In order to reach this goal, five objectives are proposed. The first objective is to create a social and policy environment that enables effective HIV/AIDS efforts. The second objective is to reduce high-risk behavior among sex workers, men who have sex with men, and migrants. The third objective is to lower the incidence of sexually transmitted infections. The fourth objective is to support the growth of civil society and non-government participation in HIV/AIDS prevention activities. The fifth objective is to strengthen and expand the epidemic surveillance system and the utilization of surveillance information in planning and implementing prevention activities.

Some goals associated with the above project delivery areas are: to increase regular condom use among vulnerable groups in project areas, to increase knowledge of HIV and HIV prevention among vulnerable groups, to reduce STI infections among vulnerable groups, and to stabilize the prevalence of HIV infection among target populations.

Objective 1 - Create an enabling social environment and strengthen policy implementation
Service delivery areas:
1.1 Media and community-based campaigns to de-stigmatize HIV/AIDS
1.2 Advocacy initiatives to improve the implementation of HIV/AIDS policies

Creating an enabling social environment is critical to the success of both this project and China’s national HIV/AIDS prevention strategy. Only by reducing discrimination and stigma will it be possible to deliver services to the most vulnerable groups. Maximizing community involvement in HIV/AIDS activities will deepen and broaden commitment and knowledge related to HIV prevention. Training key government and professional leaders on the critical nature of HIV/AIDS will support policy implementation.

Over the five year period, media and public information campaigns will be launched to raise awareness of HIV/AIDS risks and reduce discrimination against PLWHA. These campaigns will include print, broadcast, and electronic media, as well as enlisting well-known figures from film, music and sports to endorse non-discrimination messages. Other activities will include concerts, volunteer recruitment drives, university/school assemblies, and other activities to directly involve communities. It is estimated that at least 10 million people will be reached with this campaign annually.

Quarterly training, advocacy, and leadership development workshops will be organized to ensure that key policymakers and implementing are informed about HIV/AIDS issues and policies. 700 policymakers, law enforcement personnel, medical professionals, government managers, and private sector leaders will participate in these sessions annually. At a local and provincial level, workshops and seminars will be held for medical service providers to advocate for an STI control policy that promotes greater integration with HIV/AIDS prevention activities, the inclusion of a broad range of health care providers in STI detection, treatment, and control, and expanded support for STI clinical services.

Objective 2 – Use comprehensive approaches to reduce high-risk behavior/HIV transmission (including IEC, 100 percent condom use, peer education, VCT, life skills) among sex workers, MSM, and migrants and their partners
Service delivery areas:
2.1 BCC outreach and condom promotion activities targeting SW
2.2 BCC outreach and condom promotion activities targeting MSM
2.3 BCC outreach and condom promotion activities targeting to migrants
2.4 Voluntary counseling and testing services for sex workers, MSM, and migrants

Reducing high-risk behavior among vulnerable populations is the key to slowing the spread of HIV in China. A lack of reliable information, coupled with sensationalist news and information about HIV/AIDS, has convinced the bulk of Chinese that HIV is “somebody else’s problem”. By making vulnerable populations aware of the risks they may be taking, informing them of how to prevent HIV infection, and providing them with cheap, quality condoms, there will be a significant reduction in the spread of HIV among these populations.

There are three major strategies for reducing high-risk behavior among these vulnerable groups: providing HIV-related IEC/BCC and life skills; promoting 100% condom use; and targeted and accessible VCT services. The service delivery areas have necessary and different approaches for each of the three main populations targeted in this project. Outreach to each group, and primarily peer outreach by trained outreach workers, will include information about HIV prevention, VCT, and 100% condom use promotion

Among male and female SW, pilot projects in China suggest that peer-based interventions are more likely to be effective, and will be the major means of delivering IEC/BCC and life skills information. MSM groups, peer networks, websites and hotlines will help develop and exchange knowledge and skills for safe sex among MSM. Migrants will be targeted with health, reproductive, and safe sex information primarily through training schools, employers, and peer networks in their urban destinations. The intention will be to place HIV/AIDS issues within a context of skills-building for life as a migrant.

100% condom use will be promoted among sex workers, MSM and young migrants. With each population, outreach and peer activities will be used, and a variety of different methods will be used to address barriers to condom use among each group (including policy level support, promotion of condom use among SW clients, building cooperation among entertainment establishment owners, provision of free or socially marketed condoms and lubricants, promotion through websites or hotlines, STI clinics, etc.)

VCT services and links to VCT services will be strengthened, and referral networks, outreach and social marketing will all be used to improve access to VCT services. Both pre- and post-test counseling and counseling skills will be strengthened and made an integral part of the testing services, in large part through the participation of target groups, NGOs, and PLWHA in these services.

Objective 3 - Strengthen STI services and link to HIV prevention activities
Service delivery areas:
3.1 Improved STI services targeted towards SW, MSM and migrants
3.2 Improved coordination between STI services, VCT services and BCC outreach activities

There are major gaps and problems in how STI services are provided in China, which will impact the sexual transmission of HIV. STI treatment is costly, and guidelines for patient confidentiality, partner notification, and contact tracing are lacking. If services are to be effectively lnked to HIV prevention, the counseling skills of the health service providers will need to be strengthened. The services offered by a range of clinics, hospitals, health centers, and pharmacies vary greatly and are often substandard. Specialized STI clinics have had limited success reaching vulnerable groups like SW and MSM.

The approach for this objective will be to first develop and standardize systems and policies for case reporting, patient confidentiality, partner notification, and contact tracing, areas that are particularly weak at present. Better case reporting will help identify where STIs are most prevalent and where intervention resources should be directed. Improved patient confidentiality, partner notification, and contact tracing guidelines will enable a proactive and targeted strategy to find, treat, and reduce STIs.

Using these standards, STI services at designated clinics in project provinces will be expanded. Training, guidelines, technical assistance, and basic equipment will be provided to these clinics so that they can be models for case finding and reporting, case diagnosis and treatment, case holding (to maintain patients when treatment requires multiple visits), contact tracing (to quickly determine others likely to have STI), controlling the source of infections, counseling, and condom promotion. In addition, these clinics will provide HIV prevention (IEC/BCC) materials, condoms (free of charge or via social marketing) and VCT referral. Training for MSM-specific STI issues will also be provided.

Additional health care providers likely to see sex workers – such as hospitals, family planning clinics, reproductive health clinics, and maternal health clinics – will also receive training and these locations will receive the same guidelines, training, technical assistance, and equipment as the officially designated STI clinics. As many people avoid STI clinics due to fear and stigma associated with STIs, raising the level of STI care available in these secondary sites will ensure that quality care is available to those vulnerable populations most in need.

This robust effort to upgrade and expand STI services that are proactive and methodical in their approach to finding and treating STI, will reduce STI prevalence among target groups by 17 percent in 3 years and 31 percent in 5 years.

Objective 4 – Strengthen the capacity of civil society groups to plan and implement HIV/AIDS prevention activities:
Service delivery areas:
4.1 Provide support and capacity building for community organizations and NGOs working with SW, MSM, and migrants
4.2 Provide support and capacity building for PLWHA and PLWHA support groups

Current efforts to control the HIV epidemic in China are seriously hampered by the lack of effective NGO-government partnerships. This objective will help create government-NGO-community partnerships and mechanisms to increase the effectiveness and coverage of AIDS prevention activities. In particular, community outreach, especially to MSM and SW, is most effectively done with the involvement of peers and community groups. Limited government capacity will be boosted by the participation of a growing civil society.

Objective 4 is to speed up the growth of and build the capacity of civil society and foster cooperation between PLWHA support groups, NGOs, and government agencies. Because stigma and discrimination against both PLWHA and vulnerable populations such as MSM and SW is so strong in China, basic information provision regarding HIV transmission, care, and prevention will be part of this objective. Government, non-government organizations, and community groups will be targeted for capacity-building activities, as all have essential roles to play in scaling prevention, care, and treatment efforts.

Capacity building for community-based organizations (CBOs) will address the fact that community involvement in the planning and implementation of HIV prevention programs is still very weak across China. Most projects are still government-organized and run. This is due to a lack of experience on the part of government departments and reluctance to allow other groups to play an active role, as well as to a lack of mature community-based organizations. This project will work with domestic and international NGOs – in partnership with the government - to build the capacity of and give practical support to at least 36 CBOs. This will be done by creating opportunities for CBOs to work as partners in AIDS prevention activities. These activities are intended to foster ongoing cooperation between governmental organizations, CBOs, larger NGOs and vulnerable populations themselves.

Although there are a number of small PLWHA groups in China, most of them are in Beijing (ie, outside this application’s project provinces) and lack organizational and institutional capacity. At least 18 PLWHA support groups and PLWHA-led NGOs will be supported and assisted in developing organizational, logistical, communication, fundraising and leadership skills, as well as project management capacity. PLWHA activists and organizers will be supported through training workshops and internships with existing NGOs or GONGOs (government-organized NGOs). In particular, communication skills, leadership skills, treatment-related information and related functions of PLWHA groups will be supported in areas such as adherence counseling, cooperation with government and linkages with VCT centers. Basic funding support will also be provided to ensure that PLWHA groups in the target provinces can maintain basic operational capacity during the project period. Fundraising training will greatly increase the chances that PLWHA groups and their activities will be sustainable after the completion of this project.

As part of this objective, government departments and academic institutions, and larger “mass organizations” (such as the family planning association) working directly with vulnerable populations will also be targeted. Because the main government health agency working on HIV/AIDS is the China CDC, it will be targeted for advocacy and training on NGO-government cooperation (in addition to anti-stigma and anti-discrimination training). Many non-health agencies that have direct contact and cooperation with or supervise target populations, such as Public Security and Justice, will also receive medical, anti-stigma and civil society training. Universities, academic institutions, journalists, and mass organizations will be targeted for general HIV training and capacity-building, and links will be created between local NGOs, PLWHA groups, and these organizations.

Objective 5 – Strengthen the local capacity to conduct HIV situation analysis including improved surveillance, monitoring, and evaluation
Service delivery areas:
5.1 Expand and strengthen the local capacity of HIV situation analysis

The limited capacity of China’s surveillance system continues to be a major barrier to long-term prevention efforts. Though the risk of a “new wave” of HIV infection is clear, effective prevention measures will be difficult to take without a strengthened and expanded disease and behavioral surveillance system.

This objective calls for systematically compiling existing demographic and epidemiological information about the target groups, and conducting behavioral surveys among vulnerable populations using both the existing national and provincial sentinel surveillance sites, as well as adding additional survey and sentinel sites in project areas and improving links between surveillance and prevention activities. Surveys will be conducted in collaboration with governmental organizations such as the CDC, hospitals and public security departments, as well as academic researchers, NGOs, CBOs, and peer groups (especially MSM surveys). HIV prevalence information currently being collected but not utilized, such as screening of blood donations and pre-operative HIV screening in hospitals (both of which are routine) will also be captured and utilized to strengthen the surveillance system.

The size, location, and characteristics of populations will be estimated along with HIV/AIDS prevalence and risk factors. Existing surveillance activities will be expanded and strengthened, including the use of second generation surveillance, and results will be analyzed, interpreted and used for interventions run by both government and non-government agencies in order to improve the effectiveness of prevention activities. Existing national and provincial surveillance systems will be linked, and their results shared in order to improve the overall surveillance capacity.

Because the surveillance system in the seven provinces selected is less developed and the ability to detect new infections or epidemics is very weak, technical assistance will be provided to support a province-wide early warning system. The information provided by this early warning system will help direct where additional intervention activities should be concentrated. In addition, the expansion of the existing sentinel surveillance system will create opportunities to develop working relationships with the targeted populations and when appropriate, sentinel sites will be linked with prevention activities including VCT services, STI services, condom social marketing, and outreach programs. In addition they will be linked with treatment and care program for those who test positive for HIV.