The FHI 360 service delivery activity is in its fourth year of implementation. It aims to increase access to quality HIV/AIDS prevention, care and support services for the population of Kayanza, Kirundo, Muyinga, and Karusi provinces. The activity is in line with the priorities and strategies of the USG and the Government of Burundi (GOB) in response to the HIV/AIDS epidemic in Burundi. The interventions target the general population, pregnant women and their partners, people living with HIV/AIDS (PLWHA), orphans of AIDS and other vulnerable children (OVCs), youth, low-income women and most at risk populations (MARPs). Additionally, as part of the PMTCT Acceleration Plan, FHI 360 service delivery activity in Burundi will incorporate the following strategic approaches:Build upon the platform of activities to increase and expand the coverage and quality of services;Use effective community-based structures to promote a variety of health and related interventions;Intensify health and social services linkages;Sub contract to local organizations (public and private sectors) for program implementation and for capacity building and sustainability;

The planned activities will be monitored using the next generation indicators through routine data collection and a tracking system with standardized recording and reporting protocols for all types of services offered. Data Quality Assessments (DQAs) will periodically be conducted to ensure the quality of the data. A end of project evaluation after Year 5 will be conducted to objectively assess the effectiveness of the innovations and their potential for scale-up.

The FHI 360 service delivery activity will support local organizations to expand basic care and support services for PLWHA. Home-based care was provided to 11,100 individuals, including monthly psychosocial support visits provided through community health workers (CHWs) based in all the communes of Karusi, Kayanza, Muyinga and Kirundo provinces in 2011. In 2012, FHI will continue to support current activities for PLWHA with home-based care services. Additionally, CHWs will deliver a package that includes psychosocial support, health-care and hospitalization assistance, hygiene products, pain relievers and information on sexual prevention and testing. One of the key roles of the CHWs will be to ensure that PLWHAs whose health continues to decline are accompanied to a health facility for further care. Cotrimoxazole prophylaxis against opportunist infection will continue to be supported in all health clinics located in the four targeted provinces. In 2012, its expected that 28,630 adult and children be provided with a minimum of one care service.

FHI funding will complement work supported by the GOB and other development partners in selected provinces. While USG provides no programming addressing HIV/TB co-infection, FHI will collaborate with the Global Fund, Damien Foundation, and Belgian Technical Cooperation, which are supporting the national TB and HIV/TB co-infection programs. During TC for HIV, clients will be screened for common signs of TB. Clients who present with symptoms will be referred to TB centers. The same test-and-referral approach will be adopted for TB patients.

Under the FHI ROADS project, the number of OVC served increased from 1,500 in FY 2006 to 6,000 each FY (2009- 2012). FHI provided OVCs with at least two core services including school support or professional training, psychosocial support, medical care, and legal assistance. During COP 2012, FHI 360 will strengthen the capacity of households, local community groups and local administration to respond to the basic needs of OVCs. To achieve this result, FHI 360 will train additional OVC caregivers in comprehensive HIV care and support services. The child status index will be introduced and used to monitor the quality of services provided and to ensure program effectiveness. Services will be linked closely through a strong referral network including health facilities, CBOs, FBOs, NGOs and private sector partners.

FHI will continue programming for orphan-headed households, recognizing their unique vulnerability and needs. FHI 360 will also continue supporting HIV risk-reduction and care strategies specifically for OVCs who are heads of households, linking them with sexual prevention messaging, HCT, and STI diagnosis and treatment for older OVC. In addition, FHI 360 will also facilitate care in cases of rape and sexual assault.

Rounding out a family-centered care approach, home-based care providers will help identify and provide care and support for OVC. Through sub-grants and technical assistance to local organizations, the USG plans to support 15,000 OVC with a needs-based package that includes psychosocial support, school and hygiene kits, and health-care and hospitalization assistance for those over 5 years of age (the GOB provides free health care for pregnant women and children under 5). The USG will continue to collaborate with other donors, such as Food for Peace, the United National High Commission on Refugees (UNHCR), and UNICEF, to increase coverage and strengthen support for OVC activities, including in the policy areas of legal support and domestic violence reduction and mitigation.

The FHI 360 will request sub-grantees to submit monitoring data monthly, which will be used to produce quarterly and annual reports to Government of Burundi (GOB) and to the USG. FHI 360 will use the quarterly reports to facilitate feedback sessions with implementing partners that are designed to: (i) build their capacity in using data for decision-making; (ii) ensure that the data are being used by all partners to measure progress toward reaching quantitative targets and reaching/maintaining agreed-upon service quality standards; and (iii) examine barriers to achieving expected results. Such feedback sessions will continue to be part of regular management reviews and will provide a basis for assessing technical assistance needs. Additionally, FHI 360 will continue to conduct trainings, including formal and on-the-job training.

The monitoring system will include routine data collection and a tracking system with standardized recording and reporting protocols for all types of services rendered. FHI 360 will periodically conduct Data Quality Assessments (DQA) to ensure quality of the data.

In FY 2011, the FHI 360 prevention activities in Burundi reached 47,599 individuals with interventions that are primarily focused on abstinence and/or being faithful (AB) using the peer education strategy. The targeted population is this area is youth, low-income women and truckers in six communes: Kayanza, Busoni, Kirundo, Ntega, Vumbi and Muyinga. This was accomplished in partnership with 302 trained peer educators. In FY 12, the FHI 360 prevention activities will continue to support and strengthen activities implementation in the six existing communes distributed in the three provinces and new communes will be identified in Karusi province. In addition to AB messages, safer sexual behaviors will be promoted, such as reducing alcohol consumption and gender based violence mitigation. Dialogue among couples will be promoted through family day strategies and community magnet theatre performances.

The FHI 360 prevention activities will strengthen peer education and community outreach to reach 50,000 individuals with HIV prevention interventions that are based on evidence/and or meet minimum standards required. For this purpose, additional peer educators will be trained and the magnet theater will continue to be promoted. In addition, the FHI 360 prevention activities will continue to link AB interventions with other services such as HTC, OVC, PMTCT, ART, and preventive therapy against opportunistic infections.

In addition, activities will include BCC targeting young girls and family communication, use of post-exposure prophylaxis (PEP) kits for health centers, and training to ensure that CHWs, teachers, and health workers are capable of screening for and addressing risks for GBV, including providing or referring GBV victims for PEP, care, and legal services. As part of a new USG initiative in country, FHI 360 partner with another USG funded partner to begin a longer-range initiative to address social and gender norms conducive to GBV and high-risk behavior by collaborating with the Ministries of National Solidarity, Repatriation of Refugees, National Reconstruction and Social Reintegration, and of Justice and Keeper of the Seals as well as relevant CSOs, religious leaders, and womens associations, to develop a strategy for BCC, advocacy, and policy analysis and reform.

In FY 2011, FHI 360 continued to support sub partners to provide quality and confidential HTC services in accordance with the national protocol. Thus, 137,913 individuals were tested for HIV and 134,866 of them received their test results. In FY 12, FHI 360 service delivery activities will continue to extend HTC services in the provinces of Kayanza, Karusi, Muyinga, and Kirundo. The target population will be the high risk groups who circulate in those provinces and the communities in high transmission areas in those provinces. The target groups include truck drivers and their assistants, sex workers, general population, low income women, men and other community members. In 2012, it is expected that 220,602 individuals will receive testing and counseling services for HIV and get their test results. HIV CT will also be extended to STI and TB patients. The following strategies will be used to reach the target populations:

a. Training health providers in HTC. Training will be based on the national guidelines with special attention to improving counseling skills for clients who test positive, discordant couples, and identifying and counseling HTC clients with hazardous drinking behavior;b. Actively promoting testing to all family members where the index patient is found to be positive;c. Widely promoting provider-initiated testing and counseling. Interventions will emphasize couples counseling and testing among MARPs (truckers, PLWHA, sex workers);d. Collaborating with partners to increase referral to HTC services. All STI clients will systematically be counseled for HCT; ande. Continuing support for PBF for the following HCT indicator: Number of people tested for HIV.

To reduce sexual transmission of HIV, the FHI 360 and other partners will implement evidence-based communication and small-group/individual interpersonal interventions especially targeting CSWs, long distance drivers and their assistants. To facilitate and sustain behavior change, the FHI 360 service delivery activities will strengthen peer education. Peer educators will implement messages that promote behavior change, increase access to condoms, counseling and testing services, SGBV, and alcohol consumption. The FHI 360 activities will also facilitate HIV prevention through positive behavior by working with the PLHIV association and by focusing interventions on the household unit.

The recreation center based in Bujumburas main parking yard will be selected as a preferred location to reach long distance drivers using the north and the east corridors to reach Uganda, Rwanda, Tanzania, and Kenya. Condoms will be made available in the Bujumbura recreation Center and the FHI 360 service delivery activity will continue to refer users to other services such as HTC, ART, and preventive therapy against opportunistic infections. In FY 12, it is expected that 3,550 MARPs will be reached with individual and/or small group level HIV Interventions that are based on evidence and /or meet minimum standards required.

In addition, activities will include BCC targeting young girls and family communication, use of post-exposure prophylaxis (PEP) kits for health centers, and training to ensure that CHWs, teachers, and health workers are capable of screening for and addressing risks for GBV, including providing or referring GBV victims for PEP, care, and legal services. As part of a new USG initiative in country, FHI 360 partner with another USG funded partner to begin a longer-range initiative to address social and gender norms conducive to GBV and high-risk behavior by collaborating with the Ministries of National Solidarity, Repatriation of Refugees, National Reconstruction and Social Reintegration, and of Justice and Keeper of the Seals as well as relevant CSOs, religious leaders, and womens associations, to develop a strategy for BCC, advocacy, and policy analysis and reform.

In 2011 PMTCT services were provided in 82 health facilities in four provinces, reaching 76,561 pregnant women who attended the first ANC visit, 51,077 were tested for HIV and 49,568 (97%) received their test results. Antiretroviral prophylaxis was administered to 431 out of 595 HIV positive pregnant women identified.

In FY 12, FHI 360 will continue to provide service delivery support to strengthen 136 existing outlets and will enroll 15 new sites in the 4 supported provinces with a high-quality PMTCT minimum package. The package includes: (1) routine ANC services, (2) screening for syphilis, (3) counseling and testing for HIV, (3) accurate information on infant feeding, (4) a complete course of ART prophylaxis to HIV positive mothers and their babies, (5) mother and child follow-up, (6) and preventive therapy using cotrimoxazole prophylaxis to infants exposed to HIV. In collaboration with the MOH, FHIs service delivery activities will ensure that infants born to HIV positive mothers are tested for HIV at six weeks using dry blood spot/polymerase reaction chain (DBS/PCR). Nutritional support will continue to be provided to the most vulnerable women. To improve the uptake of PMTCT services, the following activities will be implemented:? An assessment of the new sites to determine needs. Funds will be made available to respond to the identified needs and to ensure confidentiality, comfort and functionality;? Training health providers in collaboration with MOH and other partners by organizing in-service training for new staff and refresher trainings for health care providers based on the weaknesses identified by supervisions. The trainings will include the HIV/AIDS epidemiological situation globally and in Burundi, the pathology of HIV/AIDS, how HIV is transmitted from mother to infant, how to provide TC, specific interventions for PMTCT (including the national protocol for clinical services), infant and child nutrition in the context of HIV infection, stigma and discrimination linked to HIV, mother-child follow-up, support for PLWHA (including sexual prevention, family planning, and partner reduction), and prevention of counselor burnout/fatigue;? Mobilizing the community through the network of PLWHA network (RBP+), to promote couple counseling and testing;? Developing appropriate IEC materials in Kirundi for clients and community members;? Continuing the support for PBF for the PMTCT indicators: Number of HIV-positive pregnant women provided with antiretroviral prophylaxis and number of newborns from HIV-positive mothers provided follow-up care, ARVs to new born.

The combination of the above described activities will target an estimated 90,602 pregnant women with known HIV status be tested for HIV and receive their results. Ninety six percent (96%) of the HIV+ pregnant women will receive ARVs to reduce risk of mother to child transmission.

The USG funding will not support any direct ART provision. The USG strategy will be to wrap critical technical assistance and procurements around existing adult and pediatric ART programs supported by the GOB, Global Fund, and others. Technical assistance will focus on improving the quality of adult and pediatric ART services, such as enhancing clinical and laboratory monitoring and improving the ability of clinical providers to identify treatment failure and ensure appropriate switches to second-line regimens. Procurement of medications will enable health providers in intervention provinces to treat opportunistic infections and STIs. In addition, the USG will continue to procure reagents for testing, laboratory equipment (including for biochemistry and hematology), and lab reagents for biological monitoring.

Since 2007, collaboration with the Global Fund resulted in providing ARVs and other essential commodities to FHI to support service delivery activities at six ART sites. By September 30, 2011, Global Fund and PEPFAR were supporting 3,757 patients on ARVs. In FY 2012, the FHI will continue to support medical doctors in the following hospitals: Kayanza, Kirundo, Mukenke, Muyinga and Musema. The physicians main role will be to provide technical support and promote ART decentralization at specific identified health centers in accordance with the national ART guidelines. For this purpose, FHI 360 will train nurses and social workers in the aspects of clinical care for adults living with HIV in order to significantly engage the health centers in day-to-day care and follow-up of patients under the first line of ART regimen. In addition, according to the needs identified during the assessment, lab equipment, reagents and supplies will be provided by SCMS to ensure that basic haematological and biochemistry tests are conducted at the health facility level whenever possible. To reinforce adherence among enrolled patients on ART, service delivery activities will continue supporting the PBF for the following ART indicator: Number of ART patients monitored semi-annually.

The FHI 360 service delivery activity has been supporting ART sites in collaboration with the Global Fund since FY 2007. By September 30, 2011, six supported ART sites were active, with 3,757 clients on ARVs by September 30, 2011. Among them 302 are less than 15 years old.

In FY 2012, FHI 360 will continue to support medical doctors in the following hospitals: Kayanza, Kirundo, Mukenke, Muyinga and Musema. The physicians main role will be to provide technical support and promote ART decentralization at specific identified health centers in accordance with the national ART guidelines. For this purpose, FHI will train nurses and social workers in the aspects of clinical care for adults living with HIV in order to significantly engage the health centers in day-to-day care and follow-up of patients under the first line of ART regimen. In addition, according to the needs identified during the assessment, lab equipment, reagents and supplies will be provided by SCMS to ensure that basic haematological and biochemistry tests are conducted at the health facility level whenever possible.

Efforts will be made to enroll more children on ART. The following strategies will be put in place: (1) encourage HTC among children born to HIV positive parents; (2) screen for HIV all malnourished children attending health clinics; (3) train the health providers on paediatric ART treatment including WHO staging for children; and (4) reinforce adherence among enrolled children.