For COP 2012, ICAP aims to continue working closely with the Government of Swazilands Ministry of Health (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 up the self-sufficiency of the Regional Health Management Teams (RHMTs). The community linkages program 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 the country, Hhohho, Manzini and Lubombo. The target population for service delivery is an estimated 140,000 PLHIV and their family members. The target populations for capacity building include the MOH at national, regional, site and community (e.g. RHMs) levels, as well as local community groups. ICAP's main strategy is to directly support and strengthen existing national systems and to avoid any parallel efforts. Although a portion of staffing supplementation is required to achieve scale up objectives within the project time frame, most of the program effort has been devoted to strengthen national policies and guidelines, existing MOH cadres and service delivery, M&E and supervision systems. In line with this approach, the community linkages program will increasingly shift its focus to engaging and better linking RHMs to health facilities. A major thrust during this period with management capacity development support from Pact will be to ensure the self-sufficiency of the RHMTs in managing and supervising the clinics.

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 the Package of Care (POC), strengthened adherence and psychosocial support (APS) and PwP, the Expert Client initiative, clinical mentoring and supportive supervision, as well as the community linkages program. A major ICAP effort will include the phased transfer of full responsibility for facility support to the RHMTs. [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 service delivery at sites. [PwP] Based on the findings of the PwP technical review and national strategy scheduled for year 3, comprehensive PwP services will be more systematically integrated into routine HIV care within all health facilities and community linkages activities. This includes couples HIV testing and counseling (CHTC); treatment as prevention for discordant couples; identification and prevention education for discordant couples; condom promotion, reducing unintended pregnancies, early identification and treatment of sexually transmitted infections as well as nutrition counseling and collaboration with the World Food Programme on food per prescription. [EXPERT CLIENTS] ICAP will continue to support Expert Clients at health facilities to work with patients in treatment literacy and will expand their scope to include a greater focus on PwP, TB screening and encouraging clients to bring family members in for testing. [CLINICAL MENTORING AND SUPPORTIVE SUPERVISION] ICAP will support the RHMTs to develop a set of performance-related criteria to assess each facilitys need for clinical mentoring and supportive supervision. Stronger performing facilities might be graduated to quarterly mentoring visits while weaker facilities may be visited twice each month. [COMMUNITY LINKAGES] ICAP will support greater involvement of RHMs in tracking clients who miss their appointments. ICAP will train over 2,000 RHMs and assign a clinic level RHM Coordinator to provide supportive supervision.

ICAP will continue to work in close collaboration with URC and the National TB Program to fully integrate sustainable TB services within ART sites. In particular, ICAP will focus on scaling up TB screening and INH 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 Expert Clients 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 Clients and 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 renovations as required.

Prioritization and separation of TB suspects.

Many of the government owned health facilities in Swaziland are inadequate for current needs. Some are 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 management facilities are often completely lacking. As a result, patient flow is inefficient and, with the high rates of TB and poor infection control, often dangerous to both patients and staff. The funds in this project will be used to undertake minor renovations to facilities to bring them up to minimum standards and provide the basic furniture needed to run the facility to support quality chronic care services (eg, filing cabinets). The funds will be leveraged with resources from the MOH and other donors like the World Bank, Clinton Foundation and MSF.

In addition to the main areas of support described under Adult Care and Support, ICAP will continue to work with Baylor College to support strengthened capacity for pediatric HIV service provision in all supported 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 and community strategies. This will include better tracking, systematic use of cell phones to send follow up message 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 and care 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.

ICAP provides a range of services to augment the delivery of services within the MOH.

Through a salary support mechanism to the Swaziland National Aids Program they provide

1.ART program management support which helps standardize the delivery of services throughout the health sector.

2.Data and research expertise to define data to be collected and to ensure collection and collation of information to direct program initiatives and measure the impact of interventions in HIV specific areas.

3.Advise on systems for clinical mentoring at the national level.

ICAP also supports the Regional Health Management Teams through regional mentoring teams which provide updates and mentorship to doctors, nurses, data clerks and M+E within three of the four regions within Swaziland.

To motivate ART clients on adherence and compliance ICAP supports a cadre of 84 expert-clients who are HIV positive individuals who work on a daily basis at the ART centers to inform clients, through firsthand experience, on potential situations that may arise as they deal with their condition on a day to day basis. They also encourage clients to adhere to treatment requirements.

In addition ICAP working closely with the planning unit and the micro-projects department to provide expertise to identify priority renovation sites among the clinics and health centers in three regions, and then to develop the bill of quantities and select and monitor the contractors.

In addition to all of the work described above under Adult Care and Support, the additional activities listed below will be undertaken in support of Adult Treatment. (1) Expansion in numbers reached with ART initiation: through ICAP support, it is expected that more than 12,000 people will be initiated on ART in FY 2013 and nearly 64,000 people will be currently enrolled on ART. This level of enrollment slightly surpasses 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 roll out of nurse-initiated ART to most facilities, including expansion of pediatric ART initiation and providing training to all registered nurses. (3) ICAP will support full implementation of treatment initiation for clients with a CD4 count of 350 or lower. This will include development and implementation of a communication strategy on the lower treatment threshold, targeting the community through HCWs and through traditional community structures. (4) Quality of service: The major thrust of effort during this two year period will be on improved and sustained quality of ART services. Multi-disciplinary teams will be supported to consolidate their skills in clinical systems mentoring and ongoing quality improvement. (5) Prisons and Uniformed Services: ICAP will continue its effort to establish quality on-site ART and effective linkages for the prison populations and uniformed services in need of HIV care and treatment.(6) Treatment as Prevention: ICAP will work with MOH and other stakeholders to improve areas in the health system that needs 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. Some are 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 management facilities are often completely lacking. As a result, patient flow is inefficient and, with the high rates of TB and poor infection control, often dangerous to both patients and staff. The funds in this project will be used to undertake minor renovations to facilities to bring them up to minimum standards and provide the basic furniture needed to run the facility to support quality chronic care services (eg, filing cabinets). The funds will be leveraged with resources from the MOH and other donors like the World Bank, Clinton Foundation and MSF.

In FY 2013, ICAP expects to support the initiation of more than 1,600 children under the age of 15 years on 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 with Baylor 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.