The partner's goals are to increase access to HIV/AIDS services for HIV/TB co-infected individuals in Kinshasa and to strengthen the laboratory system in USG-supported areas. The partner will achieve these goals through five objectives: 1) provide HIV/TB co-infection services according to national protocols in 20 diagnostic and treatment centers (CSDTs) sponsored by the National TB Program (PNT) in Kinshasa; 2) strengthen six laboratories located in six referral centers in Kinshasa to provide necessary HIV/AIDS management and monitoring services; 3) provide laboratory maintenance and supplies to USG- supported laboratories in Kinshasa and other USG-supported provinces; 4) provide adult care, support, and treatment services, including anti-retroviral therapy (ART) treatment, in four CSDTs in Kinshasa; and 5) build human capacity through training.

DR Congo ranks 10th among the world's 22 high-burdened tuberculosis (TB) countries and 4th among those in Africa. The EPP Spectrum analysis estimates that there are 131,400 HIV/TB co-infected individuals. HIV prevalence in adult-incident TB patients was 17% in USG-supported clinics in Kinshasa. PNT has a network of CSDTs throughout the country equipped with mycobacterium microscopy and

providers trained to administer Directly Observed Therapy-short course (DOTS). CSDTs counsel and test for HIV if equipped following new Provider Initiated Counseling and Testing (PICT) protocols. CSDTs provide HIV+ individuals with cotrimoxazole (cotrim) prophylaxis and referrals for care and treatment services.

The partner's TB/HIV activities will follow the model of the USG-supported Integrated TB/HIV program implemented in 17 CSDTs in Kinshasa by the University of North Carolina (UNC), which provides care, treatment, and support services for co-infected patients according to PNT protocols. According to PNT, there are 110 CSDTs in Kinshasa; however, besides the 17 supported by UNC, only 60 others provide PICT (and without any other HIV-related interventions). The partner plans to scale up co-infection services to 40 CSDTs by the end of the cooperative agreement.

Only one laboratory in Kinshasa, the National AIDS Control Program (PNLS) laboratory, is equipped to provide disease monitoring for people living with HIV/AIDS (PLWHA). Patients must pay for the laboratory services or be enrolled in a program that covers the cost. Programs without enough funding to cover lab costs for patients or those located far from the PNLS lab cannot effectively use the services provided. To increase access to quality lab services for HIV diagnosis and disease monitoring in Kinshasa, the capacity of six laboratories within six health facilities will be strengthened. The health facilities that will receive this laboratory support are large centers that receive referrals from all over Kinshasa. The partner will provide equipment, commodities, and training for lab technicians.

The partner will also provide equipment maintenance to USG-supported laboratories through maintenance contracts and training of maintenance technicians. According to the PNLS, lack of equipment maintenance has resulted in the disuse of equipment purchased previously by other donors or programs, like the World Bank or Global Fund. Short term contracts that were negotiated with some suppliers were not sustained. Without any substantial financial support, even programs that collect fees from clients are unable to provide for the maintenance of lab equipment. The partner will provide maintenance support to 10 laboratories currently supported by the USG.

Of these six health facilities receiving laboratory strengthening in Kinshasa, UNC provides care and treatment services, including ART, at two: Kalembe Lembe Pediatric Hospital (KLL) and Bomoi Health Center. The partner will provide adult care and treatment services, including ART, at the remaining four facilities, referring any pediatric patients to KLL. The co-location of TB/HIV services, including laboratory services, will ultimately increase access. Care and support services will include psychosocial support (PSS) and nutritional support; however, the partner will only fund PSS. Nutritional support will be provided through Action Contre La Faim (ACF), a subpartner funded by the USG through the Kinshasa School of Public Health (KSPH).

Finally, the partner will build human capacity through training. Training will be provided to health care workers including physicians, nurses, lab technicians, social workers and PSS group leaders. Clinicians will be offered training on TB/HIV related activities including PICT, care and treatment, and lab activities while social workers will be trained on home care, counseling of patients and caregivers on nutrition, treatment adherence including ART, and patient follow up. Overall, the partner will attribute $81,500 to the human resources for health cross-cutting area.

Ultimately, the investments made by the partner in TB/HIV, laboratory infrastructure, adult care, support, and treatment services should increase the number of health facilities in Kinshasa that can provide comprehensive services for PLWHAs and decrease the number of out-referrals made to PLWHAs, decreasing the number lost to follow-up.

Monitoring and evaluation will happen periodically throughout the life of the project, and the partner will submit quarterly and year-end reports detailing achievements, obstacles, and any remedial actions taken.

Through UNC, PEPFAR currently supports seven facilities that successfully provide comprehensive HIV/AIDS care and treatment using family-centered approach: one in a primary health care setting (Bomoi Health Center), one at a tertiary pediatric health facility (KLL), and five in CSDTs. Many HIV+ clients referred to these sites are lost to follow up, though due to the distances between the sites and their home/work. The partner will initiate care and support activities using the family-centered approach at four additional facilities in order to increase geographic coverage in Kinshasa. These four facilities will also have received laboratory strengthening and support as described in the HLAB budget code. HIV/TB co-infected and HIV+ adults referred from TB and PMTCT sites are the target population for this activity. New clients of these services will receive comprehensive HIV care modeled on services delivered by UNC, including: prevention of opportunistic infections, malaria prevention and treatment, sexual and reproductive health services including family planning, testing of family members and sexual partners, psychosocial assessments, and referrals to nutritional and psychosocial support services. First-line family members of patients, particularly caregivers, will also receive psychosocial and nutritional support. PSS groups will provide information regarding treatment adherence, nutritional management during common illnesses (such as diarrhea and vomiting), and HIV transmission prevention methods. Referral and cross referral systems will be put in place to track patients and reduce loss to follow up. PLWHAs identified through the program will be trained as outreach workers to perform home visits to or call patients who neglect to attend scheduled clinic visits.

The partner will train healthcare workers and service providers in these four facilities to provide the range of services listed above.

Continuous monitoring and evaluation will occur through database review and regular meetings based on specific program quality indicators.

The same population is targeted for this activity as for adult HIV care, which will occur at four facilities that provide adult care and support services. Again, the partner will model the adult treatment services it provides off of the services successfully provided by UNC.

Each HIV+ patient will undergo a clinical and laboratory assessment at program enrollment. HIV disease staging by clinical assessment and CD4 testing will determine ARV eligibility and patient visit schedules. Patients on ART will be scheduled for monthly visits, until deemed clinically stable after which they may

be seen every six months. Those who are seen every six months will be assessed by a nurse dispensarist on weight, ARV dosing, and drug adherence through questionnaires and pharmacy databases. At each visit, drug toxicity assessment will be conducted, and counseling on treatment adherence will be provided. Clinical patient outcomes such as improvements in CD4 counts and weights will be tracked and monitored quarterly through streamlined data collection forms and review of patient and pharmacy databases that collect program quality indicators such as: frequency of CD4 monitoring, percentages of eligible patients who receive cotrim prophylaxis, adherence to protocol requirements of confirmatory testing, percentage of clients with documented HIV status in his/her chart, and tracking of adherence and toxicity reports.

The partner will train health care workers and service providers on HIV/AIDS comprehensive care and treatment, including how to secure an adequate supply of ARVs from Global Fund, providing CD4 counts and clinical staging for ART to patients, ART administration for eligible patients.

The partner will build laboratory infrastructure in two ways: by providing opportunities for equipment maintenance to USG-supported laboratories and by increasing the number of large health facilities in Kinshasa that receive a large volume of referrals from other centers that have laboratories equipped to provide HIV-related services.

Lab equipment maintenance will be addressed in two ways: 1) contracts will be negotiated with suppliers to ensure that they provide support services to maintain the equipment and fix any problems identified during the use of the equipment; and 2) two institutions in Kinshasa, the Institute for Medical Technology and the Institute for Applied Sciences, will receive support to train maintenance technicians. The support will include curricula updates, purchasing of teaching equipment, and negotiations with suppliers of laboratory commodities for hands-on practice sessions with selected students who will eventually be assigned to work for the PNLS post-graduation.

To increase access to quality lab services for HIV diagnosis and disease monitoring in Kinshasa, the partner will provide equipment, commodities, and training for lab technicians in six laboratories within six large health facilities in Kinshasa. Each of these labs will perform six types of services: 1) HIV and sexually transmitted infections diagnostics, including syphilis rapid testing; 2) HIV disease monitoring, including CD4 count tests; 3) hematology, including hematocrit and hemoglobin tests; 4) TB diagnostics, including microscopy; 5) biochemistry analyses using spectrophotometers; and 6) an information system

to record data for reporting.

In FY 2010, the partner will initiate provider-initiated counseling and testing (PICT) for TB patients and

their first-line family members, give cotrimoxazole (cotrim) prophylaxis, and refer HIV+ individuals to

psychosocial support PSS groups, nutritional support services, and care and treatment centers to have

CD4 counts for ART staging performed, and initiate ART if necessary. This will occur in 20 high-

attendance CSDTs in Kinshasa. The partner will work with the PNT and UNC to identify CSDTs for FY

2010. PICT in CSDTs will be done by a TB nurse who also is responsible for TB diagnosis and

management. Providers of HIV/TB co-infection services will receive training on PICT as well as clinical

management of co-infected patients. All activities will be monitored regularly by program staff through

direct observation and review of patient registers and records. The partner will use the simplified

database and collection forms developed by UNC in collaboration with the PNT to monitor and evaluate

activities for program planning and quality improvement. Program monitoring will include didactic

trainings and substantial follow-up supervision at the selected CSDTs. Program evaluation will consist of

documentation of acquired training knowledge through pre and post test results, clinical skills observation

checklists and periodic quality assurance panel testing.