PLUS UP FUNDING: "Expanding PMTCT services in Private Health Sectors in Ethiopia

This is a new 2007 activity; funding will be transferred through EPHA to the Ethiopian Society of Obstetricians and Gynecologists (ESOG). ESOG is a local non-profit professional organization established in 1992, including nearly all Ethiopian obstetricians and gynecologists as members. The society has previously effectively implemented several safe motherhood and RH projects in collaboration with national and international organizations. " "This activity will support expansion of PMTCT services in private hospitals and special clinics with Maternal and Child Health (MCH) services in Addis Ababa. Expansion of PMTCT services to all public, private and non-governmental facilities that provide MCH services is a strategy employed by the GOE to scale up HIV/AIDS prevention, care and treatment services. In Ethiopia, the private sector is expanding rapidly, making significant contributions to improved health care access, particularly in urban populations. However, little effort has been made to involve the private sector in the national PMTCT program. Nearly a third of Ethiopia's obstetricians and gynecologists are providing RH services at private health facilities, and the majority of these are in Addis Ababa. Obstetricians and gynecologists could lead reproductive health promotion, and therefore, ESOG has a comparative advantage to implement PMTCT programs in the private health sector. " "According to the AIDS in Ethiopia Sixth Report, there were 135,904 ANC clients in Addis Ababa during the Ethiopian fiscal year 1998 (2005/2006), and only 19,541 (14.4%) of pregnant women were tested for HIV, demonstrating that the majority of women in Addis Ababa do not have access to PMTCT services.

Although many women receive ANC and delivery services at private health facilities, PMTCT services in Addis Ababa have to date been limited mainly to public facilities. According to the National Health and Health Related Indicators Report (1998 E.C. or 2005/6), there were 20 hospitals, 30 special clinics and 93 higher clinics privately owned in Addis Ababa, indicating urgent need to expand PMTCT services in the private facilities. " "In order to scale up PMTCT, ESOG will undertake the following activities: ESOG will provide technical input and guidance to the FMOH and regional health bureaus, supporting initiatives to expand PMTCT services in the private sector. ESOG will conduct a national pre-intervention survey: KAP on PMTCT among health professionals in private facilities, and a post survey workshop to help strategize implementation of the PMTCT program. Post-intervention, ESOG will conduct a workshop to disseminate findings, share experiences and direct future implementation of PMTCT programs at private health facilities. Findings will be published in the society's journal (The Ethiopian Journal of Reproductive Health).

" At facility level, ESOG will support site-level PMTCT activities in collaboration with the MOH, Addis Ababa regional health bureau, JHPIEGO and JHU. In FY07, ESOG will conduct staff training and supervision, and implementation of PMTCT programs at 20 private hospitals and five special clinics in Addis Ababa. ESOG will ensure that women enrolled in PMTCT are rapidly staged, receive care and treatment services, and are referred on when needed. These private facilities provide ANC services to an estimated 15,000 women annually.

Formative Assessment MSM and HIV Prevention

This is a new activity in COP07.

This project aims to assess the importance of men who have sex with men (MSM) in HIV/AIDS and STI transmission in Ethiopia.

Sex between men occurs all over the world. In Europe, America and Asia the lifetime prevalence of MSM ranges between 3 and 20%. Recent evidence highlights increasing risk levels and vulnerability in this group of people in a variety of developing countries. As a result of stigma and discrimination, male-to-male sex is frequently denied, forcing the HIV epidemic underground and threatening the health of MSM, and their male and female partners. Studies in certain developing countries indicate that the prevalence of HIV and STI among MSM was as high as 14.4% and 25% respectively. There are only a few epidemiological studies on HIV and vulnerability to sexually transmitted diseases (STD) among MSM in sub-Saharan Africa.

Even though different groups have been identified as most at risk for HIV transmission, there is little information about the MSM and their HIV risk behavior in Ethiopia. The extent of MSM and their behavior in Ethiopia is not well understood. As in most developing countries MSM community would tend to congregate in cities, in places where many NGO with expatriates are operating and along major tourist travel corridors and destinations. A recent pilot study in Addis Ababa among MSM confirms that this population has long existed but in covert ways. MSM starts at an early age and is on the increase apparently. MSM individuals were found to have misconception about HIV risk; some believe sex with men has lower risk of infection than heterosexual sex.

In COP07, an assessment of MSM and their HIV status will be carried out in Addis Ababa, Awassa, and Bahir Dar. The objective of this assessment is to understand the extent of MSM and importance of MSM in HIV transmission in Ethiopia. Due to the hidden nature of this population and difficulty in identifying the individuals, a "snowball" approach will be used for MSM. In snowball sampling, key informants in a subpopulation identify other members of their community, or in this case other locations where MSM congregate. The people in each cluster are contacted, and they in turn identify further contacts. The process goes on until an adequate number of MSM individuals are achieved and/or the number of sites exhausted. The assessment will use both qualitative and quantitative methods. Subjects will be linked to STI treatment, CT/ ART.

Added July 2007 Reprogramming: This supplemental request is for confidential clinic for MARPs. There is little information on the burden of specific STIs etiology among MARPs in Ethiopia. In 06 it was planned to conduct the Magnitude of HIV/STIs among MARPS in Rural Hot Spots: The HIV epidemic in Ethiopia is heterogeneous among regions and there exist rural high prevalence areas known as "rural hot spots. The study has been undertaken on the magnitude of HIV but it was not possible to conduct biological survey on treatable STIs etiology. Based on the evaluation on MAPRS on Rural Hotspots confidential clinics will be established in 07 with local partner. The partner is to be identified and Funding opportunity announcement for potential partner is advertised. Therefore this plus up fund will be given to a potential partner that will run the confidential clinics for STIs and conduct a biological survey among MARPS as part of their activity. Laboratory reagents and laboratory processing fees will be paid from the plus up fund.

PLUS UP FUNDING: This activity links to the Basic Care Package Provision Program. This supplemental fund will be used to conduct a systematic, quantitative program evaluation of implementation of the basic care package in Ethiopia. The goal is to determine the extent to which the package has been provided to persons enrolled in HIV care. It will entail working closely with CDC-Atlanta and the Ethiopian Public Health Association (EPHA) to design and conduct programmatic evaluation through a multi-stage scientific sampling process that will establish a study population representative of all patients enrolled in HIV care in Ethiopia. Trained study staff will interview patients, conduct chart reviews and make home visits to collect water samples and observe usage of items in homes to establish the extent to which the basic care package is being used within the study population. The results will then be analyzed to project an overall implementation rate for each element of Ethiopia's basic care package. Such analysis will allow identification of factors associated with incomplete or with full implementation of the basic care package; furthermore it will identify gaps in the use of various commodities necessary for the basic care package, or inadequate facility-level promotion of use, and identify ways to improve program implementation. Finally, this project will build capacity for program evaluation within Ethiopian Public Health Association.

Assessment of Utilization and Quality of HVCT Services in Ethiopia

This activity initially planned in COP 05 but not funded. It is submitted again for COP 07 because of its importance for the scale up of HCT service and recommendation from TA visit. Expansion and strengthening of VCT services and new sites in FY 2004, 2005, and 2006 through PEPFAR assistance has increased access for HIV Counseling and testing . VCT services under the PEPFAR Ethiopia COP 06 assistance expanded to 600 sites including hospitals and health centers and planned to increase to more than 800 HCT sites by COP 07. The very rapid expansion of HCT services has through numerous funding sources has led to concerns regarding uneven quality across sites.

Site assessment, supervision and review meeting findings showed that there are major issues that identified problems and constraints that influenced utilization and quality of services: (1) Sites are not equally initiated the service for various reasons. (2) Number of clients served by the sites varies from place to place. Low utilization VCT services noted in some regions. (3) Little is known about the performance of counselors against gained knowledge and skills in the training and the standard. (4) In regard to categories of VCT service providers, almost 100% of service providers in the sites are health care providers mainly nurses. Most of them work in rotation and they are busy with their primary clinical responsibility. Thus, affect the provision of VCT service in the sites. (5) Record keeping, timely reporting and utilization of data is weak in almost all sites. (6) No clear strategies for VCT promotion at the National and regional level. (7) Supply chain management is the major issue that affects the delivery of continuous VCT service (8) Quality assurance (QA) of HIV counseling and testing: practically no external quality control of HIV rapid test. QA of counseling also is not available. (9) Other factors that affect the quality of the service are lack of infrastructure (room, equipment…), high turnover of trained counselors, irregularity test kits supply, logistics, administration and others. Problems and constraints mentioned above also needs to be validated and identified the root cause of the problem to provide appropriate remedy for the existing sites and utilize lesson learned for future programming.

This comprehensive will address quality of service and its utilization and acceptability by the community and clients. The assessment targets health integrated, freestanding and other form HCT sites supported by PEPFAR Ethiopia.

Added value of the intended activities includes: (1) Helps in identifying focus area in improving HCT service (2) Identifies issues for the development of VCT promotional strategies (3) Uptake of counseling and testing services will be increased. (4) Through this program a standard service delivery procedure will be established for HCT service points

Activities will include the following: (1) Identify competent contractor to do the evaluation (2) Conduct close follow up of the targeted evaluation as per the scope of work (3) Assist in preparation of the evaluation report

Laboratory Capacity Development

This is a continuing activity from COP05 and COP06. As of April 2006, EPHA received 100% of COP06 funds and is on track according to the original work plan. We have increased funding based on the achievements from COP05 and partially COP06. The 50% budget increment reflects expansion of the existing activities.

PEPFAR Ethiopia will achieve its objectives with an efficient laboratory system in place and professional skill in diagnostic as well as quality assurance activities. Implementing effective lab policy, strengthening lab system/networking, establishing the Ethiopian Public Health Laboratory Association (EPHLA) and enhancing the capacity of laboratory professionals are also critical high laboratory standards. These activities will in turn contribute to the maintenance of optimum laboratory provision and this in turn to high quality of ART services in the Ethiopia.

In COP06, the EPHLA constitution has been finalized and approved by the Ministry of Justice. Support has been provided to technical working groups on drafting national laboratory policy and QA development. The draft laboratory policy is in place. Guidelines for establishing public health laboratory services in the country have been drafted.

During FY07, EPHA will continue supporting the local organizational capacity development, through laboratory education, workplace HIV/AIDS interventions, publications, dissemination of research findings, organizing laboratory related conferences. EPHA will continue supporting laboratory policy and national guidelines for their implementation. It will also provide technical assistance in local laboratory capacity development including strengthening of public health laboratory systems in Ethiopia. All these activities will be implemented in partnership with EPHLA.

The EPHLA will work closely with APHL for further development of public health laboratory that support HIV/AIDS program and continuing education to upgrade and accredit laboratory professionals. EPHLA will also closely work with Joint Clinical International (JCI).

Capacity Building for Evidence-based Decision Making, Generation and Dissemination of SI

This narrative consists of three merged activities to be performed by EPHA. This is a continuing activity from FY06. This activity is linked with National HMIS, M&E capacity building activity (5714), and Strengthening National Surveillance Systems (5717 and 5585). The partner received 50% of FY06 funds and is on track according to the original targets and work plan. We have raised the funding based on the partner performance and a major expansion of the activity planned for FY07.

In order to successfully develop and interpret SI and implement evidence-based HIV/AIDS programs and policies, Ethiopian HIV/AIDS program managers and policymakers must be able to generate, analyze, interpret quantitative information, critically evaluate and use data generated by epidemiologic studies, surveillance, program monitoring, targeted evaluations, and similar efforts. Additionally, it is essential to develop expertise in the country in field-based epidemiology and laboratory management practice as an integral component of developing an integrated public health system that develops sustainable public health and HIV/AIDS practices. Because of its investment in HIV/AIDS programs, PEPFAR Ethiopia and its partners are uniquely positioned to assist with this type of human capacity development. This activity ensures that USG investments in data collection and programs are amplified through the critical use of data for program planning.

In COP06, EPHA was provided with supplemental funds to conduct a one year Leadership in Strategic Information (LSI) training program. The objective was to enable program managers to critically evaluate and use data for decision making and for designing and implementing evidence-based programs. A diploma-granting program was conducted to train 30 program managers in a series of 5 one-week courses per year, based on distinct quantitative modules including: HIV/AIDS strategies and interventions, descriptive and analytic epidemiology, surveillance and monitoring and evaluation. This activity includes the provision of intensive follow-up support to the trained individuals.

In COP07, EPHA will continue working with PEPFAR Ethiopia to support the LSI training program. In addition, EPHA will develop a two-year field-based, service-oriented Master's degree program to teach greater analytic and management skills to potential leaders. This program, in addition to expanding on the components of the one-year program, will incorporate courses in advanced analytic epidemiology, public health program management, laboratory management, and communications. The masters program will train 10-20 medical epidemiologists and laboratory management personnel in a series of 5-6 courses over the two year period that will incorporate a total of 12 weeks of didactic training evaluated through a traditional examination process. The students will then be attached to field-based activities which include specific investigations, evaluations, and research as a part of a thesis project. The program will be coordinated with university courses but relies on a field orientation that provides practical experience and service to the ministry.

AIDS Mortality Surveillance ($450,000) This is a continuing activity from FY06. This activity is linked with the Strengthening of the Surveillance Systems activities (5717 and 5585). We recently transferred 25% of its FY06 funding. However, the partner is on track in the preparatory works according to the original targets and work plan. The funding for FY07 is raised to support a major expansion based on the very good performance of the partner in other activities.

Registration of deaths by age, sex and cause, and calculating mortality levels and differentials are fundamental to evidence-based health policy, monitoring and evaluation. With the expansion of ART programs, vital registration data are essential for monitoring HIV/AIDS, not only because prevalence data will gradually lose informative value, but because the system is necessary for monitoring the impact of treatment regimes. AIDS mortality trends are the ultimate outcome measures.

In COP06, with the supplemental received from PEPFAR, EPHA has started to support the Addis Ababa Mortality Surveillance Project (AAMSP) to monitor population level impact of ART via analyses of age and sex specific trends in AIDS mortality in Addis Ababa City.

In COP07, EPHA will continue to support AAMSP. The activity will expand to three

additional semi-urban sites which are collecting vital statistics for other purposes. On expansion of the project, mortality data will be collected from burial sites and compared with those from the already existing and ongoing demographic surveys in the sites with a focus on monitoring AIDS mortality and the population level impact of ART. The potential benefits of the vital events registration extends beyond monitoring the effect of ARV therapy on AIDS related mortality rate. Data collected from these sites will inform policy makers, program managers and the society at large on the affect of AIDS on deaths and on the affect of ART on delaying such deaths. The project will be implemented in collaboration with the EPHA regional chapters at Addis Ababa, Jimma and Gondar Universities. Building the capacity of these organizations will assist in in impriving their sustainability after PEPFAR.

Generation and Dissemination of Strategic Information ($400,000) This is a continuing activity started in FY05. Although the partner had a good track in the past we have kept the FY07 funds flat lined. In COP06, EPHA supported the generation and dissemination of strategic information by supporting postgraduate theses in areas of HIV/AIDS, STI and tuberculosis to enhance M&E. The dissemination of surveillance data, best practices and study findings through the EPHA annual conference and publications were the major accomplishments during that fiscal year. EPHA also provided support to postgraduate M&E program at Jimma University.

In COP07, EPHA will continue supporting the generation and dissemination of SI through its annual conference, Master's theses and publications. Additional activities will concentrate on developing the association's capacity to manage systems for the generation, utilization and dissemination of strategic information. An aspect of the capacity building will be improving staffing and providing training to it. The following programmatic investigations will be supported to permit post-graduate students to carry out their graduate thesis work. These include: (1) reasons for first intercourse among Ethiopian youth; (2) HIV test results among premarital couples; (3) comparative situation analysis of PMTCT in Ethiopia using ANC with PMTCT data; (4) pre-martial testing results and discordant rates; (5) barriers to and facilitators of behavior change among the armed forces; (6) the impact of malnutrition on survival in HIV+ patients starting antiretroviral therapy; (7) organizational assessment to measure human capacity and needs in terms of organizational structure; (8) factors contributing to increase in the uptake of VCT among the youth; and (9) factors that increase risk behaviors in the work place.

Assessment of Routes of Spread of HIV from Hot Spots

This is a new activity for FY07. The 2005 round of ANC-based sentinel site HIV surveillance had revealed that there are some "hot spots" in rural areas with high HIV prevalence rates. The surrounding rural areas are believed to be affected by the transmission of HIV from the hot spots. The reasons behind these high HIV prevalence rates in the rural hot spots will be investigated. Particular attention will be paid to the sexual networks and other routes that spread HIV infection from the hot spots to the surrounding rural areas.

Two questions will be answered by this investigation. The first is what types of sexual networks and relationships exist among people in these rural "hot spots" and those in the rural areas surrounding the hot spots? The second one is which of the networks are associated with high HIV transmission from the hot spots to the surrounding rural areas?

Cross-sectional studies will be conducted in selected sites and their surrounding rural areas. An attempt will be made to determine the types of sexual networks and association between risk of infection of network members and their position within the sexual networks. Both epidemiological and ethnographic factors will be studied and structural characteristics of the networks identified. Comparisons will be maded of the risk factors in smaller disconnected components (commercial sex workers, in school youth) with a large network of general populations in both areas.

Primary focus will be on the general as well as specific population groups and bridging populations in rural hot spots. Adequate sample sizes will be calculated for each group and for each site involved.

The Effects of PEPFAR Supported Interventions on the Health Sector

The national response to the HIV epidemic has included formulating several policies, establishment of establishing the national and regional HAPCO, and introduction of several types of services in the health facilities. Although many resources have supported the implementation of the multi-sector response to HIV/AIDS, little is known about the effects of all the HIV/AIDS activities in strengthening the health system of the country. This study will attempt to generate information on how the HIV/AIDS activities (including those supported by PEPFAR Ethiopia have strengthened the countriy's health system.

The evaluation question is how the national HIV/AIDS activities and interventions in general, and those of PEPFAR, in particular, have helped in strengthening the national health systems?

The study will use standard and adapted data collection instruments to capture data on national level inputs and outputs of HIV/AIDS related activities through out the period of PEPFAR Ethiopia's existence. Data will be collected by making reviews of documents on program performance and financial and property reports of relevant organizations. A study will be conducted by using qualitative methods such as focus group discussions and interviews with key informants to assess the institutional capacities of these organizations with and with out the effects of HIV/AIDS interventions in the past as well as recent years. The outcomes and affect of these activities on the national health system will be assessed. The level of contributions of PEPFAR Ethiopia towards this will be determined.

Focus will be given to interviewing heads of organizations, administrators, program managers, financial managers and planners in MOH, NHAPCO, RHB and RHAPCO. People in each of the organizations will be interviewed individually or in groups to obtain the required information. Additional data sources and documents will be obtained and reviewed through formal requests by the investigators.