For COP 10, ICAP's goal is to work closely with the Swaziland Ministry of Health (MOH) at the national, regional and site level to support the strengthening of systems, programs, facilities, healthcare workers and the respective communities to offer quality adult and pediatric HIV care and treatment services with an integrated family-centered approach to people living with HIV and AIDS (PLWHA). This will focus on decentralizing HIV treatment services, initiating HIV care services on the primary care level and better linking the community to the facility. Ultimately, ICAP will shift many of its current activities (re: technical leadership, clinical mentoring and supervision, community systems) to local governmental and non-governmental responsibility and ownership.

In COP 10, ICAP is funded under three mechanisms: CDC-care/treatment service provision cooperative agreement, CDC-technical assistance for Strategic Information use (UTAP) and HRSA - building capacity to support nurses training. This narrative applies to activities under UTAP funding.

ICAP's goals support and contribute directly to the principle goals of the GOKS-PEPFAR Partnership Framework (PF): " to decentralize and improve the quality of treatment services within a CCP in order to increase access and improve outcomes for PLWHA". The ICAP program provides substantial support to the whole national program in the areas of policy, planning, information systems, laboratory, pharmaceutical management/supply.

An ICAP M&E unit was established in January 2009. This new team has worked hard to forge a good working relationship with key MOH stakeholders in monitoring and evaluation of HIV/AIDS care and treatment. M&E staff will continue to provide technical support to all ICAP-supported facilities and participate in relevant technical working groups at the national level. The M&E unit is supported by Monitoring, Evaluation and Research department at ICAP headquarters New York (MER-NY). This technical support ensures that ICAP's global wealth of experience is shared with the ICAP-Swaziland M&E staff to ensure compliance to programmatic and funding partners reporting requirements.

The overarching goal of the M&E unit of ICAP-Swaziland program implementation is to develop and conduct high-quality, timely, and sustainable monitoring and evaluation of ICAP supported activities for program evaluation and improvement. This is a collaborative effort, with local, national, and international partners to routinely collect, analyze, and disseminate data to assess program quality, as well as program impact within the Kingdom. In Swaziland, ICAP will implement the nationally approved monitoring and evaluation system and tools. ICAP participates in PEPFAR and national committees to review and revise M&E tools.

An M&E expert joined ICAP in January 2009 as the Program Monitoring Director and head of the M&E unit. He is assisted by three data officers who also joined ICAP in January and May 2009 and a fourth officer who joined in late 2009.

All ART sites have an electronic medical record systems (developed by MSH for the MOH called RX Solution Program Monitoring System) that captures and manages patient level data. At each main care and treatment site, data clerks maintain the PMS, perform routine data quality checks, monitor patients on ART, produce monthly reports on hard copy and send (both electronically and on hard copy) to MOH headquarters through the regional health offices. ART sites' monthly reports are aggregated at the central level and distributed to partners-including ICAP.

The lack of national requirement to routinely report on HIV care indicators represents a major handicap in monitoring HIV services. With MOH approval, ICAP has assisted nine main care and treatment sites to use the Pre-ART registers, and has developed a routine monthly report tools for key care indicators. ICAP is currently piloting this new tool with the main objective to adapt it as a national care monthly reporting form. The findings will be discussed with MOH in October 2009.

Each site sends hard copy monthly reports to the national M&E headquarters. Then the national M&E unit shares hard copies with implementers. As a consequence, there are long delays in data transmission and dissemination. ICAP will provide technical support to strengthen the national M&E system for HIV/AIDS at all assisted sites. ICAP will also work with other PEPFAR partners in assisting the national M&E leadership to develop standard operating procedures, conduct routine data quality assurance at care and treatment sites, and develop analysis approaches to track key treatment outcome measures.

Lastly, ICAP M&E in collaboration with the PEPFAR team, will support the development of CCP costeffectiveness analysis capacity at the MOH. As national ART guidelines move in the direction of improved quality of care, integrated services, and change in CD4+ threshold (<350), it is important that PEPFAR and partners assist the MOH in raising awareness regarding the cost-coverage implications of policy change. Routine analysis of cost parameters in relation to coverage and quality are key to enhanced planning and implementation of sustainable service delivery models.

ICAP will continue to work with the MOH to improve its program data and thereby evaluate programmatic interventions, to measure effectiveness and to determine the most efficacious programming around HIV care and treatment. ICAP will provide TA to the MOH and other stakeholder groups (through a data analysis work group) to provide analysis of data for program improvement. ICAP will draw on its extensive experience in providing similar TA in other countries, and will explore the possibility of adapting proven tools and approaches such as a workshop on data for decision making for health officials and providers and working with the MOH to introduce site level tools such as the Standards of Care, which encourages providers to use program data to improve the quality of clinical care. ICAP will also explore with the MOHy use of the Program and Facility Characteristics Tracking System PFaCTs tool which mirrors many of the key elements of the Service Availability Mapping (SAM) but can be updated more frequently and easily and makes data more accessible on a web based system to all authorized users. PFaCTS is a standardized tool across all ICAP countries that captures several key aspects of ICAP's programming and implementation activities are not captured by routine M&E indicators, such as information on staffing, presence of an active outreach/defaulter tracing program, availability of laboratory assays, entry points and linkages, etc.

Specific data analyses supported will include;

Proportion of patients tested positive and received CD4 results (eligible for ART) are initiated on HAART

Of those enrolled on ART but not currently on ART, what proportion died, stopped therapy, transferred out of system (define system), and otherwise lost to follow up

Of those on ART, what is the median differential between the CD4+ cell count/CD4% at baseline and CD4+ cell count/CD4% at 6, 12, and 24 months

Of those enrolled in care (by whether on ART), what proportion is in care and/or on ART at 12, 24, 36 months (NOTE: feasibility depends on whether/how pre-ART/other service data are linked into data system).

Median changes in CD4 at initiation for patients enrolled in pre-ART programs, versus those who were not enrolled

Six, 12 and 24 months treatment outcomes among patients initiated on ART

Analysis of patient loss to follow up and deaths, including rigorous analysis of cause of death among a subset of patients

Documenting quality improvement processes and how they affect program implementation

The impact of decentralization on patient flow at primary care facilities

Socio-demographic, clinical and biological characteristics of patients initiating ART

Patient tracking systems efficacy of cell phone systems.