In 2006, an estimated 1 million people were living with HIV/AIDS in the Democratic Republic of Congo (DRC); only 5% of people needing treatment had access to anti-retrovirals (ARVs), while 2% of HIV+ pregnant women had access to prevention of mother to child transmission (PMTCT) methods. Most of the capital's, Kinshasa, estimated 6+ million residents have insufficient access to HIV services. The overall goals of the University of North Carolina's (UNC) Providing AIDS Care and Treatment (PACT) project are to increase access to quality services and improve health outcomes of project beneficiaries by strengthening capacity at health care facilities for HIV testing and counseling (CT) and family-centered HIV prevention, care and treatment in Kinshasa. In FY 2010, UNC will provide technical assistance to continuum of care services including PMTCT, post-delivery monitoring and care of HIV+ women and their newborns of undetermined status, TB/HIV co-infection support, and family-based HIV treatment services including diagnosis, care, antiretroviral therapy (ART) and community and clinic-based psychosocial support (PSS). In each participating facility, information on family planning options, tuberculosis (TB), and malaria prevention and treatment will be provided to patients. Women seeking care at participating maternities will receive information on safe motherhood. Efforts will be made to encourage men to undergo testing and change discriminatory behaviors and beliefs. UNC will strengthen the referral system between maternities and treatment centers to improve retention of pregnant women and their children, expand PMTCT services to eight new maternities, and cover delivery costs to increase the number of HIV+ women that return to PACT maternities for delivery. UNC will continue to distribute water disinfectant to patients, begin nutritional aid, and maintain PSS groups for those affected by HIV/AIDS. Staff at 36 maternities, 17 TB clinics, a primary health center (Bomoi Health Center), and a pediatric hospital (Kalembe Lembe Pediatric Hospital, KLL) will receive training on topics such as ART, nutrition, family planning, prevention methods, HIV testing methods, and PMTCT. The establishment of Bomoi and KLL as centers of excellence, with use of summary patient sheets and simplified databases, creation and maintenance of a telemedicine system, increased staff training, and infrastructure improvements and expansion, will be initiated for the facilities to become training centers for other healthcare professionals

to develop HIV/AIDS expertise. Distribution of complex ARV regimens for pregnant women will be pursued, contingent on reliable access of ARVs. UNC will provide technical assistance and collaborate with the National TB Program (PNLT), the National HIV/AIDS Control Program (PNLS), the National Nutrition Program (PRONANUT), and the National Reproductive Health Program (PNSR) to strengthen national HIV efforts. UNC works closely with PNLT to support CT at 17 TB clinics. UNC works closely with PNSR to keep national PMTCT guidelines current and ensure quality information about HIV prevention, care, and proper nutrition is provided to pregnant women at PACT maternities. UNC works with other organizations active in Kinshasa, i.e. the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) which provides financial and technical support for UNC's PMTCT activities and nutritional programming and Action Contre la Faim (ACF) for patient referral to nutritional support. The Clinton Foundation (CF) funds clinical supplies for pediatric testing and care and supplies at the PNLS National Laboratory. UNC will continue to work with international partners such as the World Health Organization (WHO), Family Health International, Global Fund (GF), United Nations Populations Fund (UNFPA), and United Nations Children's Fund to procure the following program commodities: ARVs, antenatal vitamins, nutritional supplements, impregnated bed nets, and water purification powder. UNC attributes $1,106,000 to salary support, in-service trainings, performance assessment and service quality improvements, and volunteer programs; REDACTED to site infrastructure improvements and renovations; $11,200 to cover policy tools and service delivery for nutritional aid; $112,000 for nutritional commodities; and $98,300 to educational programs. UNC will be supporting child survival programming at Bomoi health clinic and KLL. UNC promotes sustainability of HIV services through capacity strengthening in service provision, organizational and management support, monitoring and evaluation (M&E), and generation and use of strategic information. M&E efforts will track program effectiveness and review certain aspects on a periodic and ongoing basis. In example, UNC performs regular site visits, monitors the quality of treatment and care activities, trains health care workers, and promotes quality improvement at all participating health care centers. Additionally, UNC shares information on the quality of HIV-related diagnosis, care and treatment services and management of these services with national experts. UNC will pay particular attention to the expansion of PMTCT services to eight new maternities and the quality of services delivered therein, the increased use of volunteers to assist in tracking and retaining patients, and ensuring all pregnant women and their children receive full services throughout the continuum of care in FY 2010.

HIV+ pregnant women, TB co-infected adults, and other HIV+ adult referrals are the target population for

these activities. UNC managed activities at 7 care and treatment sites: Bomoi Health Center, KLL, and 5

TB clinics. New participants receive comprehensive primary HIV care, including: clinical follow-up with

CD4 testing, prevention and treatment of opportunistic infections, malaria prevention and treatment, ART,

sexual and reproductive health services including family planning, nutritional support and counseling,

PSS, testing of family members and sexual partners. A total of 3,060 HIV+ individuals were provided

HIV-related palliative care in the previous program year. In FY10, infrastructure improvements, such as

construction of CT and exam rooms and a pharmacy, will be made at Bomoi Health Center and KLL to

improve care delivery. UNC will develop training materials to train providers who provide care to HIV+

individuals and their families. UNC will continue to develop a mentoring program to support clinicians

trained as a part of this initiative. These training and mentoring programs will include a detailed plan for

didactic training sessions, practical follow-up of trainees in the field, and monitoring and evaluation of

their successful service implementation. Outreach workers are utilized to track and retain patients

through telephone calls and home visits. Program-sponsored PSS groups are made available to

patients. Continuous monitoring and evaluation will occur through database review and regular meetings

based on specific program quality indicators such as: frequency of CD4 monitoring as compared to

protocol recommendations, percentages of eligible patients who receive cotrim prophylaxis, adherence to

protocol for DNA PCR at 6 weeks, percentage of clients with documented HIV status in the chart,

tracking of adherence and reports, choice of family planning method documented in the charts. UNC will

also conduct two "PDSA" quality improvement activities, and share the processes and outcomes to the

rest of the medical community. The outcomes of all of the monitoring and evaluation activities will be

translated and documented in a final year end report.

The same population is targeted for this activity as for adult HIV care. UNC provided ARVs to 993 HIV+

individuals through its activities so far. Each patient undergoes a comprehensive baseline assessment at

program enrollment including clinical examination, nutritional and laboratory assessment, and

psychosocial evaluation. HIV disease staging by clinical assessment and CD4 testing will determine

ARV eligibility and patient visit schedules. Patients on ART are scheduled for monthly visits, until

deemed clinically stable after which they may be seen every six months. Those who are seen every six

months continue to be assessed by a nurse dispensarist on weight, ARV dosing, and drug adherence

through questionnaires and pharmacy databases. At each visit, drug toxicity assessment is conducted,

and counseling on treatment adherence is provided. Facility improvements will be made at Bomoi to

create dedicated pharmacy space and an HIV care and treatment-related library and at KLL to renovate

existing pharmacy space, as both facilities provide medicines to adults. 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, tracking of adherence and toxicity reports, and choice of family

planning method documented in his/her chart. UNC will also conduct two "PDSA" quality improvement

activities, and share the processes and outcomes with the regional medical community. The outcomes of

all of the monitoring and evaluation activities will be translated and documented in a final year end report.

Provider-initiated rapid testing is implemented at all ANC centers, Bomoi Health Center, and the TB

clinics according to national guidelines. 9,791 individuals were counseled and tested for HIV and

received their test results over the last program year. In the next year, UNC will strengthen the

implementation of the provider-initiated testing policy KLL, and will increase the HIV testing rate of first-

line family members and sexual partners of PACT program's patients at the ANC centers and Bomoi

Health Center. UNC will provide technical assistance to PNLT for VCT at TB clinics. UNC will also design

and implement resources and training sessions to ensure retention along the continuum of care for

pregnant women and their infants through HIV diagnosis, care and treatment for the mother, and HIV

testing and care and treatment (if indicated) of the exposed infant. All of these activities will be monitored

regularly by program staff through direct observation, provision of periodic quality assurance panel

testing and review of patient registers.

Program evaluation will be summarized through reporting on the numbers of patients tested who receive

their results, and for KLL hospital, by the percentage of admitted patients who also receive an HIV test

and result.

HIV+ children (including those co-infected with TB) referred to PACT care and treatment sites are the target population for these activities. Each HIV+ pediatric participant receives a comprehensive package of primary HIV care , including: clinical follow-up with CD4 testing, prevention and treatment of opportunistic infections, malaria prevention and treatment, ART, sexual and reproductive health services including family planning, nutritional support and counseling, PSS, testing of family members and sexual partners at Bomoi Health Center and KLL. Nutritional support will be provided to patients to reduce barriers to adherence, and providers will be trained in proper nutrition for those on ART. Facility improvements needed to establish centers of excellence, including electrical and telephone wiring repairs and construction of additional laboratory rooms, at Bomoi Health Center and KLL, as HIV services are provided to pediatric patients at both facilities. Issues specific to pediatric HIV care, such as status disclosure, will be included in training sessions for program personnel and other providers. Additional aid and education is arranged for patients through PSS groups, both for those informed of their status and those unaware of their status. Outreach workers are also utilized to track and retain pediatric patients. Continuous monitoring and evaluation will occur through database review and regular meetings based on specific program quality indicators such as: frequency of CD4 monitoring as compared to protocol recommendations, percentages of eligible patients who receive cotrim prophylaxis, percentage of clients with documented HIV status in the chart, tracking of adherence and reports, and tracking of disclosure

status. UNC will also conduct two "PDSA" quality improvement activities, and share the processes and outcomes to the rest of the medical community. The outcomes of all of the monitoring and evaluation activities will be translated and documented in a final year end report.

The same population is targeted for this activity as for pediatric HIV care. UNC provided ARVs to 647

HIV+ children through its activities so far. Each patient undergoes a comprehensive baseline

assessment at program enrollment including clinical examination, nutritional and laboratory assessment,

and psychosocial evaluation. ARV eligibility and patient visit schedule will be assessed according to age

and WHO recommendations. Patients will be seen every month for the first three months of participation

and then every three months thereafter. Patients who are seen every three months will continue to be

assessed by a nurse dispensarist on weight, ARV dosing, and drug adherence through questionnaires

and pharmacy databases. At each visit, drug toxicity assessment is conducted, and counseling on

treatment adherence is provided. Outreach workers will assist with patient tracking to improve

adherence. Construction of internet-wired and better equipped conference rooms will occur to effectively

implement a telemedicine program at Bomoi and KLL, and enable the centers to host medical

conferences and regional clinician training sessions. As centers of excellence, HIV pediatric treatment

mentorships will occur at KLL and Bomoi, and expert opinions and best practices in pediatric ART

treatment will be shared with other providers. 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 DNA PCR at 6 weeks, percentage of clients with documented HIV status in his/her chart,

tracking of adherence and toxicity reports, and choice of family planning method documented in his/her

chart. UNC will also conduct two "PDSA" quality improvement activities, and share the processes and

outcomes to the rest of the medical community. The outcomes of all of the monitoring and evaluation

activities will be translated and documented in a final year end report.

Individuals who are sexually active and are HIV tested at PACT health centers are provided information

at time of testing on condom use; STI transmission, prevention and treatment methods; and other risk-

reducing behaviors, in addition to information on fidelity and reducing the number of partners. UNC

provides this message to those presenting for care at participating maternities and PACT care and

treatment centers and at educational presentations in the local communities in which UNC operate.

Participants interested in family planning services are referred to closest service provider. Men are

specifically targeted through sensitization sessions, which are linked to testing opportunities for those

who choose to be tested. Training is provided to healthcare providers at participating health centers at

program initiation and through periodic refresher training sessions. Over 54,000 individuals received

these messages in the last program year. UNC will continue these activities in FY10, and will monitor and

evaluate the delivery of this information by quarterly input/output monitoring.

PACT's PMTCT activities are integrated into existing ANC services provided by PNSR, and currently

cares for approximately 14.3% of pregnant women in Kinshasa. HIV+ mothers and their infants are given

prophylactic ARV treatment and cotrimoxizole (cotrim), and referred for PSS and informal life skills

training. Women eligible for ARVs are referred to a care and treatment center for follow up. UNC will

expand to eight additional maternities in FY 2010. Staff at participating maternities is trained using

PLNS-approved curriculum. New clinics are supervised daily by UNC staff for 2 weeks to 1 month after

training, then by monthly site visits. Efforts are made to strengthen male partner involvement, provide

access to CD4 testing at clinics when feasible, and introduce new models for charting and documenting

visit follow up and retention, and to cover delivery costs. Regular meetings are held with midwives, clinic

nurses, and laboratory staff. UNC will provide a more intensive model for prevention with positives

counseling and "living positively" curriculum at 10 maternities to increase follow-up rates at referral sites.

UNC will provide an expanded care package of PSS, nutritional support, cotrim prophylaxis, CD4

monitoring and exposed infant follow up at these maternities. Volunteers will be identified, hired, and

trained to assist with patient tracking and retention. Funds will be provided to maternities for facility

improvements. UNC developed, and will disseminate to district health officials, a model for supportive

supervision to strengthen health systems. UNC will implement improved tools to monitor program

supervision and performance. For example, UNC will be collecting information on the performance of

trained nurses by using knowledge pre-training and post-training tests, clinical skills checklists, and

maternity "action plans". UNC will also monitor program performance at the 10 maternities implementing

more intensive case management and follow up by recording the percentages of women from each

maternity who successfully enroll at a care site, numbers of HIV exposed infants receiving cotrim

prophylaxis, and numbers of infants tested for HIV at 6 weeks.

UNC is active in 17 TB clinics in Kinshasa, and oversees HIV VCT activities in each location. All HIV+

co-infected patients receive cotrim prophylaxis and are screened for ARV eligibility based on CD4 count

and clinical staging. 984 co-infected patients were provided HIV-related palliative care in FY09. All

TB/HIV co-infected patients are referred to a PSS group. Training courses on the management of TB/HIV

co-infection are held regularly for both providers and PSS group leaders. All of these activities will be

monitored regularly by program staff through direct observation and review of patient registers and

records. Data will be reviewed for program evaluation, and UNC will support a rapid skills transfer to the

local health care personnel at those clinics formerly managed by UNC that provided ART at the clinic

level. Also at this time, UNC will intensify their technical assistance work for the National program by

developing simplified database and data collection forms for ongoing use by the National program and

their partners. UNC will expand supportive supervision activities to assist the National program in

expansion of its HIV testing activities, and UNC will also provide program evaluation for the National

program. UNC will conduct a feasibility assessment of initiating PITC in Kisangani's TB clinics and

strengthening linkages to neighboring HIV treatment centers for TB/HIV co-infected patients. Pending a

favorable assessment outcome, UNC will develop a plan at the identified sites for Provider Initiated

testing and Counseling (PITC), patient assessment, and HIV treatment referral. This plan will include

didactic trainings and follow-up supervision at the TB clinics. 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.