In COP 10 a new award - TBD PMTCT will be issued to continue the work of the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), which has supported the Government of the Kingdom of Swaziland since 2004 with the goal to prevent pediatric HIV infection and reduce HIV-related morbidity and mortality among women, children, and families. TBD PMTCT's objectives will be:

1) Support the government scale up plan to reach 100% of public facilities with comprehensive PMTCT services by 2011

2) Support the government to integrate comprehensive HIV care & treatment in MCH settings

3) Support facilities to provide high quality, comprehensive PMTCT and care & treatment services for pregnant women, mothers, infants, children, and other family members

4) Strengthen the health systems through technical assistance and capacity building to ensure sustainability of services

5) Develop and promote evidence-based interventions

TBD PMTCT's strategic support will comprise all four prongs of the comprehensive PMTCT approach adopted by the Ministry of Health (MOH): primary prevention, preventing unwanted pregnancies, preventing mother-to child transmission, and providing HIV care and treatment for the mother, child and family.

PMTCT was assessed in the PF to have rapidly grown with a remarkable increase in coverage. As described in the PF, improving the quality of PMTCT services and the integration into broader MCH and HIV care and treatment programs will continue to be a priority. TBD PMTCT's program is closely linked to the following key interventions identified in the PF: decentralized and improved quality of care and treatment services including HTC and TB/HIV; sexual prevention; impact mitigation with a focus on children; and human and institutional capacity development.

TBD PMTCT will build on EGPAF's success of using PMTCT services as an entry point to provide integrated, comprehensive HIV care & treatment, RH/FP, and MCH services for women, their partners and children using family focused approach. In consultation with PEPFAR Swaziland and the MOH, EGPAF developed a strategy to provide integrated PMTCT, care and treatment in Public Health Units (PHUs), MCH clinics, and <5 clinics, where most Swazi mothers and children receive their routine care. The PHUs will serve as the hub providing technical support, referral linkages and support to surrounding clinics.

The maturity of the Swazi PMTCT program allows a transition to targeted site support based on changing needs. Some sites will continue with basic program monitoring, QI programs and staff development; other sites need more intensive support to improve performance. To minimize disruption of service provision caused by the MOH policy of frequent staff rotation, TBD PMTCT will provide ongoing training and site support.

TBD PMTCT will provide technical assistance and advocacy on development or adaptation of guidelines, training materials, tools and policies through active participation in the national HIV TWG and its subcommittees. It will conduct critical program evaluations to inform policy.

TBD PMTCT will support the update of the national PMTCT guidelines to incorporate the new WHO guidelines expected to be released end of 2009, including prophylaxis during breastfeeding, and support implementation of these guidelines to maximize the effectiveness of the PMTCT interventions.

TBD PMTCT site level support will focus on regular support supervision and on-site clinical mentoring. In 2009, three new Program Coordinators were based in PHUs to provide support to the PHUs and their surrounding clinics in QI, linkages and integration of services between facilities and community. These Coordinators work closely with regional staff (clinic supervisors, AIDS coordinators, psychologists) in implementation of integrated comprehensive HIV prevention, care and treatment services and provide joint support supervision.

The target populations include pregnant and postpartum women, infants, and secondarily their partners, families, and communities. TBD PMTCT will continue supporting PMTCT service delivery in 47 of the total 137 health facilities across all 4 regions (5 hospitals, 4 health centers, 6 PHUs and 32 clinics), and supports maternity wards in 9 of 12 public hospitals, catering to more than 85% of facility deliveries in the country. All 47 sites provide HIV care services. By 2010, the 6 PHUs will be providing ART services, primarily to HIV-infected women, their spouses, and children. By 2011, TBD PMTCT will expand these services to ensure that all 137 government facilities are providing high quality PMTCT services.

TBD PMTCT's approach to building national capacity and sustainability will ensure cost-efficient programming. The decentralization of the integrated services for HIV prevention, care and treatment in the MCH setting brings all services under one roof, saving costs on separate buildings, staff, and maintenance. The sub grant to the MOH will have an added value of ensuring long-term ownership and sustainability.

TBD PMTCT will support integrated comprehensive HIV care and support in 32 sites where PMTCT services are offered, including PHUs, MCH units, health centers and clinics, and will expand to 10 new sites in 2010. It will provide TA to the MOH through the HIV Technical Working Group, including:

Finalization and implementation of the comprehensive care package

Finalization of pre-ART M&E tools (registers, patient files and patient hand held cards)

Decentralization of comprehensive care services to the PHUs, health centers and clinics

TBD PMTCT will also support the MOH in improving the capacity of service providers to implement integrated comprehensive HIV care and treatment through integrated management of adult illness training and supports sample transport from sites to regional and national reference labs. It will continue to improve uptake and quality of HIV care through regular on-site mentorship and supervision:

Clinical services: Early identification of HIV-positive pregnant women, partners and children at all care points; enroll and register clients in pre-ART care, prompt clinical and immunological assessment of HIV-positive pregnant/lactating women and other individuals; pain assessment and management; screen for TB and OIs; prophylaxis with CTX, INH; regularly assess for ART eligibility; ensure all HIV-positive individuals are assessed nutritionally and treated accordingly.

Linkages and follow up: strengthen the use of patient cards and referral forms for effective referral linkages; work closely with expert patients and Mentor Mothers in ensuring that clients are well counseled on care services and complete referrals; establish and strengthen referral linkages between services and clinics; improve follow-up counseling to improve adherence; work with health workers to utilize pre-ART and appointment registers to identify defaulting and lost to follow up clients; develop mechanisms (mobile phones) to trace clients who have not returned for follow-up or results.

Support services: establish family support groups and strengthen community-health facility linkage; work with rural health motivators to improve utilize and adhere to the care services provided in the health facilities.

Support supervision and mentorship: Continue to provide regular visits for data review, QI activities, case management and mentoring.

QI activities: Continue to support the MOH to develop and implement QI approaches for HIV care services to improve data use at site level, including training of health facility staff on quality improvement. TBD PMTCT will work with health care workers to use the PDSA cycle to perform site level QI activities.

In FY11, the TBD PMTCT award will support the provision of comprehensive and integrated HIV treatment in 6 PHUs and one new clinic, focusing on pregnant women and children. Eligible HIV-positive pregnant women will be initiated on ART in the PHUs. Those already on HAART and attending ANC at these PHUs will be transferred out to the main ART centers until approximately 2 years after delivery to allow for continuity of services for both mother and child in the PHU/MCH setting. The adult HIV treatment activities for TBD PMTCT in FY11 will include:

National level activities:

Provide technical assistance to the MOH in the revision of adult and adolescent HIV treatment guidelines

Support the MOH (SNAP) in the decentralization of treatment services to the 6 PHUs and 1 clinic

Support the MOH in the training of health care workers in provision of adult HIV treatment services through the in-service IMAI training

Site level activities:

The TBT PMTCT award will support sites in improving uptake and quality of HIV treatment services as follows:

Work closely with mentor mothers and expert clients to ensure that eligible individuals are adequately prepared for HAART

Work with and support health workers in drug stock management to ensure uninterrupted supply of ARVs and other OI drugs

Support and mentor health care workers to ensure proper follow up and monitoring of patients on HAART and management of any side effects or complications that might arise

Encourage adherence to treatment by regular ongoing ART adherence counseling and active tracing of defaulters and lost to follow up patients using mobile telephones. TBD PMTCT will also work with rural health motivators to track patients defaulting treatment in the community.

Support proper documentation of treatment services provided in the facilities and timely reporting of data to the national M&E unit.

Provide ongoing site supervision and mentorship. TBD PMTCT's technical staff, including the Program Coordinators, will continue to provide regular visits to the sites to review data and perform QI activities; assist in case management; and mentor health workers in HIV treatment.

Develop and support QI activities. TBD PMTCT will support the MOH to develop and implement QI approaches for HIV treatment services to improve data use at site level, including training of health facility staff on quality improvement.

Support outreach services to St. Theresa clinic for provision of ART services through King Sobhuza II PHU.

TBD PMTCT will support these pediatric care and support services:

Provide TA to revise/update pediatric HIV care and treatment guidelines

Support the MOH to adapt/develop pediatric HIV care and treatment training curriculum and harmonize pediatric guidelines with IMCI expanded HIV guidelines

Support national system for transport of blood samples and DBS

Provision of essential newborn resuscitation equipments and training of staff to improve neonatal survival.

Support the MOH in building capacity to implement pediatric HIV care through training and through provision.

Ensure that comprehensive care services are well integrated with routine child health services to ensure continuity of care.

Clinical services for exposed infants: identify exposed infants through systematic screening of child and mother health cards at each service contact; improve health worker skills in pediatric counseling through training and mentorship; support EID through DNA PCR using DBS for exposed infants at every entry point within MCH; provide pediatric PITC using antibody tests for children >12 months; provide infant feeding counseling and support routine immunizations, growth monitoring and developmental assessment; provision of CTX prophylaxis; presumptive diagnosis of HIV

Clinical services for HIV infected infants and children: provision of routine child health services; early identification of infected infants and children; clinically and immunologically staging; assess and manage pain; screen for TB/OIs; provide prophylaxis with CTX, INH; regularly assess ART eligibility; early treatment initiation for positive infants; assess nutrition status and treat accordingly; link all eligible children for treatment.

Linkages and follow up: strengthen use of patient cards and referral forms for effective referral; work closely with expert patients and Mentor Mothers in ensuring that caregivers are well counseled on care services and complete referrals; utilize pre-ART and appointment registers to identify children defaulting and lost to follow up; develop mechanisms to trace caregivers who have not returned for follow-up or results..

Support services: establish family support groups at supported sites, especially for children living with HIV.

Site supervision and mentorship: continue to provide regular visits for data review, QI, case management and mentoring.

QI activities: Continue to support the MOH to develop and implement QI for HIV care services

In FY11, the TBD PMTCT award will support the provision of comprehensive and integrated HIV treatment for infants and children in 6 PHUs and one new clinic. All HIV positive infants less than 12 months of age and eligible HIV-positive children above 12 months will be initiated on ART in the PHUs and will be transferred out to the main ART centers at 2 years of age. TBD PMTCT's support for pediatric HIV treatment activities for FY11 will include:

National level activities:

Provide technical assistance to the MOH in the revision of pediatric HIV care and treatment guidelines

Support the MOH in the training of health care workers in provision of pediatric HIV treatment services

Site level activities:

Continue to support the sites to ensure all HIV-positive infants less than 12 months are initiated on HAART, irrespective of their clinical or immunological staging, to decrease morbidity and mortality.

Work closely with mentor mothers and expert clients to ensure that eligible infants and children are adequately prepared and initiated on HAART with minimal delay.

Work with and support health workers in drug stock management to ensure uninterrupted supply of pediatric ARVs and other OI drugs. TBD PMTCT will advocate for the use of FDC ARVs for infants and children to improve adherence to treatment.

Support health care workers to ensure proper follow up and monitoring of children on HAART and management of any side effects or complications that might arise.

Ensure all children on HAART are also provided with other routine child services including immunizations and growth monitoring.

Support adherence to treatment by regular ongoing ART adherence counseling for children and caregivers; establishment of support groups for caregivers and children; active tracing of defaulters and lost to follow up patients using mobile telephone. TBD PMTCT will also work with rural health motivators to track infants and children defaulting treatment in the community.

Support proper documentation of treatment services provided to children in facilities and timely reporting to the national M&E unit.

Site supervision and mentorship. TBD PMTCT's technical staff including the program coordinators will continue to provide regular visits to the sites for: reviewing of data and perform QI activities; case management and mentoring HWs in their day to day work in HIV treatment

TBD PMTCT will also support outreach services to St. Theresa clinic for provision of ART services through King Sobhuza PHU to increase accessibility.

EGPAF currently provides support to health facilities in order to optimize all 4 prongs of PMTCT through integration into MCH services, following mother/infant pairs, and links to care and treatment at all levels. Services include high quality provider-initiated HIV testing and counseling (PIHTC), ARV prophylaxis and treatment, counseling and support on infant feeding, nutrition assessment, FP, TB/OI screening, CD4 and clinical staging, CTX prophylaxis for eligible women and exposed infants, safer delivery practices, psychosocial counseling, support, follow up and referral of HIV-positive women and HIV-exposed infants and family members to care and treatment.

TBD PMTCT will continue these services, add 10 new sites in FY2010 to the existing sites currently supported by EGPAF, and additional sites in FY2011 to reach the MOH goal of 100% PMTCT coverage and:

Achieve 98% HTC uptake, using the opt-out approach with same day rapid test results in ANC, L&D and postnatal clinics

Support scale up of couple counseling through training support, on-site clinical mentoring

Improve counseling quality, especially for couples and those testing negative in ANC to reduce seroconversion and pediatric infection during pregnancy/breastfeeding

Strengthen retesting in ANC and L&D to ensure that newly infected women and exposed infants receive ARV prophylaxis

Provide HTC for HIV-exposed infants, siblings and family members

Provide mentorship and support supervision for mother mentors and expert clients

TBD PMTCT's priority will be to provide HIV-positive women access to more efficacious ARVs (sdNVP+AZT/3TC), including HAART, in line with latest national and WHO guidelines, to improve facility and community linkages and to support quality improvement.