 Democratic People's Republic of Korea

345

20Mauritania

337

21Guinea

334

22 Congo DR 327

23 CAR 319

24Angola

304

25 Papua New Guinea

303

26Kenya

298

Countries with 26 Highest TB Incidence Rates 1

Countries in bold italic had WFP TB activities in 2011

In 2011, WFP worked in 56% (14) of 26 countries with the highest TB incidence rates

Rank Country TB Incidence

1Swaziland

1,287

2South Africa

981

3Sierra Leone

682

4Zimbabwe

633

5Lesotho

633

6Djibouti

620

7Namibia

603

8Gabon

553

9Mozambique

544

10Botswana

503

11Marshall Islands

502

12Timor-Leste

498

13Zambia

462

1 http://www.who.int/tb/publications/global_report/en/ and http://www.who.int/tb/country/data/download/en/index.html

WFP Global Contribution to TBCountries with Highest TB incidence rate

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WFP’s Global Contribution: TB (2)

WHO Stop TB Plan II Priority Countries

Country1 Afghanistan2 Bangladesh3 Brazil4 Cambodia5 China6 Congo DR7 Ethiopia8 India9 Indonesia

10 Kenya11 Mozambique12 Myanmar13 Nigeria14 Pakistan15 Philippines16 Russian Federation17 South Africa18 Thailand19 Uganda20 Tanzania21 Viet Nam22 Zimbabwe

In 2011, WFP supported TB programming in 8 out of the 22 WHO TB Priority Countries (36%)

WFP Global Contribution to TB WHO Stop TB Plan II Priority Countries

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HIV RESPONSE IN HUMANITARIAN SETTING(PREPAREDNESS AND RESPONSE)

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Partnerships WFP’s Role in HIV in Emergencies

Within Joint Outcome Framework and Division of Labour (2010):

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WFP is co-convenor with UNHCR to address HIV in Humanitarian emergencies

IACS guidelines HIV in Humanitarian Settings

In 2004 by the Inter-Agency Standing Committee (IACS)

Issued

Assist humanitarian and AIDS organizations to plan the delivery of a minimum set of HIV prevention, treatment, care and support services to people affected by humanitarian crises

Purpose

Mid-level programme planners and implementers from agencies involved in providing humanitarian assistance

Target Audience

The tool is generic and can be applied to any humanitarian setting in different epidemic scenarios

Use

1.HIV awareness;2.Health;3.Protection;4.Food security, nutrition and livelihood;5. Education 6. Shelter; 7.Camp coordination and Camp management; 8.Water sanitation and hygiene; 9. HIV in the workplace

Multisectoral response

http://www.aidsandemergencies.org/cms/

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IASC guidelines HIV in Humanitarian Settings

http://www.aidsandemergencies.org/cms/

HIV awareness raising and community support 1

Health2

Protection3

Food Security, nutrition and livelihood support4

Education5

Shelter6

Camp coordination and camp management 7

Water, sanitation and Hygiene8

HIV in workplace9

Key sectors in humanitarian plan:

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For each of these sectors essential actions need to be taken in response to humanitarian crises in two different phases: I) Early stages of any emergencies (minimum initial response) II) expanded response

Example of action framework Food security, nutrition and livelihood

Sector: Food security, nutrition and livelihood support

Preparedness Action sheet title

Initial Response Expanded Response

Preposition supplies in the country and at regional hubs

Determine criteria for food assistance to affected individuals and communities

Develop agreement on procurement of stocks, transport and distribution of commodities

Train staff and partners on (a) integration of HIV interventions in food and nutrition programmes and (b) integration of food security, nutrition and livelihoods skills in support of PLHIV and OVC

Integrate HIV proxy indicators (household headed by children or elderly, presence of a chronically ill person in a household) into food security and vulnerability analyses

1. Ensure food security, nutrition and livelihood support

Target and distribute food assistance to HIV-affected communities and households Integrate HIV into existing food assistance and livelihood support programmes and food security, nutrition and livelihoods in HIV projects and activities

Introduce specific measures to protect/adapt the livelihoods of HIV-affected households and support homestead food production

Adapt agricultural methods and build capacity

Provide appropriate relief inputs and training to vulnerable and affected households to restore/rebuild livelihoods

Adapt food distribution rations for hyperendemic settings

2. Provide nutritional support to PLHIV

Ensure adequate nutrition and care for vulnerable PLHIV

Respond to the specific needs of pregnant and lactating women living with HIV and their children

Expand nutrition and care programmes for PLHIV

Integrate nutritional support with other services

Strengthen the capacity of PLHIV and those on ART to provide for their nutritional needs

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Coordination of the HIV response In Humanitarian Settings

UN Country Team, under UN Resident coordinator, activates in coordination with the Government the cluster approach to coordinate the humanitarian response. UNAIDS Country Coordinator is part of the Humanitarian Country Team and has a role to ensure link between humanitarian response and existing pre-crisis HIV coordination mechanisms and programming capacity in the country

UNAIDS Country Coordinator should seek guidance from the UN resident Coordinator/Humanitarian Coordinator on the humanitarian coordinator mechanism in place and should ensure appropriate linkages between the humanitarian coordination mechanism and UN Joint Team on AIDS and the National AIDS programme

Coordination when cluster is

activated

Coordination when cluster is not activated

Coordination of the HIV response In Humanitarian Settings

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Needs assessment and information management: Emergency–specific needs should be integrated and assessed into all sectoral initial rapid assessments to determine the scale and the type of assistance needed

Preparedness, contingency planning and early recovery: all key humanitarian and HIV actors should integrate HIV in all plans and activities from preparedness and contingency planning

Resource mobilization:a) Inclusion of HIV into flash and consolidates appeals like CERF; b) reprogramming regular HIV funds form bilateral donors and GF; c) Allocating existing funds for HIV to the humanitarian response; d)mainstream HIV programming within other proposal for funding

HIV should be integrated into all the following actions

CBA

WFP focal point should work with the Country Team to ensure HIV as well Food & Nutrition support are captured within the needs assessments, contingency plan and resource mobilization

WFP HIV Strategy fitted in Humanitarian settings

Food and Nutrition strategy in HIV settings

Care & Treatment• Malnourished ART, TB-DOTS and

PMTCT Clients• Sometimes HH members

Mitigation & Safety Nets• Food insecure HH affected by

HIV/TB (HH of ART, TB-DOTS pre-ART, PMTCT clients and OVC)

HIV-SPECIFIC INTERVENTIONS

General Food Distribution

HIV-SENSITIVE INTERVENTIONS

Enabling environment: advocacy/advisor role to government and collaboration with stakeholders

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1 2

3

School feeding

Food for asset/Food for work/Food for

trainings

Nutrition:Targeted

Supplementary Feeding

Cote d’Ivoire: WFP support malnourished ART clients in areas of country most affected by displacement due

to political turmoil

Ethiopia: Training to decentralised government

officials to ensure familiarity to HIV and thus guarantee appropriate HIV response in areas hosting

refugees

In DRC and South Sudan, where it is uncertain HIV

impact, WFP offered support to extremely

vulnerable population, ensuring sensitivity to

HIV/AIDS issue

Horn of Africa: WFP support to

malnourished ART and TB clients has been

integrated into the TSFP

4

WFP HIV AND AIDS POLICY &

PROGRAMME STRATEGY

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31

OVERVIEW CORPORATE CHANGES between 2010-2011

HIV and AIDS POLICY

In 2010, a new WFP HIV and AIDS policy has been approved.

Two main pillars have beenoutlined

HIV/TB PROGRAMMING REVIEWPrevious the 2010 Programme category review all HIV and TB activities were classified under SO4. With the closer link established between programme category and SO, HIV and TB activities have been added to SO1 and SO3, as well

2010 PROGRAMME CATEGORY REVIEW

In the 2010 programme category review session of the Executive Boardattention was called to the need for a clearer link between programmecategory and Strategic Objectives (SO)

2010

STRATEGY RESULT FRAMEWORK REVIEWIn 2011, the 2008-2013 SRF has been revised to translate its mandate and strategy into tangible outcomes by linking the five SOs with specific corporate outcomes and outputs, measured by indicators

2011

HIV &TB M&E FRAMEWORK REVIEWBased on the new SRF, a new HIV and TB M&E framework has been designed and corporate and project specific outcomes introduced. HIV &TB M&E guidelines finalised and shared

1 2

3

32

WFP HIV and AIDS POLICY

HIV and AIDS POLICYIn 2010, a new WFP HIV and AIDS policy has been approved

While continuing to affirm the importance of safety nets in mitigating the effects of HIV, the new policy places stronger emphasis on good nutrition as a critical part of any HIV and TB regimen

The Policy outlines two main pillars:1. Care and Treatment: Ensuring nutritional

recovery and treatment of individual 2. Mitigation and Safety Nets: Mitigating the

effects of AIDS on individuals and households

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HIV &TB Programme Pillars

The Policy outlines two programme pillars

Care & TreatmentEnsuring nutritional

recovery and treatment

Mitigation & Safety nets

Mitigating the effects of AIDS on individuals and

households

1 2

Treatment, Care and Support (Curative)

• Nutritional assessment, education and counselling (NAEC), including infant feeding

• Specialised food products for nutritional rehabilitation

• Finite income transfer in the form of food , voucher or cash (conditional to the above)

• NAEC for all infected

• For all malnourished on treatment

• Households of malnourished client

• NAEC throughout the treatment (TB)/life (HIV)

• Food nutritional recovery usually 6 months

• For duration of client support (Curative)

Intervention Target Duration

Mitigation & Safety

Net(Enabling/

Preventative)

• Finite income transfer in the form of food , voucher or cash

• Finite income transfer in the form of food, voucher or cash for household hosting orphans and vulnerable children

• HIV/TB-sensitive safety nets

• Affected household

• Affected household hosting orphans and vulnerable children

• All

• Until indicators of food security improved

• Based on need, may be longer term

• Long-term

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Pillar one: Care & treatment

NAEC is provided to all clients regardless the nutrition status. It is composed of:• Nutritional assessment- the client’s nutritional status (anthropometric measurements)

and dietary practices are investigated and reviewed• Nutritional Education- It include peer education, provision of information, education

and communication (IEC) materials• Nutritional Counselling-Advices/suggestions are provided to any single client based on

the medical status on simple lifestyle changes on diet, exercises, health living in order to manage metabolic changes and treatment side effects

A

Treatment, Care and Support

(Curative)

• Nutritional assessment, education and counselling (NAEC), including infant feeding

• Specialised food products for nutritional rehabilitation

• Finite income transfer in the form of food, voucher or cash (conditional to the above)

• NAEC for all infected

• For all malnourished on treatment

• Households of malnourished client

• NAEC throughout the treatment (TB)/life (HIV)

• Food nutritional recovery usually 6 months

• For duration of client support (Curative)

A

Intervention Target Duration

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Pillar one: Care & treatment

• Specialised Food products is only for those clients found to be malnourished during the nutritional assessment

• They receive a nutritional supplement, usually composed of fortified blended food ration integrated with salt and sugar

• It is a short term intervention aimed to rehabilitated from malnutrition, thus it is provided until the client reaches specific anthropometric target with a maximum of 6-8 months

• Income transfer (food, vouchers or cash) sometime, it is provided to the client’s households:• It is conditional to the client’s support and will last until the client is discharged• Income transfer should be designed either as a incentive or to complete the household’s

members diet

B

Treatment, Care and Support

(Curative)

• Nutritional assessment, education and counselling (NAEC), including infant feeding

• Specialised food products for nutritional rehabilitation

• Sometimes, finite income transfer in the form of food, voucher or cash (conditional to the above)

• NAEC for all infected

• For all malnourished on treatment

• Household of malnourished client

• NAEC throughout the treatment (TB)/life (HIV)

• Food nutritional recovery usually 6 months

• For duration of client support (Curative)

B

Intervention Target Duration

C

C

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Pillar one: Care & treatment Clinical process

37

HIV &TB Programme Pillars

The Policy outlines two programme pillars

Care & TreatmentEnsuring nutritional

recovery and treatment

Mitigation & Safety nets

Mitigating the effects of AIDS on individuals and

households

1 2

• Nutritional assessment, education and counselling (NAEC), including infant feeding

• Specialised food products for nutritional rehabilitation

• Finite income transfer in the form of food , voucher or cash (conditional to the above)

• NAEC for all infected

• For all malnourished on treatment

• Households of malnourished client

• NAEC throughout the treatment (TB)/life (HIV)

• Food nutritional recovery usually 6 months

• For duration of client support (Curative)

Intervention Target Duration

Mitigation & Safety

Net(Enabling/

Preventative)

• Finite income transfer in the form of food, voucher or cash

• Finite income transfer in the form of food, voucher or cash for household hosting orphans and vulnerable children

• HIV/TB-sensitive safety nets

• Affected household

• Affected household hosting orphans and vulnerable children

• All

• Until indicators of food security improved

• Based on need, may be longer term

• Long-term

Treatment, Care and Support (Curative)

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Pillar two: Mitigation & Safety Nets

• This intervention support households affected by HIV or TB that also exhibit other vulnerabilities such as food insecurity and asset depletion, including households hosting OVC

• It is a temporary relief intervention during the acute stage of disease for clients receiving care and treatment

• It is should be designed according to food security needs, including food availability, access and utilization

• Households are targeted based on food insecurity information

C

Mitigation & Safety Net(Enabling/

Preventative)

• Finite income transfer in the form of food , voucher or cash

• Finite income transfer in the form of food, voucher or cash for household hosting orphans and vulnerable children

• HIV/TB-sensitive safety nets

• Affected household

• Affected household hosting orphans and vulnerable children

• All

• Until indicators of food security improved

• Based on need, may be longer term

• Long-term

C

D

Intervention Target Duration

• All the interventions should be linked to livelihood promotion activities such as Food for Assets (FFA), Food for training, Food for Work, Income generating Activities (IGA) to ensure economic/productive recovery and long term adherence

D

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2010 Programme Category Review & Strategic Objectives

Programme Category Strategic Objective

SO1

SO3, sometime SO1

SO4

SO2 and SO5

EMOP

PRRO

CP and DEV

Cross-Cutting

Strategic Objective 1: Save lives and protect livelihoods in emergenciesStrategic Objective 2: Prevent acute hunger and invest in disaster preparedness and mitigation measuresStrategic Objective 3: Restore and rebuild lives and livelihoods in post-conflict, post-disaster, or transition situationsStrategic Objective 4: Reduce chronic hunger and undernutritionStrategic Objective 5: Strengthen the capacities of countries to reduce hunger, including through hand-over strategies and local purchase

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The 2010 Programme Category & the HIV/TB programming REVIEW

Following the programme categories review, ODXP successfully advocated to include HIV and TB activities also to SO1 and SO3

Before2010 After 2010

Previous to the programme category review session: all HIV and TB activities were classified under SO4

STRATEGIC OBJECTIVES

SO1

SO3, sometime SO4

PROGRAMME CATEGORY

HIV&TBPROGRAMME

EMOP

PRRO

CP/DEV

Care & Treatment

Care & Treatment Mitigation &Safety Net

Care & Treatment Mitigation & Safety net

SO4

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Workflow of outcomes From shock to development

In an emergency context (EMOP):

Food assistance has a role in stabilizing and maintaining access to treatments by preventing default

In a recovery/transition context (PRRO), HIV/TB activities should be focused on:

• Nutritional recovery of clinically malnourished ART and TB clients for improved treatment adherence and a return to a productive life

• To prevent the adoption of negative coping strategies and the deterioration of productive assets of households affected by HIV or TB, including OVC

In a development context (CP/DEV) allows for a longer-term focus, HIV/TB activities can concentrate on:

• Nutritional recovery of malnourished ART and TB clients

• Improve adherence to ART or TB treatment success

• Support food insecure households affected by HIV or TB, including OVC

2011 Programme overview & Beneficiaries Trends

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Programme Pillar No. of beneficiaries

Care& treatment 1 406 535

Mitigation& Safety Nets 852 655

Percentage of beneficiaries per pillar

WFP HIV&TB Programmes in 2011

Trends in Beneficiaries, 2007-2011

M&SN 38% C&T

62%

2007 2008 2009 2010 20110

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

M&SN C&T

Pre-policy

Beneficiaries have slightly decreased from 2010 to 2011, however the decrease can be explained by a realignment of activities to the new Policy and a greater focus on individual C&T rather than M&SN pillar

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Trends in Programming: 2007-2011 ART & TB Beneficiaries

2007 2008 2009 2010 20110

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

C&T

Pre-policy

ART

ART Beneficiaries TB Beneficiaries

2007 2008 2009 2010 20110

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

A look at ART beneficiaries reveals a strong and steady increase from 2007-2011, which shows the more focused direction that WFP HIV programmes have taken on over the past four years. As shown, the 2010-2011 increase can be explained by the increased focus on C&T

In 2011 TB beneficiaries have slightly increased due to the implementation of the stand-alone TB M&SN activity under the Tajikistan Development project. Totally, under the M&SN pillar more than 100,000 additional beneficiaries have been reached.

HOW TO DESIGN HIV & TB PROGRAMMES

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Step I Context analysis

1. Know your epidemic

• Describe HIV & TB epidemiology (HIV and TB prevalence, incidence; HIV/TB co- infection, etc.)• Distinguee between concentrated and generalised HIV epidemic• Describe the HIV underlying determinants •

2. Know your national ART and TB treatment coverage and outcomes

• Describe the ART and TB coverage• Provide information on adherence, default rate, TB treatment success, etc.• Describe the factors that hinder or facilitate ART and TB treatment access and success

3. Know the food security and malnutrition levels in your context

• Provide information on food insecurity, poverty levels, malnutrition rates, etc.• Provide geographically distribution of food security

4. Describe the linkages

• Linkages between malnutrition and HIV and AIDS • Linkage between HIV and AIDS and food insecurity

Fist of all, it is crucial to define the CONTEXT CATEGORY, thus if we are in• Emergency• Transition phase • Development context

46

Step 2National Framework- Policy and Capacity

1. Describe National Policy Context• Indicate the presence of HIV National Policy Context• Indicate the presence of Nutrition Policy including HIV information• Indicate the presence of Nutrition Guidelines and if integrated with HIV •

2. Describe the extent of implementation of national strategy and level of funding outcomes

• Provide information on the programmes implemented national wide by the Government and other partners

• Provide information on the financial situation

3. Describe the presence of co-ordination mechanism & key stakeholders

• Indicate the presence of any national and/or UN HIV and TB co-ordination body• Define key stakeholders and their roles within the HIV&TB framework

4. Outline WFP participation within the HIV and TB framework

• WFP roles within the national framework• WFP participation within the UN Joint Country Team on HIV

47

Mitigation & Safety netHousehold (HH) support for ART/TB/PMTCT/OVC

Support affected by HIV/TB that exhibit vulnerabilities (food insecurity, asset depletion, etc.)

HH targeting based on food insecurity data

HH of ART, TB, PMTCT, Pre-ART clients and OVC

Food insecurity

Until food security indicators improves or limited timeframe of 6 months or 12 months

N/A

HH support contributes to HH food access, income transfer, asset protection, reduction in adoption of risky behaviours, and is an enabler to improve participation in services (school, training, PMTCT, etc.)

It should be designed according to food security needs including food availability and access, food utilization, dietary diversity, nutritional balance, etc.

Linkages with livelihood activities, such as FFA, FFT, IGA in order to ensure economical/productive recovery and long term adherence

Care & treatmentRehabilitation of moderate malnourished ART and/or TB clients

Improve health and/or treatment outcomes in clients who are malnourished

Individual targeting based on nutritional status

ART, TB, PMTCT, pre-ART clients and sometimes their households (HH)

Undernutrition/Anthropometric screening

Until client reaches specific anthropometric target with a maximum duration of 6 months or 8 months for TB clients

Energy-dense food commodities (FBFs or RUFs)

HH support is conditional to client’ s support and will last up to client’s discharge. This support seen as income transfer and an enabler for treatment

If provided it should be designed either as an incentive or to complement the HH’s members diet to meet daily requirements

Nutritional education & counselling- throughout the program for clientsEquipment, time and capacity building

Also Know

Purpose

Clients served

Targeting

Entry Criteria

Exit Criteria & duration

Client ration

Household support

Family ration

Complementary activities

Step 3 Identification of strategy and target

48

Context analysis National Framework

Identifying needs and gaps

Understand country contextAmbrosia: Development context

1 2

HIV EPIDEMIOLOGY

• 1.8% HIV prevalence (14-49 year)• Higher prevalence in Northern (3%) and

Eastern regions (4%)• 35% ART Coverage• 40% default rate• 23% HIV/TB co-infection

POVERTY & FOOD INSECURITY• 135 out of 187 countries in the UNDP

Human Development Index • About 16.3% of HIV-affected households

are food insecure and 32% classified as Vulnerable to food insecurity

NATIONAL STRATEGIES• Nutrition identified as critical element for

HIV treatment in the National Strategic Plan (NSP) on HIV and AIDS

• Ghana Health Service National developed a nutrition protocol for PLHIV

• Government provides free access to ART

PARTNERSHIP• UNICEF/WFP assisting MAM PLW and

Children under MCHN (activity sensitive to HIV)

This case study is not based on a real situation, the information is hypothetical and has been added to better illustrate explain how to design a programme

EXAMPLE: “AMBROSIA” Country Understand Country Context

3

49

Context analysis Understand national response

Understand country context1 2

3 Identification of needs and gaps

CURRENT INTEVENTIONS & PARTNERSHIP

Lack of interventions aimed to support adults on ART and/or TB treatment

GEOGRAPHICAL COVERAGENorthern and Eastern regions

TARGET• Malnourished ART and DOTS clients• Food insecure HH

PROPOSED INTERVENTIONS• DEV project• C&T for malnourished ART and TB clients

(no PMTCT because covered under MCHN) and their HH (HH size of 5 members)

• M&SN for HH affected by HIV based on food insecurity level

EXAMPLE: “AMBROSIA” Country GAP ANALYSIS & IDENTIFICATION OF STRATEGY

Describe your strategy

GEOGRAPHICAL DISTRIBUTIONHigh HIV in Northern and Eastern regions (4%)

HIV/TB & FOOD INSECURITY• High default rate• HIV-affected HHs are food insecure

Index Client

Step 4 Definition of beneficiaries

An individual who is entitled to WFP food at distribution site, either on-site consumption or as a take-home ration

A social unit composed of individuals, with family or other social relations among themselves, eating from the same pot and sharing a common resource base

Household of ART, TB, pre-ART and PMTCT clients entitled to food assistance either under C&T (conditional to client’s support) or M&SN (to compensate for lost income and as enabler to improve participation). The household size average is estimated of 5 members

Household hosting Orphans and Vulnerable Children likely due to HIV/AIDS and/or TB. The household size average is estimated of 5 members

Household

Household of clients

Household of OVC

Definition of Beneficiaries

50

51

If it is new or a reviewed

programme

If the programme already in place

Step 4 Estimation of client caseload

Caseload = Population * HIV or TB Prevalence * Treatment coverage * Malnutrition prevalence

Use the information collected to estimate the new caseload, bearing in mind potential variations which might affect the programme such as geographically re-orientation, food insecurity, roll out strategies, etc.

If targeting is:

Malnourished PLW with HIV or TB • Estimated population of pregnant and lactating women of children under 6 months

of age * Estimated HIV or TB prevalence in this group (if not available use HIV prevalence in child-bearing age women) * Estimated of PLW on ART or DOTS treatment * Malnutrition prevalence for this group (if not available use a proxy from other country or international publication)

Malnourished Man or Malnourished Women or Malnourished Children with HIV or TB• Estimated population of women or man or children * Estimated HIV or TB prevalence

in this group * Estimated on ART or DOTS treatment * Estimated malnutrition prevalence for this group (if not available use a proxy from other country or international publication)

52

Household support in C&T

Step 4 Estimation of household caseload

HH support is conditional to the malnourished client, thus :• the number of HH correspond to the number of malnourished clients• the number of household’s members is calculated normally multiplying the number of

clients by an average of five members per HH

HH support is based on food insecurity data

Estimated number of beneficiaries of HH affected by HIV/TB, hosting ART, DOTS and PMTCT clients• [Estimated population in target geographical zone* Estimated HIV or TB prevalence in

this group * Estimated on ART or DOTS treatment * Food insecurity rate in this group (if not available food insecurity in general population)]* Average of HH size (usually 5 members)

Estimated number of beneficiaries of HH affected by HIV/TB, hosting OVC• Estimated population in target geographical zone* Estimated OVC prevalence * Food

insecurity rate in this group (if not available in general population)* Average of HH size

Household support in

M&SN-

HIV/TB HH members caseload = (Population * HIV or TB prevalence * Treatment coverage * Food insecurity) * Size of HH

OVC HH members caseload = (Population * OVC prevalence * Food insecurity) * Size of HH

53

Step 5 Ration design

Care and

Treatment-

INDIVIDUAL

ONLY (client)

• SUPERCEREAL, oil & sugar (INDIVIDUAL)• A

dult ART, TB and PMTCT malnourished clients

• SUPERCERAL PLUS (Children 6-59 months)

Care &

treatment –

INDIVIDUAL +HH

SUPPORT

• SUPERCEREAL, oil &

sugar (INDIVIDUAL)

• +

FOOD BASKET or CASH&VO

UCHER

(CLIENT HH ME

MBERS)

• Individual ration for client only

• This HH basket is conditional to the client’s support- calculated for average of 5 HH members (client included)

• Designed based on food security data

Mitigation &

Safety

nets- HH

SUPPORT

ONLY

• FOOD BASKET

• or CASH&VOUCHER

• (HH me

mbers,

including clients)

• All ration calculated for 5 HH members, including client

• Designed based on Food security data

Ration Nutrients profile

Supercereal 1

200-250 gOil 20-25 gSugar 15-20 g

1000-1200 Kcal35-45 g protein30-40 g fat

Ration (Example)

Nutrients profile

(INDIVIDUAL)Supercereal 1

200-250 gOil 20-25 gSugar 15-20 g

+(HH SUPPORT)

Maize 200 gPulses 60 gOil 20g

1000-1200 Kcal35-45 g protein30-40 g fat

+

1100 Kcal31 g protein9 g fat

Ration(Example)

Nutrients profile

Maize 160 gSupercereal 20gPulses 24 gOil 10g

836 Kcal22 g protein14 g fat

Rice 320 gPulses 50gOil 20gSupercereal 40g

1658 Kcal44 g protein24 g fat1 The ration of Supercereal should be

preferably integrated with sugar and oil. However each CO can decide based on national situation.

54

Step 6 Design your logframe

Project activities and outcomes should be linked to the relevant WFP Strategic Objectives (SO) and follow the correct programme category per each SO

Corporate outcome(s) and indicator(s) corresponding to the SO should be inserted in the logframe. Targets should be set according to the country’s context

Additional and optional project specific outcomes and related indicators can be chosen to build up a body of data that provides a more accurate and in depth performance measurement providing a comprehensive picture of the project dynamics

Programme

Category (EMOP, PRRO,

DEV/CP)

Strategic Objective

s

CorporateOutcome

s

Project Specific

Outcomes

Corporate & Project Specific

Indicators

55

Step 6 Design your logframe

56

• Vulnerability- Identify the most vulnerable subgroup amongst the vulnerable HIV/TB infected and/or affected population

• Geographical coverage- Identify the most vulnerable area for high HIV prevalence, high Food insecurity rate or a combination of both

Identified all the activities run in country by partners in order to• Avoid overlapping• Define possible linkages with programmes• Synchronize/harmonise the interventions

• Encourage when possible short term interventions with clear exit strategy to avoid dependency• Build and ensure linkages to productive safety nets livelihood interventions in order to

contribute to economic development of local community • Assess the capacity of national entities that might be involved in the implementation in order to

ensure feasibility of a correct and effective execution

• Explore alternative source of funding and familiarize with different funding mechanism process of the main donors in case, in future, WFP is not longer able to support the interventions

• Assess the capacity of Government to sustain financially the programme in the future• Assist the Government in resource mobilization process, such as GFATM

Resource-constrained Settings How design a Programme

In resource constrained settings these steps need further consideration in order to prioritise activities, fine-tune

the interventions and thus elaborate a cost efficient technically-sound programme

TARGET

Keys aspects to be addressed

PARTNESHIP

SUSTANAIBILTY

FUNDING

THE GLOBAL FUNDA FUNDING OPPORTUNITY

FOR FOOD AND NUTRITION INTERVENTIONS

57

WFP is the lead agency and responsible for integration of food and nutrition into HIV response

58

HIV and/or TB increase nutritional needs of infected individual while decreasing ability of taking food, absorbing essential nutrients and meeting energy needs required for a strong immune system

Increased morbidity and HIV and TB treatment-related costs often impact negatively household productivity, disposable income and food security

Food insecurity and poverty may create barriers to treatment adherence and retention in care, while malnutrition increases risk of morbidity and mortality among people living with HIV (PLHIV) or infected by TB

Food and nutrition (F&N) interventions as critical element of comprehensive HIV response• Nutrition stabilization, improved access and adherence to treatment, reduced morbidity

and mortality, effective safety nets

As UNAIDS Cosponsor, WFP is lead agency and responsible for integrating F&N support into HIV response

Several organizations advocate for F&N in HIV/TB programmes

F&N interventions increasingly included in Global Fund proposals

Global Fund

UNAIDS

WFPPEPFAR

FANTA-2WHO

Sources: Global Fund, http://www.theglobalfund.org/documents/rounds/11/R11_FoodNutrition_InfoNote_en/; PEPFAR, http://www.pepfar.gov/press/strategy_briefs/138410.htm; WFP, http://home.wfp.org/stellent/groups/public/documents/resources/wfp221697.pdf; UNAIDS, http://data.unaids.org/pub/Manual/2008/jc1515_policy_brief_nutrition_en.pdf; WHO, http://www.who.int/nutrition/topics/hivaids/en/index.html; FANTA-2, http://www.fantaproject.org/downloads/pdfs/Food_Assistance_Context_of_HIV_Oct_2007.pdf; WHO: Analysis of Global Fund Round 5-10. Unpublished

Round 5 Round 6 Round 7 Round 80%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

23%

44%

55%60%

% of funded HIV proposals with F&N component

Only HIV data available

59

Food and nutrition (F&N) increasingly considered important element of HIV and TB programming

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

1

2

3

4

5

6

7

8US$ billionGlobal source of funds for HIV and AIDS Programmes (US$ billion)

Sources: UNAIDS

UNAIDS

Clinton Foundation

Global Fund (GF) - HIV only)

PEPFAR

60

PEPFAR and GF two main funders of global HIV responseInternational assistance to HIV at US$ 8.7 billion in 2009 and US$ 7.6 billion in 2010

The

Glo

bal F

und

The Global Fund (GF) attracts and allocates resources to prevent and treat HIV/AIDS, TB, Malaria and support Health System Strengthening• Since 2002 US$ 22.9 billion committed in 151 countries for the three diseases

− 55% portfolio for HIV/AIDS programs, 28% malaria and 17% TB• Round 10 (2010) approved grants for US$ 1.7 billion

− 40% approved proposals focused on HIV/AIDS programs

GF does not implement programmes directly but fund programmes with emphasis in scaling up proven concepts and filling gaps• Programmes¹ should be technically sound, country-specific, evidence-based

and aligned with national strategy and capacity

Estimated US$ 9 billion potentially available over next years (3 diseases and health system strenghtening)• US$ 8 billion for Phase 2 existing grant re-programming• US$ 1 billion for new funding mechanism - to be launched in Q4 2012

61(1) Typical grant duration of 5 years – Phase 1 lasts 2 years and Phase 2 lasts 3 years

US$ 9 billion potentially available from Global Fund for prevention and treatment of 3 diseases over next 2 years

Global Fund provides two types of funding opportunities for F&N interventions1. Call for proposals

− Proposal written at country level in a multi-stakeholder process − New funding mechanism under finalization

• National strategic plans and/or investments cases as starting point for any request• Countries grouped in bands - funds allocated by band

2. Re-programming of existing grants (Phase 2 – Years 3,4,5)− Grant re-programming can begin 18-24 months after starting implementation

When included, F&N component tipically accounts for 5-10% of a new proposal budget

− US$ 1-10 million for a 5 years period can potentially be allocated to fund F&N interventions

62

F&N interventions can be included in new GF proposal or during grant re-programming (Phase 2 – Years 3,4,5)

1.07

0.7

0.8

ss

8

8

HIV TB

HIVHSS

TB5/10

7

8

5

US$ million potentially available in total for grant Reprogramming

Source of information: The Global Fund

GF grant in Ph. 1 (disease)Opportunity for Reprogramming and for new proposal submission

GF grant in Ph. 2 (round) Opportunity for new proposal submission only

xxM

10

ss

TB17M

41M

34M8M

12M

9M

8M

14M

12M

Status of Global Fund Grants in ODD countries

63

TB

Overview of grant opportunities for ODD countries

New funding mechanism

Concept note developmentTechnical review (TRP) –

dialogue based on concept note

Grant negotiation

Reprogramming opportunity

Technical review panel • Independent group of

international experts reviews concept note

• TRP determine/approve adjusted allocation

National strategy as starting point

GF Secretariat provides guidance on level of funding

CCM (country coordination mechanism) enters dialogues with in-country stakeholders• Constituted by a multi-stakeholders

partnership http://www.theglobalfund.org/en/ccm/

CCM Secretariat coordinates concept note development

Technical writing group develop concept note for CCM’s review

Final country-level funding amount determined

Concept note translated into disbursement-ready grant

Board approves disbursement-ready grant

1 2 3 4

64

Board approval

Grant implementation

PR and CCM request for grant renewal after 18-24 months of implementation• Detailed

information on grant renewal process: http://www.theglobalfund.org/en/activities/renewals/

Country-led multi-stakeholder platform leads GF process4 stages of proposal development and grant implementation

Open doors for F&N

PHASE 1 – CONCEPT NOTE DEVELOPMENT

• Active participation in workshops analysing national response, gaps and needs to shape proposal priorities

• Integration and active participation in technical writing group (TWG) for Global Fund proposal development

What does it mean in practice?

Active participation in TWG and national workshops

Lay the ground: prepare tools for engagement

1

Situationalassessment

Interventiondesign

Stakeholdercollaboration

A

B

C

Goal Include F&N into GF proposal

65

To tap future funding opportunities with Global Fund, critical to invest time and engage in preparation phase…

• Maintain close relationship with CCM, TWG and Nutrition coalition members

• Ensure F&N stays in negotiated proposal

Grant negotiation

3 4

What does it mean in practice?

Goal Avoid F&N drop out last minute

Reprogramming opportunity

Grant implementation

• Maintain relationship with CCM structures and Principal Recipient(s) and Sub-Recipients(s)

• Be informed on implementation progress and Re-programming opportunities

Be alert on reprogramming potential

66

…and to make sure F&N does not drop out last minuteDuring grant implementation, critical to be alert for reprogramming opportunities

Available toolkits to develop F&N interventions for HIV response (short selection)

WFP manual for stakeholders in the provision of F&N interventions

Joint Global Fund info note on F&N for HIV response http://www.theglobalfund.org/en/application/infonotes/

FANTA-2 and WFP toolkit for integrating F&N in GF grants (http://www.fantaproject.org/downloads/pdfs/Round11_GlobalFundToolkit_Oct2011.pdf)

WFP M&E Guide for HIV and TB Programming (2011)http://docustore.wfp.org/stellent/groups/public/documents/manual_guide_proced/wfp235338.pdf

WFP’s response to HIV and TB website and knowledge centre (http://www.wfp.org/hiv-aids)

67

What tools are already available to WFP RBs, COs and Governments to integrate F&N into successful proposals?

RwandaBurundi

United Republic of Tanzania

CentralAfrican Rep.

Djibouti (TB)ChadNiger

Burkina Faso

Benin

Mali

Ghana

Togo

Guinea

Mauritania

Côte d'IvoireLiberia (HIV)

Sierra Leone

Cameroon

Guinea-BissauGambia

Senegal

Cape Verde

Congo TheDemocratic Republicof the Congo

MalawiZambia

Zimbabwe

SouthAfrica

Lesotho

Mozambique

Swaziland(OVC and TB)

Ethiopia

Kenya

Madagascar

Nigeria

Somalia

Uganda

South Sudan

Sudan

F&N included into GF proposal – proposal approved

Recent success from TA to include F&N into GF proposalsAvailable expertise from RBs, HQ

and Geneva

Technical assistance to COs and Governments • Advocate for F&N• Presentation on funding

mechanisms for F&N• Support GF proposal

development with sound F&N component

Situation analysis and coalition building at country level• Available tools and expertise

On-going effort at global level to advocate for F&N and liaise with stakeholders9.7M

2.7M

Haiti (HIV) 1.2M

Afghanistan (TB)

6M0.5M

F&N included into GF proposal – proposal under review by GF

XM Budget for F&N component included into GF proposal

68

Customized technical assistance also available to COs and Governments to tap potential funding opportunities

69

Concrete opportunities exist to access significant funds for Food and Nutrition interventions for HIV Response

Upfront effort and commitment is necessary to engage with Global Fund mechanisms at country level to tap funding opportunities

Tools and expertise are available from RB, HQ and Geneva to support WFP COs, Governments and Stakeholders in successfully engaging with Global Fund

– Wide-ranging of tools available, concrete examples and lessons learnt– Customized technical assistance can be provided to countries

1

2

3

To sum-up: what are the main take away?