This is a continuing activity from FY06. I-TECH has been working with JHPIEGO in providing site level support for hospital-based PMTCT programs at 32 hospitals in Amhara, Tigray and Afar regions. The funding level for FY07 has increased from the FY06 amount, in part because I-TECH has taken additional PMTCT responsibilities including training of staff in PMTCT service areas, formerly carried out by JHPIEGO, and in part in response to recommendations from the OGAC PMTCT TA visit held in July 2006.

Their major areas of emphasis include the use of the maternal child health (MCH) platform to identify HIV-infected women and families, providing PMTCT interventions, and engaging HIV-infected patients in care and treatment. This expertise will enhance I-TECH activities in Ethiopia as they expand to include PMTCT training and direct implementation of PMTCT services in COP07.

At the national level, I-TECH will continue to provide technical input and guidance to the MOH and RHB, supporting initiatives to expand PMTCT beyond single-dose NVP where appropriate, enhancing PMTCT-plus training, and supporting links between PMTCT programs, ART programs, and pediatric services.

In COP06, JHPEIGO provided central-level support and training on PMTCT, while I-TECH supported site-level PMTCT activities, in collaboration with the MOH and RHB. In COP07, I-TECH will add PMTCT training activities to its portfolio, expanding its activities to include training, supervision, and implementation of PMTCT programs at 31 hospitals. In FY07, I-TECH will increase the quality and uptake of PMTCT services and ensure that women enrolled in PMTCT are rapidly staged and referred for care and treatment services when needed. The PMTCT intervention package will include: - Assessment of new sites, followed by development of site-specific work plans. This includes evaluation of each site's capacity to provide more advanced ART regimens, with the idea that sites should move beyond single-dose Nevirapine PMTCT regimens when sufficient capacity exists. - Immediate assessment of HIV-infected pregnant women for ART eligibility, routine CD4 testing, and provision of appropriate clinical services, including ART when indicated. - Promotion of a family-centered care model in which women are encouraged to bring their children, partners, and other family members to the facility for counseling, education, testing and care and treatment if needed. - Support for appropriate post-natal follow up of mothers and infants that will include close follow-up of infants, nutritional counseling and support, provision of prophylactic cotrimoxazole, and ongoing assessment of eligibility for ART - Tracking the supplies management required for PMTCT services. - Referral linkages between PMTCT and TB, STI, FP, and ART clinics; - Access to appropriate pre-natal care, including nutritional counseling and multivitamins; - Facilitation of access to IPT and bed nets in coordination with the Global Fund and other partners; - Access to nutritional education, support and "therapeutic feeding" for pregnant and breast-feeding women in the 6-months post-partum period; - Promotion of safer infant feeding, especially exclusive breastfeeding with rapid cessation when replacement feeding is not acceptable, feasible, affordable, sustainable and safe ("AFASS"); - Quality assurance by supporting staff to implement performance standards and the JHPIEGO-supported Standard-based Management Program; - Implementation of peer educator programs and support groups at selected sites, designed to maximize adherence to care and treatment among pregnant HIV-infected women, and to strengthen their links to support groups and community resources. - Provision of PMTCT-Plus training to multi-disciplinary teams at the facility level. Ongoing clinical mentoring and supervision will be provided by I-TECH, in partnership with RHB in the respective regions. - Ongoing production and distribution of provider job aids and patient education materials related to PMTCT-plus. - Routine monitoring of PMTCT-plus programs, reporting of their progress against targets and enhancement of patient tracking to enable assessment of linkages within facilities (from PMTCT to ART clinics, for example) and to evaluate the uptake of services by family members. - Support for the availability and correct usage of PMTCT registers and forms, timely and complete transmission of monthly reports to regional and central levels, and appropriate

use of collected data to support quality care and ongoing performance improvements.

HIV/TB at Hospital Level

This activity also relates to activities in Counseling and Testing (#5725), ART (#5658), Palliative care (#1057), and PMTCT (#5639).

I-TECH will build on activities started in 2005 and 2006 and will continue to support and expand TB/HIV activities in Operation Zone 1 (Amhara, Tigray, and Afar regions) in FY07.

In 2006, I TECH assessed the ART hospitals in its operational regions, recruited medical officers, and gave training to TB/HIV health workers in 31 ART hospitals. In addition, I-TECH supported strengthening TB diagnostics among HIV+ patients through improved smear microscopy services, quality assurance of laboratory networks and support for regional referrals.

In 2007, I-TECH will support improved access to high-quality HCT among patients at TB clinics by ensuring trainings, supportive supervision, and other interventions that will ensure that TB screening (including routine symptom checklists), prevention, care, and referrals are included as part of the basic package of care for all HIV+ individuals.

I-TECH will support sites to implement routine provider initiated HIV counseling and testing (with an opt-out approach) for all TB patients at hospital level, as well prevention counseling, education, and referral for HIV care.

I-TECH will introduce intensified TB/HIV detection by incorporating TB symptoms screening into post-test counseling for persons newly-identified as HIV+ in VCT centers, STI clinics, and ANC clinics, and linking those with symptoms to the appropriate service to ensure accurate TB diagnosis and treatment. In addition, I-TECH will support efforts to improve adherence to TB therapy. Through its region-based clinical mentoring teams, I-TECH will sensitize ART adherence nurses to the importance of adherence to TB treatment. I-TECH will collaborate in regional and national interventions related to MDR-TB treatment and containment.

Additionally, I-TECH will initiate family-focused care within the TB/HIV clinics to increase TB screening and treatment for family members of HIV/ TB patients. This effort will specifically target pediatric screening and diagnosis of TB in co-infected persons. I-TECH will work with Columbia University and the MOH to assess training needs and curricula related to family-focused TB/HIV activities, including PIHCT guidelines for children.

Region-based ART clinical mentoring teams will include appropriate diagnosis and treatment of active TB in HIV+ persons as part of their routine activities. I-TECH will ensure that HIV+ patients, after being screened for active TB, are appropriately provided with isoniazid preventive therapy (IPT), through regular supportive supervisory visits by field-based clinical mentoring teams to all 31 hospital sites. I-TECH will support sites in the provision of cotrimoxizole preventive (CPT) therapy for all TB/HIV patients. I-TECH will establish and strengthen the multi-disciplinary care teams in each facility, with representation from the TB service to facilitate the referral. I-TECH's M&E unit (both field and Addis-based) will support facilities in monitoring the referral system for co-infected patients, and regularly evaluate/analyze referral data to inform efforts to improve the current system. I-TECH will also support monitoring and evaluation of TB/HIV activities through supportive supervision of ART-clinic-based data clerks and data managers, and on-site training and mentoring in data collection using TB/HIV data collection forms.

I-TECH will support laboratory TB diagnosis through regular mentoring visits to TB clinics by a laboratory technician with experience in TB diagnosis by smear microscopy. These laboratory-mentors will provide on-site troubleshooting, training, as well as a link to the regional referral laboratories.

Finally, I-TECH will work closely with the other USG partners, RHB, hospital ART committees, regional TB/HIV working groups, the MOH and local universities in its focus areas in the program planning activities and policy development that addresses the co-morbidity of HIV/AIDS and TB.

The following indicators will also be used to monitor the program:

(1) Number of HIV+ clients from VCT/PMTCT/ART clinics screened for TB (2) Number and percentage of TB patients recorded to be HIV+ (3) Number and percentage of registered TB/HIV patients accessing ART for the reporting period (4) Number and percentage HIV/TB accessing CTX for the reporting period.

This is a continuing activity from FY06. In FY06, I-TECH supported HIV counseling and testing services in 31 ART hospitals; this included an initial site assessment, site level training in collaboration with JHPIEGO, minor renovation, improving data collection and reporting, and supervision of counseling and testing services. This activity was introduced to the hospitals in the four regions of Amhara, Tigrai and Afar. The site level support aimed at improving performance to deliver quality HIV Counseling and testing services for the community and patients. The partner is on track according to the original targets and workplan. We have increased funding based on the achievements from partially FY06. This activity is linked to COP ID # new 1052 and 5751 (palliative care basic and TB/HIV) and COP ID 5658 (treatment: ARV Service).

During COP 07 I-TECH would intensify complementary interventions to ensure quality HIV Counseling and Testing (HCT) services in the 32 hospitals within Afar, Amhara and Tigray regions. In line with the Family Centered Care approach, couples would be encouraged to be counseled, tested and receive test results together. Efforts will be made to ensure privacy and autonomy of both individuals and couples. Appropriate child counseling and testing would be ensured as part of diagnostic testing, family and couple counseling. Considering the high prevalence of HIV among the youth and women, efforts also would be made to promote premarital and preconception routine HCT offered for Family Planning Clients

ITECH will consolidate ongoing effort to ensure that both client and providers initiated HIV Counseling and testing service are readily available at all 31 hospitals in the three I-TECH operation regions. Counseling and testing cadres will be expanded and same-hour result models through HIV testing points will be expanded. Routine offer of HIV testing for all TB, FP, STI clients and patients in the in-patient and outpatient department will be a norm in all hospitals. Appropriate intra-facility referral tools will be developed to ensure functional linkage among the different units within a hospital: VCT, ART, STI, in-patients and out-patients.

I-TECH will collaborate with relevant partners to pursue on -site training of health care providers as fulltime counselors and in the use of rapid HIV testing in the three operational regions. At least three such trainings will be scheduled during 2007. Gondar and Mekele universities will be supported to be training sites for counselors. A pool of TOT for health care provider training in HCT techniques would be ensured to sustain local needs and assure regional ownership of the programme.

Furthermore, I-TECH will fully support and complement the national effort in piloting and scaling up the lay counselors initiative throughout the three operation regions (based on the piloting of lay counselors by JHPIEGO in 2006).

Through bi-monthly coaching and mentoring visits to hospitals, I-TECH field-based clinical teams would make sure of the quality of HCT services, both client and provider initiated. Functional hospitals HIV committees would be encouraged to foster adherence to quality HCT standards and enhance the formation of a multi-disciplinary care teams for all testing sites within the facility. Hospitals will be supported to establish functional referral mechanisms and linkages with private sector facilities.

Recognizing the fact that Afar region is part of the high risk corridor belt along the Addis Ababa - Djibouti route, where a large segment of the pastoral community, mobile work force and commercial sex workers are found, efforts will be made to launch outreach VCT services using a mobile van in collaboration with USG partners. The initiative also will made extra effort to access the Afdera area, where more than 50,000 labor forces are estimated to work in the local salt production sector.

Since limited space for counseling and testing, and high turnover of hospital staff, in particular trained counselors are important challenges to increase timely access to HIV care and treatment services, I-TECH will expand testing services by initiating weekend VCT services in all of the major hospitals within the regions.

I-TECH will also continue to work closely with national and regional partners and USG agencies to promote HCT services, training of health care providers and sharing best practices.

All activities will be closely monitored by I-TECH regional office staff and central office Clinical Advisors. The university will support to strengthen administrative and technical coordination mechanism to improve the management system of the service. The activity will help to reach PEPFAR Ethiopia target for care and treatment.