The broad objectives of Elimination of Pediatric AIDS in Swaziland (EPAS ) are to: 1) achieve universalaccess to PMTCT with expanded delivery of services to achieve elimination of mother-to-childtransmission of HIV; 2) support and sustain s quality, comprehensive, integrated PMTCT services atGKOS health facilities; 3) strengthen the National Health System in accordance with the MOH's plans forPMTCT; and 4) promote the regular review and improvement of MOH's policies, protocols and guidelinesfor PMTCT services. As described in the PF, improving the quality of PMTCT services and the integrationinto broader MCH and HIV care and treatment programs will continue to be a priority for EPAS. EGPAFworks in all the 4 regions serving primarily HIV pregnant women, their spouses, children and other familymembers. EPAS supported the MOH to achieve 100% coverage of government health facilities withPMTCT services in 2011. Combined with additional FBO and private sector facility coverage, this willresult in EGPAF's support reaching 83% of pregnant women in Swaziland. EGPAF's approach to buildingnational capacity and sustainability ensures cost-efficient programming. The decentralization of integratedservices for HIV prevention, care and treatment in MCH settings brings all services under one roof, savingcosts on separate buildings, staff, and maintenance. Seconding program staff to the MOH with ultimateabsorption by the MOH will have an added value of ensuring long-term ownership and sustainability. Tominimize disruption of service provision caused by the MOH policy of frequent staff rotation, EGPAF willcontinue to provide ongoing training and site support. Progress and results will be tracked through acomprehensive performance monitoring plan.

Clinical HIV care services will be supported in 34 health facilities in the four regions while thepsychosocial support services will be mainly through establishment of support groups for people livingwith HIV. EGPAF will participate in the HIV Care and treatment TWG and its sub-TWGs to help reviewand plan for HIV care services; provide TA in the review and development of national HIV care tools e.g.M&E tools, job aids; provide TA and financial support in the training of health care workers in HIV careservices; support the decentralization of comprehensive care services to the PHUs, health centers andclinics; and work with the MOH SNAP to ensure successful implementation of pre-ART services in the34 facilities. EGPAF will work with health care workers to ensure early identification of HIV-positivepregnant women, partners and children at all care points and enrollment into pre-ART care. This will bedone through mentorship and support supervision to health workers to provide PIHTC at all points ofcontact; encouraging use of patient hand held cards; and encouraging a family centered approach tocare and support. EGPAF will pilot use of family files for care in a few high volume sites. EGPAF will workwith health care workers to ensure prompt clinical and immunological assessment of HIV-positivepregnant/lactating women and other individuals; pain assessment and management; screening for TBand OIs; prophylaxis with CTX, INH; regularly assess for ART eligibility; and ensure all HIV-positiveindividuals are assessed nutritionally. EGPAF will strengthen the use of patient cards and referral formsfor effective referral linkages; work closely with expert patients and Mentor Mothers; establish and

strengthen referral linkages including MNCH/FP; improve follow-up counseling to improve adherence;work with health workers to identify defaulting and lost to follow up clients; and develop mechanisms totrace clients. EGPAF will provide regular visits for data review, QI activities, case management andmentoring. EGPAF and partners will support psychosocial services through the formation of supportgroups for women and men living with HIV.

Strategic Area Budget Code Planned Amount

Clinical services will be supported in 39 health facilities in the four regions of the country while thepsychosocial services will be mainly through establishment of support groups for children living with HIV.EGPAF will participate in the Pediatric HIV sub-TWG; provide TA in the review and development ofnational pediatric HIV care tools; provide TA and financial support in the training of health care workers inHIV care services; and provide TA in the orientation of health workers on the revised Pediatric HIVguidelines. EGPAF will work with health care workers to ensure early identification of HIV exposed andinfected 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 throughDNA PCR using DBS for exposed infants at every entry point within MCH; provide pediatric PITC usingantibody tests for children >12 months and strengthen exit test at 18 months; and use of presumptivediagnosis of HIV. EGPAF will work with health care workers to ensure proper provision of infant feedingcounseling; routine immunizations, growth monitoring and developmental assessment for all infants andchildren; prompt clinical and immunological assessment of HIV-positive children; pain assessment andmanagement; screening for TB and OIs; prophylaxis with NVP, CTX, INH; regularly assess for ARTeligibility; and ensure all early ART initiation for all HIV-positive infant and children less than 2. EGPAFwill strengthen the use of patient cards and referral forms for effective referral linkages; work closely withexpert patients and Mentor Mothers; establish and strengthen referral linkages between services andclinics; improve follow-up counseling to improve adherence; work with health workers to utilize pre-ARTand appointment registers to identify defaulting and lost to follow up children; and develop mechanismsto trace clients. EGPAF will support psychosocial services through the formation of support groups forchildren living with HIV. 2 support groups will be established in the two years bringing the total of thesupport groups for children to 6.

Strategic Area Budget Code Planned Amount

At present EGPAF is supporting 93 sites. By the end of FY2012 EGPAF will add 20 new facilities making

a total of 113 health facilities. In FY2013 EGPAF will expand its support to 10 high volume private sectorfacilities. EPAS will accelerate its support to optimize comprehensive PMTCT services using the fourPMTCT prongs: Prong 1: Strengthen PITC for pregnant women at first contact and PITC forcouples/partners and retesting of HIV negative pregnant women in ANC, labor and delivery and afterdelivery; strengthen prevention for HIV negative women to keep them HIV negative and identificationsero-discordant couples and linking them to HIV care. Prong 2: Integrate family planning services intoART services in 6 PHUs. Prong 3 & 4: Strengthen health workers skills on CD4 testing and clinicalstaging to determine ART eligibility; advocate for the procurement of point of care CD4 machines;support implementation of the more efficacious ARVs for HIV positive women (option A); supporteffective implementation of extended infant NVP prophylaxis for breast feeding infants; strengthen theimplementation of the national infant feeding guidelines to maximize HIV free survival; integrateneonatal/adult male circumcision messages into PMTCT counseling and training; support provision ofessential HIV care for pregnant women and HIV exposed infants according to the nationalcomprehensive HIV Care Package; and strengthen follow up care along the continuum of ANC, labor anddelivery and post partum care for pregnant and breastfeeding women, their partners and family membersthrough integration and linkages of comprehensive PMTCT services within MCH settings, using mobilephones, fast tracking of HIV positive pregnant and breastfeeding women eligible for ART initiation, strongpeer support such as mentor mothers and expert clients and support groups, and use of hand heldmother and child health cards. EGPAF and its partners will intensify community-level interventionsincluding: strengthening linkages between communities and facilities, women's and men's supportgroups, male dialogues, community family days and mass media campaigns as strategies to generatedemand for HTC and PMTCT.

Strategic Area Budget Code Planned Amount

EGPAF will support the provision of comprehensive and integrated HIV treatment in 7 PHUs and oneclinic, focusing on pregnant women and children less than 2 years. Eligible HIV-positive pregnant womenwill be initiated on ART in the PHUs. Clients initiated on ART at the PHUs will be kept at the PHU forapproximately 2 years after delivery to allow for continuity of services for both mother and child in thePHU/MCH setting and then transferred out to the main ART centers. Through mentorship and supportsupervision, EGPAF will ensure sustainability of treatment services at all supported sites. National levelactivities include: participate in the Care and Treatment TWG and sub-TWGs to help review and plan forHIV treatment services; provide TA to MOH in the review/development of national ART policies,guidelines, job aids, M&E tools; and support MOH in the roll out of the Nurse-Led ART Initiation(NARTIS) through training, mentorship, and support supervision of nurses. EGPAF will continue to

support sites in improving uptake and quality of HIV treatment services as follows: work closely withmentor mothers and expert clients to ensure that eligible individuals are adequately prepared for ART;work with and support health workers in drug stock management to ensure uninterrupted supply of ARVsand other OI drugs; support and mentor health care workers to ensure proper follow up and monitoring ofpatients on ART and management of any side effects or complications that might arise and identify anytreatment failures; and encourage adherence to treatment by regular ongoing ART adherence counselingand active tracing of defaulters and lost to follow up patients using mobile telephones. EGPAF will workwith CBOs to track patients defaulting treatment in the community and support proper documentation oftreatment services provided in the facilities and timely reporting of data to the national M&E unit. EGPAFwill provide regular visits to the sites to review data and perform QI activities; assist in case management;and mentor health workers in HIV treatment. EGPAF will support QI approaches for HIV treatmentservices to improve data use at through formation and strengthening of multi-disciplinary teams at sitelevel.

Strategic Area Budget Code Planned Amount

EGPAF will support the provision of comprehensive and integrated HIV treatment for infants and childrenless than 2 years in 7 PHUs and one clinic. Children initiated on ART at the PHUs will be kept at the PHUfor approximately 2 years after delivery to allow for continuity of services for both mother and child in thePHU/MCH setting and then transferred out to the main ART centers. Through mentorship and supportsupervision, EGPAF will ensure sustainability of treatment services at all supported sites. National levelactivities: participate in the Pediatric HIV sub-TWG to help review and plan for HIV treatment services forinfants and children; provide TA to MOH in the review/development of national ART policies, guidelines,job aids, M&E tools; support MOH in the roll out of the Nurse-Led ART Initiation (NARTIS) throughtraining, mentorship, and support supervision of nurses; and support training of nurses in basic IMAIwhich includes pediatric ART. EGPAF will continue to support sites in improving uptake and quality ofHIV treatment for children services as follows: work closely with mentor mothers and expert clients toensure that caregivers are adequately counseled and prepared for ART to improve uptake andadherence of ART among children less than 2 years; provide onsite trainings on pediatric phlebotomy toimprove immunologic staging of infected infants and children; work with and support health workers indrug stock management to ensure uninterrupted supply of ARVs and other OI drugs; support and mentorhealth care workers to ensure proper follow up and monitoring of children on ART and management ofany side effects or complications that might arise; and identify any treatment failures; encourageadherence to treatment by regular ongoing ART adherence counseling and active tracing of defaultersand lost to follow up patients using mobile telephones; establish facility based support groups for children

living with HIV to help improve adherence to treatment; and support proper documentation of treatmentservices provided in the facilities and timely reporting of data to the national M&E unit.