The broad objectives of Elimination of Pediatric AIDS in Swaziland (EPAS ) are to: 1) achieve universal access to PMTCT with expanded delivery of services to achieve elimination of mother-to-child transmission of HIV; 2) support and sustain s quality, comprehensive, integrated PMTCT services at GKOS health facilities; 3) strengthen the National Health System in accordance with the MOHs plans for PMTCT; and 4) promote the regular review and improvement of MOHs policies, protocols and guidelines for PMTCT services. 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 for EPAS. EGPAF works in all the 4 regions serving primarily HIV pregnant women, their spouses, children and other family members. EPAS supported the MOH to achieve 100% coverage of government health facilities with PMTCT services in 2011. Combined with additional FBO and private sector facility coverage, this will result in EGPAFs support reaching 83% of pregnant women in Swaziland. EGPAFs approach to building national capacity and sustainability ensures cost-efficient programming. The decentralization of integrated services for HIV prevention, care and treatment in MCH settings brings all services under one roof, saving costs on separate buildings, staff, and maintenance. Seconding program staff to the MOH with ultimate absorption by the MOH will have an added value of ensuring long-term ownership and sustainability. To minimize disruption of service provision caused by the MOH policy of frequent staff rotation, EGPAF will continue to provide ongoing training and site support. Progress and results will be tracked through a comprehensive performance monitoring plan.

Clinical HIV care services will be supported in 34 health facilities in the four regions while the psychosocial support services will be mainly through establishment of support groups for people living with HIV. EGPAF will participate in the HIV Care and treatment TWG and its sub-TWGs to help review and 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 care services; support the decentralization of comprehensive care services to the PHUs, health centers and clinics; and work with the MOH SNAP to ensure successful implementation of pre-ART services in the 34 facilities. EGPAF will work with health care workers to ensure early identification of HIV-positive pregnant women, partners and children at all care points and enrollment into pre-ART care. This will be done through mentorship and support supervision to health workers to provide PIHTC at all points of contact; encouraging use of patient hand held cards; and encouraging a family centered approach to care and support. EGPAF will pilot use of family files for care in a few high volume sites. EGPAF will work with health care workers to ensure prompt clinical and immunological assessment of HIV-positive pregnant/lactating women and other individuals; pain assessment and management; screening for TB and OIs; prophylaxis with CTX, INH; regularly assess for ART eligibility; and ensure all HIV-positive individuals are assessed nutritionally. EGPAF will strengthen the use of patient cards and referral forms for 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 to trace clients. EGPAF will provide regular visits for data review, QI activities, case management and mentoring. EGPAF and partners will support psychosocial services through the formation of support groups for women and men living with HIV.

Clinical services will be supported in 39 health facilities in the four regions of the country while the psychosocial 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 of national pediatric HIV care tools; provide TA and financial support in the training of health care workers in HIV care services; and provide TA in the orientation of health workers on the revised Pediatric HIV guidelines. EGPAF will work with health care workers to ensure early identification of HIV exposed and infected 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 and strengthen exit test at 18 months; and use of presumptive diagnosis of HIV. EGPAF will work with health care workers to ensure proper provision of infant feeding counseling; routine immunizations, growth monitoring and developmental assessment for all infants and children; prompt clinical and immunological assessment of HIV-positive children; pain assessment and management; screening for TB and OIs; prophylaxis with NVP, CTX, INH; regularly assess for ART eligibility; and ensure all early ART initiation for all HIV-positive infant and children less than 2. EGPAF will strengthen the use of patient cards and referral forms for effective referral linkages; work closely with expert patients and Mentor Mothers; 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 children; and develop mechanisms to trace clients. EGPAF will support psychosocial services through the formation of support groups for children living with HIV. 2 support groups will be established in the two years bringing the total of the support groups for children to 6.

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 sector facilities. EPAS will accelerate its support to optimize comprehensive PMTCT services using the four PMTCT prongs: Prong 1: Strengthen PITC for pregnant women at first contact and PITC for couples/partners and retesting of HIV negative pregnant women in ANC, labor and delivery and after delivery; strengthen prevention for HIV negative women to keep them HIV negative and identification sero-discordant couples and linking them to HIV care. Prong 2: Integrate family planning services into ART services in 6 PHUs. Prong 3 & 4: Strengthen health workers skills on CD4 testing and clinical staging 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); support effective implementation of extended infant NVP prophylaxis for breast feeding infants; strengthen the implementation of the national infant feeding guidelines to maximize HIV free survival; integrate neonatal/adult male circumcision messages into PMTCT counseling and training; support provision of essential HIV care for pregnant women and HIV exposed infants according to the national comprehensive HIV Care Package; and strengthen follow up care along the continuum of ANC, labor and delivery and post partum care for pregnant and breastfeeding women, their partners and family members through integration and linkages of comprehensive PMTCT services within MCH settings, using mobile phones, fast tracking of HIV positive pregnant and breastfeeding women eligible for ART initiation, strong peer support such as mentor mothers and expert clients and support groups, and use of hand held mother and child health cards. EGPAF and its partners will intensify community-level interventions including: strengthening linkages between communities and facilities, womens and mens support groups, male dialogues, community family days and mass media campaigns as strategies to generate demand for HTC and PMTCT.

EGPAF will support the provision of comprehensive and integrated HIV treatment for infants and children less than 2 years in 7 PHUs and one clinic. Children initiated on ART at the PHUs will be kept at the PHU for approximately 2 years after delivery to allow for continuity of services for both mother and child in the PHU/MCH setting and then transferred out to the main ART centers. Through mentorship and support supervision, EGPAF will ensure sustainability of treatment services at all supported sites. National level activities: participate in the Pediatric HIV sub-TWG to help review and plan for HIV treatment services for infants 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) through training, mentorship, and support supervision of nurses; and support training of nurses in basic IMAI which includes pediatric ART. EGPAF will continue to support sites in improving uptake and quality of HIV treatment for children services as follows: work closely with mentor mothers and expert clients to ensure that caregivers are adequately counseled and prepared for ART to improve uptake and adherence of ART among children less than 2 years; provide onsite trainings on pediatric phlebotomy to improve immunologic staging of infected infants and children; 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 children on ART and management of any side effects or complications that might arise; and identify any treatment failures; encourage adherence to treatment by regular ongoing ART adherence counseling and active tracing of defaulters and 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 treatment services provided in the facilities and timely reporting of data to the national M&E unit.