This is a continuing activity from FY06. Columbia University's International Center for AIDS Care and Treatment Programs (CU) has been working with JHPIEGO in providing site level support for 30 hospitals, organizing PMTCT trainings for providers and doing site level assessment of additional hospitals using FY06 resources.

The funding level for FY07 has increased from the FY06 amount, in part because CU has taken additional PMTCT responsibilities including training of staff in PMTCT service areas, formerly carried out by JHPIEGO, and in part because CU will expand services from 30 to 42 hospitals. The budget increase is also in line with the recommendations from the OGAC PMTCT TA visit held in July 2006.

CU has extensive experience supporting PMTCT and "PMTCT plus" programs (programs that link PMTCT initiatives with care and treatment for women and families) in resource-limited settings. 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 CU activities in Ethiopia as they expand to include PMTCT training and direct implementation of PMTCT services in COP07.

At the national level, CU will continue to provide technical input and guidance to the MOH and Regional Health Bureaus (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.

At the facility level, hospital-based PMTCT programs were initiated by the MOH and have previously been supported by JHPIEGO. In COP06, JHPEIGO provided central-level support and training on PMTCT, while CU supported site-level PMTCT activities, in collaboration with the MOH and RHB. In COP07, CU will add PMTCT training activities to its portfolio, expanding its activities to include training, supervision, and implementation of PMTCT programs at 42 hospitals in Oromia, Somali, Dire Dawa, and Harari.

In COP07, CU 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 CU-supported package of PMTCT Plus/family-focused care includes: - Formation of multi-disciplinary care teams in each facility, including representation from the PMTCT service. - 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, including close follow-up of infants, growth and development monitoring, provision of appropriate immunizations, nutritional counseling and support, provision of prophylactic cotrimoxazole, and ongoing assessment of eligibility for ART (see CU's Pediatrics narrative); - Attention to supplies management for services; - Referral linkages between PMTCT and TB, STI, FP, and ART clinics; - Access to appropriate pre-natal care, including nutritional counseling; - 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"); 12) Increased infant diagnosis capacity (DBS) at selected facilities and strengthened linkages with regional labs with infant diagnosis capacity (see the Pediatric narrative); - Determination of infection status at 18 months for HIV-exposed infants; - 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 CU's Clinical Advisors, in partnership with RHB in the respective regions; - Ongoing development 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; and - 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.

Added July 2007 Reprogramming: Public education through radio and production of IEC/BCC materials

In COP07, in addition to the package of PMTCT Plus/family-focused care support, Columbia University will undertake Public education through radio and production of IEC/BCC materials to improve the uptake of PMTCT services in Oromia, Harari and Somali regions.

The CU-supported program will run for one year and activities include: • Social marketing and branding of PMTCT in collaboration with other partners, which brings important social marketing skills to improve knowledge and create demand for PMTCT services. • The social marketing of PMTCT services will unveil a communication campaign using television, radio, print and road shows in local languages (i.e. Oromiffa, Somali and Harari) to help address misconceptions about PMTCT and create demand for services.

Strengthening STI Services for MARP

In FY05 and FY06, the prevention and control of STI was implemented by PEPFAR Ethiopia in collaboration with the MOH and WHO. Major achievements during this period include, support to the revision of STI guidelines, development of STI training materials, training of STI providers and production of job-aids.

During COP07, Columbia University's International Center for AIDS Care and Treatment Programs (CU) will support expanded access to STI prevention and treatment services and improved STI services at 42 CU supported ART sites in its working area (Oromia, Somali, Harari and Dire Dawa). Prevention of STI among the general population, most vulnerable groups, and PLWHA is a critical activity in preventing new HIV infections and slowing the pace of the epidemic. Complete and appropriate treatment of STI is also a key element of CU's multi-disciplinary, family-focused approach to care and treatment.

CU will work with Regional Health Bureaus to help facilitate and coordinate linkages between STI and HIV/AIDS services, to strengthen external referral linkages between hospitals, health centers, and CBO, FBO and PLWHA Support Groups and Associations. Regional linkages will be supported so that patients who do not respond to syndromic management of STI symptoms at health center level are referred for hospital care.

CU will support provision of optimum STI services at 42 public and private hospitals in Oromia, Somali, Harari and Dire Dawa Regions. While it is likely that most persons with STI symptoms will seek attention nearest to their homes, there are many who seek primary care at hospitals if they live in towns or cities, HIV+ persons receiving palliative care and/or ART at hospitals are also at risk for STI and require focused services at these facilities. Specific activities will include: (1) In collaboration with respective RHB, needs assessments at all CU supported hospitals, followed by joint action planning with facility staff to improve STI services and linkages between STI and other services (counseling and testing, care and treatment, ANC, etc.); (2) Provision of on-site technical assistance to improve STI diagnosis and treatment following national syndromic management guidelines; (3) CU will conduct training for 168 providers (physicians, nurses etc) on STI prevention, diagnosis, and treatment, with a focus on linkages between STI and HIV infection, as per national guidelines; (4) Training of facility-based peer educators on STI prevention and treatment for people living with HIV/AIDS and their partners, as well as community education regarding the symptoms of STI and the need to seek care; (5) Linkage with Global Fund and USG-funded partners to ensure adequate supplies of STI drugs at all facilities; (6) Linkages to HIV counseling and testing (C&T) services, promoting a provider-initiated, opt-out approach, for all STI patients, and linkages to care and treatment services for those who are HIV+; (7) STI education focused on risk reduction, screening, and treatment for patients enrolled in HIV/AIDS care and treatment at the hospitals, including PMTCT services; (8) Provision of condoms and education on usage, to patients enrolled in care and treatment, with a special focus on most at-risk patients/populations. STI services will also be integrated into antenatal and PMTCT services to ensure that all pregnant women are educated on STI, treated when necessary are given educated on STI prevention during pregnancy (according to national STI management and antenatal care guidelines); (9) Linkages to community-based organizations that promote risk reduction and HIV/STI prevention and early/complete treatment in communities surrounding CU supported ART sites; and (10) Supportive supervision and mentoring of clinical providers on STI services and STI/HIV linkages by CU Clinical Advisors.

Palliative Care - Basic

This is a continuing activity from FY06, programmatically linked to the following activities: access to home water treatment (HWT) and basic hygiene counseling (6630), TB/HIV at hospital level promote positive living and self reliance for HIV/AIDS affected beneficiaries of urban nutritional support program (New-1061), HIV/TB at hospital level (5750), Regional PMTCT Service Delivery - Hospital Level (COP ID: 5637), technical support for ART scale-up (5661).

In FY06, CU introduced a basic palliative care approach to the 32 ART facilities it supports. This approach included an initial assessment of the palliative care activities conducted at the sites, development of site level training in collaboration with the national leadership, and supervision of palliative care activities. Training and supervision focused on identifying pain and discomfort among HIV patients, and providing cotrimoxazole prophylaxis, TB screening and targeted elements of the preventive care package such as multivitamins, nutritional assessments and prevention for positives. This program was introduced to the hospitals in Oromia, Somali, Dire Dawa, and Harar (Operational Zone 2).

In FY07, CU will support palliative care activities at 42 hospitals providing HIV/AIDS care and treatment via a multi-disciplinary, family-focused approach to provision of the preventive care package for both adults and children. This approach will incorporate best practices for health maintenance and the prevention of opportunistic infections for PLWHA, to slow disease progression, and reduce morbidity and mortality. CU will play a lead role among the PEPFAR Ethiopia's US university partners in pediatric HIV care and treatment. CU will play an active role in the development of national guidelines and standard operating procedures for pediatric HIV care, and will share experiences and best practices with other PEPFAR Ethiopia partners.

CU will assist hospitals in Operational Zone 2 to provide the preventive care package, complementing Global Fund, MOH, and other USG-funded activities when possible. CU will focus on provision of the preventive care package which for adults includes: active TB screening, cotrimoxazole prophylaxis, symptom management, micronutrient (multivitamin) and nutrition supplements and counseling, insecticide mosquito nets (linkage), positive living strategies, counseling and testing of family members and contacts, and promoting safe water usage through the provision of safe water vessels at all CU supported hospitals. The preventive care package for children includes: prevention of serious illnesses like PCP, TB and malaria; prevention and treatment of diarrhea; and nutrition and micronutrient supplements and linkage to national childhood immunization programs. OVC will be prioritized for palliative care and linked to other OVC care programs in order to receive a continuum of care.

CU will work closely with other PEPFAR Ethiopia university partners to ensure complementary of activities with, for example, UCSD on implementation of national pain management guidelines. More details on delivery of these aspects of the preventive care package are outlined below.

CU support to facilities will be continued or expanded as follows: (1) strengthen the internal and external linkages required to identify HIV+ individuals and provide them with access to care (internal linkages include referrals to the HIV/AIDS/ART clinic from ANC, TB clinic, under-5 clinics, inpatient wards, OPD, and VCT, and external linkages include referrals to and from community-based resources providing counseling, adherence support, home-based care, and financial/livelihood and nutritional support; (2) provide on-site implementation assistance, including staff support, implementation of referral systems and forms, and support for monthly HIV/AIDS team meetings to enhance linkages; (3) provide training on palliative care and the preventive care package to multi-disciplinary teams; (4) provide clinical mentoring and supervision to multi-disciplinary teams related to the care of PLWHA -- including those who do not qualify for or choose not to be on treatment -- in partnership with RHB in the respective regions; (5) continue to develop and distribute provider job aids and patient education materials related to palliative care and positive living ; (6) identify and sensitize community-based groups on palliative care and the importance of adherence to both care and treatment for PLWHA and the palliative care services available at the facility-level; (7) improve nutrition assessment at health facilities; (8) promote intervention (pharmacologic/opioids and

non-pharmacologic) to ease distressing pain or symptoms; (9) continue patient management after hospital discharge if pain or symptoms are chronic; and (10) link patient with community resources after discharge.

CU's activities will promote OI prophylaxis and treatment in accordance with national guidelines. Appropriate use of cotrimoxazole prophylaxis (pCTX) is an essential element of care for HIV+ adults and children, and for HIV-exposed infants, and will be an important component of CU's implementation activities, especially at those sites not yet providing ART. CU will ensure that all supported sites have reliable stocks of cotrimoxazole tablets and syrups, and will provide emergency supplies when absolutely necessary to ensure quality and care continuity. Similarly, TB screening and isoniazid prophylaxis will be promoted and provided for HIV+ adults and children. (See also the activity section on TB/HIV activities.) Supportive supervision and the institution of standard operating procedures will improve the use of cotrimoxazole and INH prophylaxis. Attention will be given to the issue of HIV/malaria co-infection, and routine provision of impregnated bednets, at minimum, to pregnant patients in HIV/AIDS and PMTCT programs in collaboration with Global Fund.

Health education and behavior change communication for HIV+ individuals will be provided by facility and lay staff, complementing Global Fund and other USG-funded activities. Patients will have access to nutritional counseling and multivitamins. With guidance from JHU, the university lead for hospital-level nutrition, "therapeutic feeding-by-prescription" of patients who qualify based upon criteria agreed upon by PEPFAR Ethiopia (e.g. HIV+ pregnant or breast feeding women, HIV exposed or infected infants who are no longer breast feeding, malnourished patients) will be provided in at least five hospitals. Clear criteria will be established for patient selection, and an exit strategy developed as part of all initiation of therapeutic feeding support. Health education, counseling, and support will encourage positive living to forestall disease progression, promote prevention among positives to prevent further transmission of HIV, and strengthen adherence to both.

TB/HIV at Hospital Level

This activity relates to activities in Counseling and Testing (#5722), ART (#5661), Palliative Care (#5772), and PMTCT (#5637).

Columbia University's International Center for AIDS Care and Treatment Programs (CU) has much experience in strengthening linkages between TB and HIV programs in PEPFAR focus countries, including Ethiopia. CU will continue and expand activities from FY05 and 06 at the national, regional, and local levels to improve the vital linkages between these closely related services and to establish programmatic components that will enhance the diagnosis and management of TB/HIV co-infected patients.

Columbia University will scale up to 40 hospitals in its operational regions; two of which are the largest regions of Ethiopia (Oromia and Somali). Columbia will also continue its lead role on TB/ HIV work amongst the university partners. Based on these increases funding levels will increase.

At national level, CU will: As leader on TB/HIV amongst university partners, CU will be responsible for coordinating TB/HIV activities amongst partners and providing technical support to MOH at National Level, which includes updating and maintaining the TB/HIV website, supporting reprint and distribution of TB/HIV implementation guidelines, TB/HIV registers and reporting formats, and supporting MOH to conduct bi-annual TB/HIV collaboration review meetings. Additionally, CU will work with MOH, CDC-E and the other university partners on development of guideline on management of MDR TB, training of physicians and selection of treatment centers.

Continue to support the MOH technically in development of policies and program design. Support a national workshop/conference to update and standardize Ethiopia's guidelines for the management of latent TB infection (LTBI).

Columbia has a lead role in pediatric HIV/AIDS, therefore, will ; 1) Support the government to create and expand integrated TB/HIV programs for children 2) Develop standardized screening tools and diagnostic algorithms 3) Work on integrating the TB care package into programs caring for HIV-exposed infants and HIV+ children 4) Explore effective referral mechanisms between facilities. 5) Collaborate with JHEPIGO to incorporate pediatric provider initiated counseling and testing (PIHCT) in the PIHCT training manual. Pediatric TB/HIV will be highlighted at the second Ethiopian Pediatric HIV/AIDS Situational Analysis Conference, which CU will co-host with the MOH.

CU will (1) support regional TB/HIV Technical Advisors to liaise with Regional Health Bureaus in Oromia, Somali, Dire Dawa and Harar; and (2) collaborate with Jimma and Alemaya Universities, and with other partners such as JHPIEGO, on pre-service TB/HIV curricula and in-service training initiatives, developing local capacity to train health care professionals and provide regional technical assistance.

At the facility level, CU will: (1) Assist 40 hospitals in four regions (Oromia, Somali, Dire Dawa, and Harari) to provide TB/HIV services. Thirty-two of these hospitals began receiving CU assistance in 2005-2006 and an additional ten will receive support in COP 2007 to initiate and/or expand TB/HIV activities as part of comprehensive HIV/AIDS services.

(2) Support standardized TB screening and intensified TB detection in HIV+ patients, focusing on CU supported ART sites but ensuring that experiences are made available for nationwide adoption. This will include training, 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. (3) Support the implementation of routine provider-initiated HIV counseling and testing (with an opt-out approach), prevention, education, and referral for HIV care (if needed) for all patients at TB clinics and TB inpatient wards. (4) Encourage all patients with TB to bring family members and household contacts to the clinic (particularly children 5 and younger) in order to promote early TB detection.

(5) Provide isoniazid preventive therapy (IPT) to HIV+ patients in whom active disease has been ruled out. (6) Provide cotrimoxazole preventive therapy (CPT) for all TB/HIV co-infected patients. (7) Design, implement, and evaluate systems for referral of HIV+ TB patients to ART services. (8) Provide close clinical monitoring for TB/HIV patients started on ART to identify and manage immune reconstitution reactions. (9) Support strategies to engage families into care when HIV is found in TB patients, such as home visits to screen for HIV infection and disease in the household. (10) Develop and share clinical support tools for TB/HIV management, including TB symptom screening questionnaires, job aids, posters, and clinical algorithms. (11) Support TB/HIV refresher trainings and ongoing supportive supervision for site staff. (12) Support a TB/HIV technical advisor (as above), who will spend approximately 50% time at ICAP-supported ART sites. The purpose of these visits will be to provide technical assistance and oversight of TB/HIV integration activities, to work with CU clinical advisors to ensure that TB/HIV integration activities are initiated and expanded appropriately, and to provide hands-on technical and educational support to site-level staff to build capacity and improve services.

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

Columbia University (CT)

This is a continuing activity from FY06. In FY06, CU supported HIV counseling and testing services in 32 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 Oromia, Somali, Dire Dawa, and Harari. 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 # 5772 and 5750 (palliative care basic and TB/HIV) and COP ID 5661 (treatment: ARV Service).

During COP 07, Columbia University's International Center for AIDS Care and Treatment Programs (CU) will support expanded access to counseling and testing (C&T), improve C&T quality, and enhance linkages between C&T and ART services. CU will coordinate the required increase in the number of C&T sites in four regions (Oromia, Somali, Harari and Dire Dawa), in collaboration with CDC - Ethiopia, other donors and PEPFAR Ethiopia partners, and will work with sites to support and manage the necessary increase in C&T staff. CU will promote the use of innovative testing strategies, including Provider-Initiated Counseling and Testing (PIHCT) and routine opt-out C&T in inpatient wards (adult and pediatric) and outpatient settings with a particular focus on , TB, ANC, under 5, STI and other clinics, to facilitate enrollment into treatment programs. In collaboration with the sites CU- ICAP will establish QA system for counseling and HIV testing. Innovative C&T strategies will include: (1) In collaboration with RHB and JHPIEGO, CU will support the training and deployment of lay counselors in the four CU supported regions. CU will work closely with the MOH and other partners in the selection, training, and supportive supervision of this new cadre to expand C&T services. (2) In collaboration with RHB and Organization for Social Service for AIDS (OSSA), CU will support the implementation of mobile C&T services which are critically needed to serve hard-to-reach nomadic populations, particularly in Oromyia and Somali Region. (3) In collaboration with Jimma, Alemaya Universities and other higher learning institution, CU will support C&T campaigns for students and staff. CU will also support VCT services for students and staff, as well as access to care and treatment.

At the REGIONAL level, CU will support C&T service delivery at hospitals in Oromia, Somali, Harari and Dire Dawa Regions, as described below. C&T cadres will be expanded and point-of-service testing models will be implemented, permitting same-day results. Mechanisms to facilitate smooth referral from C&T to ART will be introduced, and external referral linkages between hospitals and NGOs, FBO and PLWHA Support Groups and Associations will be strengthened.

CU staff will work closely with partners and USG agencies in development and distribution of promotional materials on PIHCT and VCT services. CU will play a major role in developing and implementing infant diagnostic strategies and services at the national, regional, and facility level. In collaboration with other partners will develop child counseling and testing training document.

CU will explore the feasibility of extending C&T services to the most vulnerable groups, such as prisoners, in selected regions, providing education, C&T, and linkages to prevention, care, and treatment services.

Other specific activities include ensuring establishment of QA system for counseling and HIV testing. Support development of tools, job-aids to strengthen this activity. CU will support refurbishment and minor renovation of physical space to ensure privacy. Ensure availability of HCT supplies including laboratory by coordinating with relevant partner

All activities will be closely monitored by CU 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.

Technical Support for ART Scale-up

This is a continuing activity from FY05, FY06 and relates to activities in Counseling and Testing (5752), TB/HIV (5750), Palliative Care (5772), PMTCT (5637), STI Services (1031), laboratory Infrastructure (New) as well as activities implemented through the Twinning Initiative (5678).

CU has played a critical role as the lead for TB/HIV, Pediatric ART and the involvement of PLWHA, and has implemented ART in Operation Zone 2. The partner is currently on track in meeting targets for COP06.

Following Ethiopian national guidelines, CU supports development and expansion of full-spectrum comprehensive hospital-based ART programs. CU will lead the national pediatric care and treatment program. It will provide technical support in the areas of pediatric and family-centered HIV care and treatment. It will work closely with the national ART program to ensure that the growing PMTCT program is closely linked to care and treatment services, and that the challenges of caring for pregnant women and their families, including access to CD4 testing for HIV+ women, rapid referral for more intensive PMTCT regimens and to ART programs are addressed at the national level. CU will use its extensive experience to assist in implementing the national pediatric treatment guidelines.

There is great need for coordination program action between the HIV and malaria control programs. At the national level, CU will support various HIV and malaria related activities including (1) working closely with the MOH to address the issue of malaria and HIV co-infection, (2) conducting a national conference on malaria/HIV to discuss the current status of disease interaction and programmatic implications and help move the HIV/malaria agenda forward, (3) supporting MOH in the development of national HIV/malaria guidelines, (4) supporting the development of a web-based resource on malaria/HIV interaction, (5) supporting development of training materials on malaria/HIV and their integration into HIV/AIDS curricula, (5) supporting development of IEC materials, clinical support tools, and patient education materials on malaria/HIV, and (7) strengthening M&E systems to capture pertinent information on malaria/HIV.

CU will work to build regional capacity to design, implement and effectively evaluate comprehensive HIV/AIDS programs. CU and RHB will assess and prepare hospitals to initiate and expand ART services. The clinical, infrastructural, management and informatics needs of facilities will be evaluated and strategies developed to enable them to meet the required national standards. Assistance will be provided to support the implementation of the national treatment guidelines.

CU will work with RHB to strengthen linkages across the hospital-health center networks, and to assist partners as they assess health center capacity. These assessments and the strategies developed in conjunction with the health centers for appropriate "down referral" will enable health centers to follow-up stable patients or initiate ART services in some cases. "Up referral," in which health centers refer complex cases to hospitals will also be facilitated. CU will continue to build the capacity of Jimma and Alemaya universities to provide technical assistance, supportive supervision and mentoring to their respective RHB and catchment health networks. These universities will eventually provide technical assistance to the health networks in the four regions, enabling external partners to exit smoothly.

CU will support provision of comprehensive, high-quality HIV/AIDS services, including ART, at 42 hospital networks. Specific site level activities will include (1) support to HIV/AIDS committees and multidisciplinary ART teams to enhance facility ownership and leadership, (2) training and quality improvement activities all for health workers, (3) supportive supervision and ongoing clinical mentoring of staff, (4) linkages among ART services and entry points to care and treatment, (5) linkages of ART services to family planning, TB/HIV, STI, and palliative care services (6) establishment of a family-centered treatment and care model,(7) implementation of a pediatric treatment and care package, (8) standardized HMIS and on-site M&E support, (9) renovations conducted by RPSO, and (10) coordination through site-support teams.

CU will collaborate with WHO to initiate second level IMAI at hospitals in ART Operation

Zone 2. CU will provide site level laboratory support to all hospital networks in its Operation zone (Details are given under the laboratory section.) CU will assist ART health networks to follow standardized clinical procedures.

CU will support establishment of a systematic and ongoing assessment of adherence to care and adherence to treatment. It will provide technical assistance to MOH, RHB, and USG teams. Specific activities will include (1) hosting a national stakeholders' meeting with implementers at the national, regional, facility, and community levels, (2) reviewing effective approaches to adherence support and sharing tools, (3) developing a web-based Adherence Tool Box, (4) developing a model "adherence profile" for facilities and regions, (5) developing a "minimum package" for the assessment and support of adherence to care, (7)developing a "minimum package" for the assessment and support of adherence to medication, and (8) supporting peer educator (PE) adherence support programs.

In COP07, particular focus will be given to associations of PLWHA to involve their members in HIV/AIDS program activities. CU will (1) support PLWHA involvement in the Treatment Working Groups, (2) work closely with the Network Association of Ethiopians Living with HIV/AIDS (NEP+) to foster their greater involvement, (3) build the capacity of NEP+ in program management and implementation, (4) hold a PLWHA involvement workshops, (5) hold a national peer educators' review meeting, and (6) provide facility level assistance in Oromia, Somali, Dire Dawa, and Harari to involve PLWHA as case managers and peer educators.

As part of its human capacity development scheme, CU will collaborate with the International Twinning Center to expand the voluntary health care corps by recruiting retirees with experience in clinical or project management and by involving students during summer vacation.

Site-level laboratory Support

In COP07, CU will support provision of comprehensive high-quality HIV/AIDS services, including ART, at 42 public and private hospital networks in Oromia, Somali, Harari and Dire Dawa regions. The availability of consistent and quality laboratory services at all these sites is critical to ensure the provision of quality comprehensive HIV/AIDS services. In COP07, CU is planning to provide a comprehensive site level laboratory support to 42 hospital networks in CU supported regions. Procurement and distribution of laboratory equipments and supplies for all these sites will be handled by CDC /MOH/EHNRI.

CU will work directly with the regional lab, hospital labs and health center personnel to implement and monitor these QA and QC measures at the sites. Implementation of QA and QC guidelines will be expanded to all sites. CU will support the national programs of QA for blood safety, VCT, PMTCT, TB prevention, HIV and OI surveillance by disseminating the guidelines to the regional level and assuring uninterrupted links between hospital, regional and national laboratories.

The support of CU will focus on site-level support. The following are the specific activities included in CU comprehensive site-level laboratory support at the 42 Hospital Networks.

(1) Initiation and improvement of the site level laboratory quality system with main emphasis on initiation of quality assurance programs in partnership with EHNRI and respective regional reference laboratories in CU supported regions: preparation and provision of standard operational procedures for HIV disease monitoring (Hematology, Clinical Chemistry, and CD4), specimen management, laboratory safety, and QA/QC program; and preparation and provision of standard documentation and recording formats including QC forms, lab request forms and registers, to facilitate the implementation and monitoring of quality assurance program at all sites.

(2) Ensuring uninterrupted quality laboratory services at all 42 Hospital Networks. This includes: ensure continued and sufficient reagent supply to the sites, ensure timely provision of preventive and troubleshooting maintenance services, assist in regional capacity building to have essential laboratory equipments maintenance capability, assist in developing and use of laboratory inventory system at the hospital networks, and ensure the availability of adequately trained laboratory personnel at all sites.

(3) Capacity building of site laboratories: conducting site assessment and addressing gaps as appropriate including supportive minor renovations; provision of laboratory accessories important for the day-to-day delivery of HIV/AIDS related laboratory services; facilitate maintenance of essential equipments important for the over all HIV/AIDS laboratory support; on-site visits and technical assistance to site laboratories; the support will also include laboratory management, internal re-organizational lab set up, specimen management, test procedures, documentation, reporting, and inventory management.; services will support inventory and stock management of laboratory supplies at each health facility; support to the national laboratory reporting systems; conduct regular mentoring on standard record keeping and timely and accurate reporting.

(4) Provision of standard trainings using nationally approved curricula, in collaboration with partners (PEPFAR Ethiopia, EHNRI, APHL, and ASCP) in the following areas: site level and regional trainings on HIV diagnosis (HIV serology testing, rapid test); HIV disease monitoring (Hematology, Clinical Chemistry, and CD4); and OI diagnosis. A total of 100 laboratory personnel will be trained.

(5) CU will technically assist in referral laboratory services, specimen collection at health centers or peripheral hospitals, transport to next hospital laboratory and regional laboratory for diagnosis and monitoring ART, patient sample tracking, reporting of results, and implementing and ensuring that standard guidelines and procedures are followed. CU will also technically assist the rollout of HIV-1 DNA PCR for infant diagnosis.

Site Level Data Support

This is a new activity for FY07. This activity relates and linked to other program areas including Counseling and Testing, TB/HIV, Palliative Care, PMTCT in addition to ART services in Oromia, Diredawa, Harari and Somali regions. This activity will also be strengthening the implementation of the national HMIS.

The MOH has established a chronic disease record-keeping system for the national ART program. Standardized tools include intake and follow up forms, pre-ART and ART registers, monthly cohort analysis and reporting forms among others. The national ART monitoring and evaluation system provides the means to collect data in a standardized manner. However, data at site level is currently under-utilized.

The ART program would be strengthened further by increasing the capacity of treatment-providing hospitals, RHB and regional universities to collect, manage, analyze and utilize ART-related data generated at site level for decision making to improve clinical and program management.

PEPFAR Ethiopia will expand provision of comprehensive HIV/AIDS services to 131 hospital networks in FY07. Despite the rapid expansion of HIV/AIDS services all over the country very little attention was given to systematically analyzing, documenting and sharing the information by and with stakeholders at all levels (i.e. health care personnel at facilities, health managers at the zonal and regional levels). Consequently, limited information is available on the quality of services, barriers to utilization of services, and best practices in PMTCT, HCT, TB/HIV, palliative care and ART services.

In FY07, CU will support the four RHB and the 42 hospitals providing comprehensive HIV/AIDS services in its operational zone to assess and monitor HIV/AIDS services coverage, quality and supporiting processes. In addition, CU will support development of data collection systems streamlined to capture required data for calculation of standard indicators.

Institutions will be supported to fully and effectively manage and use the data. Sites will be assisted in appropriate ways to tabulate and visualize their data such as through the use of GIS, tables, charts, line and bar graphs and other standard methods. Appropriate options for tabulation include aggregation of data by patient, clinic and regional levels.

Specific activities include training of health care providers at facilities in basic computer skills and data management which includes data entry, data analysis, technical paper writing and presentations, and the provision of technical support. The support will include bi-annual regional review meetings which will serve as a forum where facilities will present their data and share experience. The support to the sites will strengthen the national M&E system the MOH/HAPCO and regions are developing with other PEPFAR Ethiopia funds.

CU will also support documentation of best practices and presentations of findings and experiences both at local and international scientific and programmatic.

Implementation mechanisms for this activity will include providing the necessary modeling at site and RHB levels within CU regions.