For COP 2012, ICAP aims to continue working closely with the Government of Swaziland's Ministry ofHealth (GOS MOH) at the national, regional and site level to ensure sustained access to high quality,comprehensive, family-focused HIV care and treatment services for people living with HIV (PLHIV).Decentralization of HIV services to all planned sites will be achieved and consolidated while building upthe self-sufficiency of the Regional Health Management Teams (RHMTs). The community linkagesprogram will be further integrated within the Rural Health Motivator (RHM) community cadre of the MOH.ICAP supports the MOH at the national, regional and site level covering three of the four regions in thecountry, Hhohho, Manzini and Lubombo. The target population for service delivery is an estimated140,000 PLHIV and their family members. The target populations for capacity building include the MOH atnational, regional, site and community (e.g. RHMs) levels, as well as local community groups. ICAP'smain strategy is to directly support and strengthen existing national systems and to avoid any parallelefforts. Although a portion of staffing supplementation is required to achieve scale up objectives within theproject time frame, most of the program effort has been devoted to strengthen national policies andguidelines, existing MOH cadres and service delivery, M&E and supervision systems. In line with thisapproach, the community linkages program will increasingly shift its focus to engaging and better linkingRHMs to health facilities. A major thrust during this period with management capacity developmentsupport from Pact will be to ensure the self-sufficiency of the RHMTs in managing and supervising theclinics.

ICAP will support the MOH to firmly establish sustainable HIV care and support services in all 114 public

and mission facilities in the three regions. This effort will include full roll out of pre-ART as part of thePackage of Care (POC), strengthened adherence and psychosocial support (APS) and PwP, the ExpertClient initiative, clinical mentoring and supportive supervision, as well as the community linkagesprogram. A major ICAP effort will include the phased transfer of full responsibility for facility support to theRHMTs. [PREART] The pre-ART register and systems will be fully rolled out to all health facilities. [APS]ICAP will continue to support the integration of standardized APS services into the overall health servicedelivery at sites. [PwP] Based on the findings of the PwP technical review and national strategyscheduled for year 3, comprehensive PwP services will be more systematically integrated into routineHIV care within all health facilities and community linkages activities. This includes couples HIV testingand counseling (CHTC); treatment as prevention for discordant couples; identification and preventioneducation for discordant couples; condom promotion, reducing unintended pregnancies, earlyidentification and treatment of sexually transmitted infections as well as nutrition counseling andcollaboration with the World Food Programme on food per prescription. [EXPERT CLIENTS] ICAP willcontinue to support Expert Clients at health facilities to work with patients in treatment literacy and willexpand their scope to include a greater focus on PwP, TB screening and encouraging clients to bringfamily members in for testing. [CLINICAL MENTORING AND SUPPORTIVE SUPERVISION] ICAP willsupport the RHMTs to develop a set of performance-related criteria to assess each facility's need forclinical mentoring and supportive supervision. Stronger performing facilities might be "graduated" toquarterly mentoring visits while weaker facilities may be visited twice each month. [COMMUNITYLINKAGES] ICAP will support greater involvement of RHMs in tracking clients who miss theirappointments. ICAP will train over 2,000 RHMs and assign a clinic level RHM Coordinator to providesupportive supervision.

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ICAP will continue to work in close collaboration with URC and the National TB Program to fully integratesustainable TB services within ART sites. In particular, ICAP will focus on scaling up TB screening andINH prophylaxis among HIV clients and improved infection control. Specific activities will include:

Intensified Case Identification and Follow Up• Ensuring systematic and periodic TB screening for all PLHIV, including expanding the scope of ExpertClients to include periodic TB screening and education on self-screening• Initiating or ensuring successful linkage of identified TB cases to treatment services,• Provision of quality TB information and education for clients by health care professionals, Expert Clientsand RHMs,

• Support through Baylor for better integration of TB services within pediatric HIV care and treatment.

INH Prophylaxis• Support for INH prophylaxis in hospital ART programs and roll out to the clinics

Infection Controls: Administrative & Engineering• Promotion of cough screening and cough hygiene/etiquette• Support for better ventilation and separate waiting areas, including the possibility of minor renovationsas required.• Prioritization and separation of TB suspects.

Many of the government owned health facilities in Swaziland are inadequate for current needs. Someare in outright disrepair; others are not designed in a manner that meets the chronic care needs of thecurrent population: waiting areas are too small; infection control needs (windows, ventilation) are unmet;adequate space for consulting rooms, record keeping, point of care laboratories, and waste managementfacilities are often completely lacking. As a result, patient flow is inefficient and, with the high rates of TBand poor infection control, often dangerous to both patients and staff. The funds in this project will beused to undertake minor renovations to facilities to bring them up to minimum standards and provide thebasic furniture needed to run the facility to support quality chronic care services (eg, filing cabinets). Thefunds will be leveraged with resources from the MOH and other donors like the World Bank, ClintonFoundation and MSF.

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In addition to the main areas of support described under Adult Care and Support, ICAP will continue towork with Baylor College to support strengthened capacity for pediatric HIV service provision in allsupported facilities. Areas of priority emphasis during this period will include:

• Intensified follow up of HIV exposed infants and children who test positive using both facility andcommunity strategies. This will include better tracking, systematic use of cell phones to send follow upmessage and home visits through the community linkages program.• Health care workers, Expert Clients and RHMs encouraging PLHIV to bring their families for HTC.• Promoting APS messages for children and for parents to talk with their children about the status andcare and treatment needs.• Bidirectional support to integrate HIV services within child clinics and to ensure that HIV exposed and

infected children receive their immunizations and other well child services.• Better equipping RHMTs to mentor and supervise pediatric HIV services.• Support facilities through the procurement of pediatric-specific equipment and supplies.

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The Swaziland HIV Incidence Measurement Survey (SHIMS): USG has completed the initial phase of afirst-of-its-kind evaluation of trends in HIV incidence. In addition to its principle objective of evaluatingthe impact of HIV combination prevention efforts under "real world" conditions, the SHIMS project isbuilding the foundation of national learning institutions around public health evaluation.

Strategic Area Budget Code Planned Amount

In addition to all of the work described above under Adult Care and Support, the additional activities listedbelow will be undertaken in support of Adult Treatment. (1) Expansion in numbers reached with ARTinitiation: through ICAP support, it is expected that more than 12,000 people will be initiated on ART inFY 2013 and nearly 64,000 people will be currently enrolled on ART. This level of enrollment slightlysurpasses the PFIP target of 60,000. (2) Nurse-initiated ART has been implemented in 15 sites to date.During this period, ICAP will work with the MOH to provide evaluation of the pilot initiative and further rollout of nurse-initiated ART to most facilities, including expansion of pediatric ART initiation and providingtraining to all registered nurses. (3) ICAP will support full implementation of treatment initiation for clientswith a CD4 count of 350 or lower. This will include development and implementation of a communicationstrategy on the lower treatment threshold, targeting the community through HCWs and through traditionalcommunity structures. (4) Quality of service: The major thrust of effort during this two year period will beon improved and sustained quality of ART services. Multi-disciplinary teams will be supported toconsolidate their skills in clinical systems mentoring and ongoing quality improvement. (5) Prisons andUniformed Services: ICAP will continue its effort to establish quality on-site ART and effective linkages forthe prison populations and uniformed services in need of HIV care and treatment.(6) Treatment asPrevention: ICAP will work with MOH and other stakeholders to improve areas in the health system thatneeds to be strengthened in order to introduce a higher CD4 threshold for initiating treatment.

Many of the government owned health facilities in Swaziland are inadequate for current needs. Someare in outright disrepair; others are not designed in a manner that meets the chronic care needs of the

current population: waiting areas are too small; infection control needs (windows, ventilation) are unmet;adequate space for consulting rooms, record keeping, point of care laboratories, and waste managementfacilities are often completely lacking. As a result, patient flow is inefficient and, with the high rates of TBand poor infection control, often dangerous to both patients and staff. The funds in this project will beused to undertake minor renovations to facilities to bring them up to minimum standards and provide thebasic furniture needed to run the facility to support quality chronic care services (eg, filing cabinets). Thefunds will be leveraged with resources from the MOH and other donors like the World Bank, ClintonFoundation and MSF.

Strategic Area Budget Code Planned Amount

In FY 2013, ICAP expects to support the initiation of more than 1,600 children under the age of 15 yearson ART. During that year, it is anticipated that over 6,700 children will be currently enrolled on ART.

In addition to the activities described under Pediatric Care and Support, ICAP will continue to work withBaylor College to support the following activities specifically targeting pediatric treatment:

• Intensified efforts to test all children of clients enrolled in HIV care and treatment.• More aggressive facility and community follow up of children on ART who miss their appointments.• Better integrated and strengthened APS for children on treatment and their caregivers.