HIV Prevention for Most at Risk Populations in Amhara

This is a new activity in FY07. This is a comprehensive HIV prevention BCC activity with AB and OP components. This activity will form the basis for focused implementation of HIV prevention BCC activities in the greater Bahir Dar - Gondar area. At present, PEPFAR Ethiopia has limited outreach to most at risk populations in this geographic area. Linkages with additional prevention activities are discussed at the end of this document.

Amhara, Ethiopia's second largest region, with a population of 19 million has the highest HIV burden in urban and rural areas. 2005 ANC surveillance and EPP modeled data project a regional HIV prevalence of 4.2% (urban 13% and rural 3%). Approximately 13% of Amhara-based VCT clients were HIV+. Bahir Dar and Gondar Health Centers are ANC sentinel surveillance sites reporting 13.5% and 10.3% (2005). The 2005 EDHS indicates 1.8% females and 1.6% males are HIV+. HIV prevalence among couples reflects 1.4% male partner discordance and 0.7% female partner discordance. Individuals from surrounding villages are drawn to Bahir Dar, Gondar and secondary district towns because of market days, governmental functions, economic opportunity (including commercial sex work) and family breakdown due to early marriage or divorce. Trafficking of women to Sudan also occurs. Early marriage and related sexual debut of girls below the age of 15 is present. Wife inheritance and additional female partners during peri-natal abstinence form low degree sexual networks. In addition, Bahir Dar and Gondar are major tourist destinations, have large student populations, host uniformed service facilities, and are centers of commerce and trade within the Amhara region, from Addis-based transportation drivers and from long distance truck drivers originating the Port of Sudan. Recently, the road connecting Bahir Dar and Gondar to each other, Addis Ababa, Tigray region and Port of Sudan have been upgraded facilitating increased mobility and trade.

This activity is non-clinical and will implement within the facility catchments of several Care and ART health networks (i.e. health centers and hospitals providing HIV clinical services) in/around Bahir Dar, Gondar, Debre Markos, Debre Tabor and Lalibela areas. Sexually active youth, especially girls 15 - 24, residing in these urban and peri-urban areas are considered most at risk due to their proximity to HIV prevalence in existing sexual networks in these communities. Men reporting multiple partners, deployed or transiting these areas are also highly exposed to HIV infection.

This activity has several different components. One component is to provide comprehensive ABC interventions to most at risk populations, through both existing community structures and targeted outreach activities, in urban and peri-urban areas of high HIV prevalence. The activity will assume a facilitation role in the Bahir Dar - Gondar hub to support an enhanced HIV prevention "plus" approach with existing partners such as IOCC, Population Council, Health Communications Partnership, Private Sector Program (VCT), Family Health International (VCT and Palliative Care), University of Washington (ART), Intrahealth International (PMTCT), USAID's RH/FP partner and USAID's Livelihoods Security partners to support a context where safer sexual decision-making of most at risk populations are enhanced. Existing community structures will be provided technical assistance to strengthen BCC activities addressing social norms that hinder people's ability to make choices on ABC. Activities addressing community social norms facilitating gender violence and rape, males having multiple partners, transactional and cross-generational sex and correct and consistent condom use will be widely implemented. The already established Multi-Purpose Center and community-based care program will support outreach to persons living with HIV/AIDS to support secondary prevention efforts in discordant relationships. Outreach activities, through local organizations, will be implemented in market environments, tourist settings, public hot springs, bars, hotels, nightclubs in urban areas and truck stops where at risk populations congregate. The activity will collaborate with Abt Associates and TBD/Targeted Condom Promotion. This component of the activity is anticipated to reach 17,000 most at risk individuals with repetitive BCC interventions and referral to existing community structures. Existing materials on HIV prevention will be adapted. Most at risk populations targeted include: (1) Commercial sex workers, their partners and clients; (2) Youth 15 - 24, specifically girls who are sexually active or in secondary school/college; (3) Males (urban-based) reporting multiple partners or within uniformed services and transportation sectors.

The second component of this activity is to support local indigenous partners to implement behavioral change interventions, including administrative and resource mobilization training, BCC implementation training, provision of BCC materials and equipment for implementation and partial activity grants to be leveraged against other funding sources. This component of the activity will support five TBD local organizations with training opportunities for 75 persons with organizational capacity building.

The third component of this activity is to provide technical assistance to several government bodies with capacity building to implement evidence-based HIV prevention activities to most at risk populations. Government bodies include: Amhara Regional HIV/AIDS Prevention and Control Office, Amhara Regional Health Bureau, Municipal Offices of Bahir Dar, Gondar, Debre Markos, Debre Tabor and Lalibela Administrations. Technical assistance will encompass experience sharing and best practices among USG partners in Ethiopia and Africa, training on HIV prevention implementation and implementation assistance to additional regional efforts funded by GFATM resources.

This activity will build linkages with additional prevention activities including Health Communications Partnership, Targeted Condom Promotion (10404), Population Council (10521), Private Sector Program(10374), High Risk Corridor Initiative, National Defense Force of Ethiopia's HIV(10565, 10578, AB prevention activities, AIDS Resource Center. In addition, this activity will leverage community-level activities in the Counseling and Testing and Palliative Care areas.

ROADS/Transportation Corridor HIV Prevention Programming

This is a new activity. This activity is linked to several prevention activities including Save the Children's High Risk Corridor Initiative (AB 16394 and OP 10392), Family Health International's HIV Prevention for MARPS in Amhara (AB 10594 and OP 10641), TBD's Targeted Condom Promotion and Abt Associates' Private Sector Program (AB 10376 and OP 10374).

This activity has two components: 1) Sharing best practice and building south-to-south networks among HIV prevention partners and their local sub-partners; and 2) Address Regional HIV prevention programming for truckers in Djibouti and Kenya.

Sharing Best Practices/South-to-South Networks: The primary purpose of this activity is to share best practices and south-to-south experiences on transportation corridor initiatives and outreach to communities at risk along the corridors with HIV prevention outreach partners. This activity will collaborate with the Regional HIV/AIDS Prevention and Control Offices and HIV prevention partners in-country and through experience sharing with ROADS sites in East Africa to demonstrate effective models of community outreach to most at risk populations.

Based on new HIV prevalence and behavioral information, multiple prevention partners in Ethiopia will intensify their efforts on HIV prevention among most at risk populations in specific geographic areas. This activity provides an important opportunity to share successful models and lessons learned to develop programs for most at risk populations with partners across the portfolio as re-programming begins. This assistance will identify gaps, review existing models for most at risk populations including commercial sex workers, their clients and partners, transportation workers and men residing in communities at risk.

Regional HIV Prevention Programming: This activity will collaborate with Save the Children High Risk Corridor Initiative to harmonize communication materials used in HRCI and ROADS activities for cross-border traffic at the Djibouti - Ethiopia border crossing.

Ethiopia's agriculture, import and export, construction and transportation industries account for the majority of formal economic activity. The vast majority of imports arrive in the Port of Djibouti. Two additional ports, Port of Sudan and Berbera, Somaliland are also entry points for imports. From that point, thousands of truckers converge in these areas for days to clear and transport items back to Ethiopia.

This activity will assist in the following "abstinence/being faithful" prevention activities in FY07: (1) Share best practices and lessons learned from the ROADS project on HIV prevention, ABC, and care activities. Potential activities include magnet theatre geared toward in- and out-of-school youth, peer education, peer counseling, men's discussion groups, family-to-family dialogue and other activities.

(2) Conduct a collaborative analysis with Save the Children USA (SCUSA) on the High Risk Corridor Initiative (HRCI) models and on-the-ground HIV prevention IEC/BCC activities to most at risk populations, including commercial sex workers, out of school youth and transportation workers.

(3) Harmonize communication materials used in HRCI and ROADS activities for cross-border traffic at the Djibouti - Ethiopia border crossing. This may include identifying relevant Amharic SafeTStop materials used in Djibouti to support HIV prevention goals; and

(4) Provide assistance in identifying hubs for additional transportation corridor HIV prevention activities and identify best practices for HIV prevention and care activities.

(5) Inform partners on behavior change communication campaigns in existing HRCI, PSP and FHI/Amhara sites in relation to the ROADS campaigns to promote abstinence and faithfulness among youth, community men and women, truck drivers and other key

audiences. Potential activities, to be discussed with SCUSA, include magnet theatre geared toward in- and out-of-school youth, peer education, peer counseling, men's discussion groups, family-to-family dialogue and other activities. Relevant SafeTStop materials have already been translated into Amharic for Djibouti.

Summary of the ROADS project: The main objectives of the ROADS Transport Corridor Initiative, branded "SafeTStop", are to: (1) Safeguard community health through increased access to and use of HIV/AIDS health services. (2) Create a safe environment for people to talk openly about HIV and AIDS and take action to address it. (3) Reduce unsafe use of substances such as alcohol that can lead to HIV risk behaviors. (4) Increase the ability of HIV-vulnerable populations to secure a safe means of income. (5) Safeguard women and children from sexual violence and abuse, coercion and exploitation. (6) Create or strengthen safety nets for the most vulnerable families, orphans and other children.

To date, SafeTStop has been launched in key HIV transmission hotspots in Djibouti, Kenya, Rwanda and Uganda, and sites are currently being planned for Burundi, DRC, Southern Sudan and Tanzania. Existing sites include major truck stops and border crossings such as Mariakani, Kenya; Busia and Malaba on the Kenya/Uganda border; Gatuna and Katuna on the Uganda/Rwanda border; and PK 12, a vulnerable Djiboutian community along the main highway from Ethiopia.

HIV prevention to MARP in Amhara

This is a new activity in FY07. It is a comprehensive HIV prevention BCC activity with AB and OP components. It will form the basis for focused implementation of HIV prevention BCC activities in the greater Bahir Dar - Gondar area. At present, PEPFAR has limited outreach to the most at risk populations (MARP) in this geographical region. See supplemental document entitled HIV prevention in Ethiopia COP07 for program geographic coverage, population density information and health facility coverage. Linkages with additional prevention activities are discussed at the end of this document.

Amhara, Ethiopia's second largest region with a population of approximately 19,200,000 has the highest HIV burden in both urban and rural areas. 2005 ANC surveillance and Epidemic Projection Package (EPP) showed HIV prevalence of 4.2% (urban 13% and rural 3%). Approximately 13% of Amhara-based VCT clients were HIV+. Bahir Dar and Gondar Health Centers are ANC sentinel surveillance sites reporting 13.5% and 10.3% (2005). The 2005 EDHS indicates 1.8% females and 1.6% males are HIV+. HIV prevalence among couples reflects 1.4% male partner discordance and 0.7% female partner discordance. Individuals from surrounding villages are drawn to Bahir Dar, Gondar and secondary district towns by market days, governmental functions, economic opportunity (including commercial sex work) and family breakdown due to early marriage or divorce. Trafficking of women to Sudan also occurs. Early marriage and related sexual debut of girls below the age of 15 is common. Wife inheritance and additional female partners during peri-natal abstinence form low degree sexual networks. In addition, Bahir Dar and Gondar are major tourist destinations, have large student populations, host uniformed service facilities, and are centers of commerce and trade within the Amhara region, from Addis-based transportation drivers to long distance truck drivers originating the Port of Sudan. Recently, the roads connecting Bahir Dar and Gondar to one other, to Addis Ababa, Tigray region and Port of Sudan have been upgraded facilitating increased mobility and trade.

This activity is non-clinical and will implement within the facility catchments of several care and ART health networks (i.e. health centers and hospitals providing HIV clinical services) in/around Bahir Dar, Gondar, Debre Markos, Debre Tabor and Lalibela. Sexually active youth, especially girls 15-24, residing in these urban and peri-urban areas are considered most at risk due to their proximity to HIV prevalence in existing sexual networks in their communities. Men reporting multiple partners, deployed or transiting these areas are also highly exposed to HIV infection.

This activity has several components. One component is to provide comprehensive ABC interventions to MARP, through existing community structures and targeted outreach activities, in urban and peri-urban areas of high HIV prevalence. Family Health International will assume a facilitation role in the Bahir Dar - Gondar hub to support an enhanced HIV prevention "plus" approach with existing partners such as IOCC, Population Council, Health Communications Partnership, Private Sector Program (VCT), Family Health International (VCT and Palliative Care), University of Washington (ART), IntraHealth International (PMTCT), USAID's RH/FP partner and USAID's Livelihoods Security partners to support a context where safer sexual decision-making of MARP are enhanced. Existing community structures will be provided with technical assistance to strengthen BCC activities addressing social norms that negatively influence people's ABC choices. Activities addressing the community norms which sanction gender violence and rape, males having multiple partners, transactional and cross-generational sex and correct and consistent condom use will be widely implemented. FHI's existing Multi-Purpose Center and community-based care program will support outreach to persons living with HIV/AIDS to support secondary prevention efforts in discordant relationships. Outreach activities, through local organizations, will be implemented in market environments, tourist settings, public hot springs, bars, hotels, nightclubs in urban areas and truck stops where at risk populations congregate. FHI will collaborate with Abt Associates and TBD/Targeted Condom Promotion to support targeted condom distribution and BCC materials to MARP in settings (i.e. hotels, bars and night clubs) where sexual activities congregate. This component of the activity is anticipated to reach 17,000 MARP with repetitive BCC interventions, including one to one outreach, and referral to existing community services. Existing materials on HIV prevention will be adapted. Most at risk populations targeted include:

1) Commercial sex workers, their partners and clients; and 2) Youth 15- 24, specifically girls who are sexually active or in secondary school/college; 3) Males (urban-based) reporting multiple partners or within uniformed services and transportation sectors.

The second component is to support local indigenous partners to implement behavioral change interventions, including administrative and resource mobilization training, BCC implementation training, provision of BCC materials and equipment for implementation and partial activity grants to be leveraged against other funding sources. This component of the activity will support five to be determined local organizations with training opportunities for 75 persons on organizational capacity building.

The third component of this activity is to provide technical assistance to several government bodies with capacity building to implement evidence-based HIV prevention activities for MARP. Government bodies include: Amhara Regional HIV/AIDS Prevention and Control Office, Amhara Regional Health Bureau, Municipal Offices of Bahir Dar, Gondar, Mota, Debre Markos, Debre Tabor and Lalibela Administrations. Technical assistance will encompass experience sharing and best practices among USG partners in Ethiopia and Africa, training on HIV prevention implementation and implementation assistance to additional regional efforts funded by GFATM resources.

This activity will build linkages with additional prevention activities including Health Communications Partnership, Targeted Condom Promotion, Population Council, Private Sector Program, High Risk Corridor Initiative, National Defense Force of Ethiopia's HIV prevention activities, AIDS Resource Center. In addition, Family Health International will leverage community-level activities in the Counseling and Testing and Palliative Care areas.

Community-level Response to Palliative Care This is a new activity for FY07 which links to Care and Support Contract Palliative Care (5616); Care and Support Contract- HCT (5654), Care and Support Contract TB/HIV (5749), ART Service Expansion at Health Center Level; JHU (5618), ITECH (5767), UCSD (5770) CU (5772) palliative care activities.

Recent analysis of the health network by PEPFAR Ethiopia indicates there are limited linkages to and use of community-based care services. There is a lack of operational non-governmental services providers in most health networks. Furthermore, a limited number of indigenous organizations provide psychological and social services. To address this situation, this activity will augment the network capacity at community level. This activity will strengthen PEPFAR Ethiopia supported health networks associated with 28 high prevalence urban areas. FHI will strengthen the health network by addressing the critical community component and maximizing opportunities for wraparounds. An end of project evaluation indicated that PEPFAR Ethiopia supported FHI/IMPACT activity contributed substantially to the rapid increase of HIV services, including expansion of HIV CT services in 469 government and private facilities; establishment of TB/HIV and chronic care services at health center level; establishment of HCBC programs and mobilization of communities to engage in AIDS care and support, community-level ART and TB treatment adherence support; and development of multi-sectoral referral networks within and between community, health center and hospital services. While the facility-based services will be handled under the Care and Support Contract, FHI's community level role will continue in FY07 with special emphasis on increasing community ownership of HIV/AIDS services, strengthening and expanding PLWHA support groups and building capacity of indigenous organizations. FHI's international capacity and Ethiopia-specific experience in providing palliative care services at community level is a resource that can be used instrumentally for sustainability of PEPFAR Ethiopia programs.

During COP07, this activity will strengthen the health network by increasing the capacity of indigenous CBO and FBO. These organizations will strengthen home and community-based care programs to provide palliative and preventive care from the moment of diagnosis through end-of-life, and to enable widespread community-level engagement in advocacy, networking, caring for OVC and provision of quality integrated general palliative care services at all levels.

The activity will also strengthen the capacity of indigenous organizations to provide independently quality palliative care and preventive care packages. These services will include adherence to OI and ART, referral of household contacts for VCT, screening for TB, nutrition counseling, prevention for positives, stigma reduction, community planning and mobilization thorough the engagement of community-based volunteers, care for OVC, home and community-based care providers, PLWHA associations, idirs, youth groups, women's associations, religious leaders and the community at large.

A family-centered approach to palliative care will continue to be promoted, including care for adults and children. The family-centered approach is key to strengthening pediatric palliative care by referral of children and family members on home and community-based care for HIV counseling and testing and TB screening. This activity will work with volunteers and local kebele HIV/AIDS committees to identify and refer OVC who are family members of PLWHA on HBC care. This will involve promoting and facilitating access to reproductive health (RH) and family planning (FP) services for palliative care clients, and PMTCT counseling and support for PLWHA desiring children.

This activity will work with CBO, FBO, communities and HIV/AIDS Prevention and Control Offices to: (1) Build capacity of community groups and indigenous organizations to mobilize resources for HCBC services. (2) Establish and/or strengthen community HIV/AIDS committees on indigenous resource mobilization, CBO/FBO planning and management. (3) Build the capacity of PLWHA associations in advocacy, media relations, resource mobilization and provision of palliative care services. (4) Train community groups on effective ways to access services, consult with providers, and work with case managers to ensure quality care. (5) Establish community-based palliative care support groups who will support their

members in treatment adherence, stigma mitigation, information exchange on utilization of preventive care services (6) Train a pool of HBC palliative care master trainers to support CBO, FBO and communities. (7) Distribute tailored communication tools to support palliative care efforts of the community-level partners described above.

This activity will involve limited provision of equipment, including bicycles and commodities, to facilitate linkage between HCBC services. It will collaborate with US Universities and the Care and Support Contract to ensure strong and functional multi-sectoral referral networks. This activity will build capacity of community organizations within the health network to map existing services in their communities, develop service directories including contact info, regularly update the service directories, and share and utilize the service directories throughout the health network to ensure that palliative care clients receive services to meet their diverse needs. It will also build capacity of the community referral networks to develop and utilize user-friendly referral systems and tools to track referrals made and received and to match these per client.

All of this activity's palliative care support efforts will be underscored by gender equity and empowerment. This includes but is not limited to assessing and addressing barriers which limit access to general palliative care and support for women and girls with HIV/AIDS, and ensuring that both male and female volunteer care givers and community workers are engaged in palliative care efforts.

During FY07, this activity will support expansion of community and home based palliative care support services to 28 high prevalence urban and peri-urban communities within the health network through sub granting to local indigenous organizations. This activity will provide TA to strengthen the synergy and close collaboration with other partners, including US Universities, CSC, the WFP, IntraHealth, RPM+ and PSCMS, ABT, injection safety, reproductive health services, and re-service training. The activity will be focused on building capacity of the MOH, HAPCO, regional Health Bureaus (RHB), HCBC program managers, health extension workers and community groups including PLWHA groups to effectively manage implementation and quality assurance of integrated holistic general palliative care services at community level.

Community-level counseling and testing service support in Ethiopia

This activity is linked to the High Risk Corridor Initiative (5719); Mobile and Private Sector Counseling and Testing Services (5718); Care and Support Contract Palliative Care (5616), Care and Support Contract counseling and testing (5654), and ART Service Expansion at Health Center Level.

This is a continuing activity. To date, the partner has received 100% of FY06 funds and is on track according to the original targets and workplan. Through IMPACT, FHI has played a leading role in HIV C&T service scale up in Ethiopia, supporting C&T service establishment in 469 government health centers in the country, establishment of C&T quality assurance systems and tools, establishment of counselors' support associations in four major regions In FY05, FHI IMPACT supported 288,000 clients to receive CT services at the community level. In FY06, FHI IMPACT significantly contributed to country targets using FY05 funds.

Based on preliminary ANC and EDHS analysis, HIV prevalence is mainly concentrated in urban and peri-urban areas throughout Ethiopia, and overall prevalence appears to be much lower than previously projected. Although several rural hotspots have been identified for enhanced HIV service delivery, it will be necessary to reach substantially higher numbers of at risk populations through targeted outreach activities in these areas. At present, community-based VCT coverage is low beyond Addis Ababa. Furthermore, access to CT services in the regions is minimal. Maintenance of existing services is made more difficult because of frequent supply shortages. For these reasons, facility based CT services are unable to meet current demands for testing.

This activity will support the expansion of highly targeted VCT services to most at risk populations including: HCBC households and family members, areas of mass congregations of the general population in urban areas (through FBO collaborations) and MARP including migrant populations, female sex workers, girls 15-19 (especially out of school) and street children and adolescents. In addition, FHI will partner with community organizations that can access large at risk populations and maximize intake of high yield clients through fixed sites in urban and regional capitals and secondary towns along transportation corridors identified as hot spots. Furthermore, FHI, in collaboration with USG partners, will prime demand through a VCT promotion campaign that targets MARPS and is linked to HIV prevention efforts (See FHIAB and OP activities in the prevention program area). Client uptake from these MARPS is crucial if PEPFAR Ethiopia is to reach its care and treatment targets.

FHI, building on the IMPACT project will further expand VCT services at the community level in high prevalence areas using simple testing techniques, such as finger prick testing and DBS for QC. This activity will be linked to CDC/EHNRI's Laboratory Services, BERHAN, US Universities and existing HIV outreach activities. This activity will: (1) Establish integrated outreach VCT services within existing HCBC programs targeting household members of PLWHA, (2) Ongoing counseling services for PLWHA with strong emphasis on prevention for positive counseling and positive living (3) Establish and strengthen youth-friendly VCT services and outreach in clinics in university campuses, public and private colleges in high prevalence areas, (4) Integrate promotion and referral for VCT into inter-personal HIV prevention programs for MARPS (5) Establish and/or strengthen VCT services, in collaboration with Woreda health offices and Health Extension Workers in identified rural and peri-urban "hotspots" and outreach VCT services to high risk migrant agricultural communities.

FHI will work with the MOH and RHB to operationalize and standardize the utilization of whole blood (finger prick) rapid testing to enable non-laboratory CT staff, including lay counselors, to perform the HIV test and give same-hour results.

This activity will provide technical assistance that includes: (1) Training will be conducted to enable referral between community and health facility-level services and the involvement of youth-friendly approaches. Special attention will be given to the needs of girls and young women that includes reproductive health

referrals, PMTCT counseling, the promotion of HIV prevention to discordant couples and clients, 2) Target men and women more than 29 years of age at (higher HIV prevalence and lower VCT uptake among this group according to the preliminary ANC and EDHS data) (3) Engage private health care services in rural areas, in collaboration with Abt Associates, to provide quality VCT services at low cost, respecting RHB quality control and providing all VCT service data to the RHB, in exchange for free test kit supply by the RHB, (4) Ensure that condoms are available in all community VCT services and outreach activities and that condoms are provided to HIV+ clients, (5) Ensure that community VCT service providers as well as lay counselors take clinical histories to elicit if the VCT clients have symptoms of TB or OI, and refer to the health network, (6) Ensure practice of universal precautions in community VCT service provision and related waste management, (7) Support RHB to assure quality assurance of VCT services.

Provide supportive supervision at mobile-outreach community sites (non health center) and provide coaching and mentoring to improve service quality and data management. Collaborate with SCMS and GFATM to ensure logistics and supply chain management of HIV test kits and essential supplies are available. In addition, FHI will procure emergency stocks of commodities and provide limited supplies and equipment (including bicycles or motorcycles) to community-level partners to catalyze service coverage.

PLUS UP FUNDING: PEPFAR will support the GOE plan to expand the successful pilot of Community Counselors for HCT provision under the broad framework of task shifting in HIV/AIDS prevention, care and treatment activities. The introduction of community counselors (lay counselors) into public health facilities in September 2006 boosted VCT uptake and decreased the burden on health care workers; the counselors also conducted large numbers of HIV rapid tests. The pilot was a great success and the Federal HIV/AIDS Prevention and Control Office (FHAPCO) plans to deploy an additional 700 community counselors in hospitals and health centers in the next few months. The government secured funds for recruitment of 743 lay counselors (including the existing 43). PEPFAR support through the plus up will used for 6-week training courses for 700 lay counselors, logistics, training follow-up and evaluation of the community counselors' performance. The project will be implemented jointly through JHPIEGO and FHI.

ART Service Expansion at Health Center Level

Award expected in December, 2006. This is a continuing activity from FY06 currently being conducted by FHI. It continues supplemental activity conducted by FHI for the expansion of antiretroviral therapy (ART) decentralization to health centers. To date, the partner received 100% of the FY06 funds and is on track according to the original targets and workplan. The partner has coordinated the assessment of 120 health centers for site ART readiness and trained 402 health professionals in 11 regions, in close collaboration with WHO, with existing funds. This is a critical activity that is linked to care and support, ARV Services (5658) and Technical Support for ART Scale-up, allowing PEPFAR Ethiopia to meet ART country targets and to ensure quality of patient care through fully functional HIV service networks.

In FY06, the Government of Ethiopia rapidly expanded access to ART at health centers. Supporting this effort, a site readiness assessment was carried out by the USG at 120 health centers. Human resources consisted, on average, of one health officer, one lab technician and a few nurses at each site. As this shows, health center ART readiness is hampered by basic infrastructure inadequacies in, human resources, and by administrative capacity of woreda health offices and RHB. Despite these findings, the Government of Ethiopia remains committed to implementing HIV care and treatment services including ART at health centers. Without adequate investment in operational readiness, however, the quality of ART care for patients will be compromised.

This activity addresses ART service expansion at health centers by increasing their operational capacity to manage ART services, including integration into the health network. ART services will be supported with the following activities:

1. Operational site readiness: Human resources will be strengthened through training in multiple program areas and supportive supervision in conjunction with Government of Ethiopia personnel. The activity will facilitate training on HIV disease management and ART services, including adherence counseling, nutrition, case management, laboratory and pharmacy services.

In close collaboration with RHB and woreda health offices, Standard Operating Procedures or clinical care protocols will be implemented with other relevant stakeholders and partners. To strengthen clinical management in the ART health network, mentoring and monitoring of ART patients with experienced hospital and private sector clinicians will be organized, helping build provider capacity to manage patients and improving patient care.

2. Commodities: The activity will complement the focused activities of USG partners in supply chain and pharmacy management, collaborating with RPM+ and PSCMS to ensure that their interventions achieve maximum impact at site level. The project will work with relevant PEPFAR Ethiopia partners and key stakeholders such as the HIV/AIDS Prevention and Control Office (HAPCO), implementer of the Global Fund To Fight AIDS, Tuberculosis (TB) and Malaria ((GFATM) grants, complementing their efforts to strengthen laboratory services at 240 ART sites.

3. Health Management Information System (HMIS): Site level ART patient monitoring will be enhanced through collaboration with Tulane University's health center-level HMIS activities supporting an ART patient tracking system, with data clerks trained in this paper-based system by Tulane. Through this activity community networks supporting adherence, follow-up and new patient intake will be strengthened. This activity will also support community-based organizations to strengthen monitoring for ART adherence and follow-up. This will facilitate multi-agency referral channels for clinical and non-clinical services to reinforce the existing continuum of care and treatment.

4. Infrastructure and Equipment: This activity will assess and prioritize renovation needs at health centers in collaboration with Crown Agents, to ensure a synchronized scale-up of ART service capacity in high client flow sites. There will a needs assessment to look at what basic medical equipment is required to support delivery of a minimum ART service package. Additionally, procurement coordination with woreda health offices and USG partners will leverage GFATM resources.

5. Network implementation: patient-centered approaches: This activity will be linked with multiple services in health centers and hospitals to support integrated ART services. Furthermore, this will be integrated with the Care and Support Contract (CSC) activities, linking households and community members to the health networks through outreach efforts by USG and Government of Ethiopia supported community outreach workers, community based organizations (including Idirs), private providers and case managers.

This activity will support ART services at 240 health centers. By the end of COP07, through linked activities within palliative care, services will be extended to support 500 health centers and community-based care. The CSC provides rapid expansion of health services among three progressively more comprehensive tiers. The first tier, 500 health centers, offers basic services including TB/HIV and VCT. The second, with 393 health centers, offers TB/HIV, VCT and palliative care services. The third tier, at 240 health centers, offers ART as well as the above services (see the Annex- for more details). This activity will support all links in the ART and care network continuum, from patient and household to community, health center and hospital, with a focus on the delivery of ART services at the health center and community level. In close collaboration with CDC Ethiopia, the PEPFAR Ethiopia lead agency in the transport of samples to hospitals from health centers, this activity will facilitate patient receipt of critical lab results. Furthermore, by leveraging previous PEPFAR investments at the hospital level, laboratory linkages to hospitals will be maximized to ensure that patients who present with complicated case diagnoses will receive further laboratory services, with specialized equipment at hospitals functioning optimally through effective health network implementation.

6. Support to Nurse-centered ART Service Delivery at Health Center Level through I-TECH, University of Washington and Hadassah University, Jerusalem: FHI's ART site readiness assessment showed that highly capable nurses are present in larger numbers at the health centers assessed, though more personnel of all types are needed. In response to this situation, the MOH is supporting the initiation of nurse-centered HIV/AIDS services, featuring task-shifting, particularly in the area of ART services.

Supporting ART service delivery at the hospital level, in the last two years the Hadassah University AIDS Center (HAC), in collaboration with PEPFAR Ethiopia partner I-TECH, has implemented training of trainer (TOT) courses in integrated HIV/AIDS patient care. A total of 40 Ethiopian physicians, nurses and laboratory staff have been trained so far in Israel.

To support the current country-wide decentralization of ART services, the HAC will collaborate closely with the World Health Organization, the Care and Support contractor, and the four US universities currently supported by PEPFAR Ethiopia.

The Care and Support Contract will support Hadassah in identifying nurses who can serve as trainers supporting nurse-initiated ART, and will coordinate with these personnel on their return to support follow-up activities in Ethiopia. The Care and Support Contract may also collaborate with Hadassah in designing and implementing the evaluation of the nurse-centered ART model, focusing on programmatic factors that may affect ART effectiveness.

This is a continuing activity from the COP06 Supplemental. The Government of Ethiopia has prioritized the expansion of ART to primary care centers on a National scale. To support the Government's priorities, PEPFAR Ethiopia supported ART services in 115 health centers in 2006/2007 through Family Health International in Addis Ababa, Amhara, Oromia, SNNPR and Tigray . In underserved regions, US Universities provide ART services in 11 health centers. During 2007, PEPFAR Ethiopia envisions approximately 240 health centers to be supported with comprehensive HIV/AIDS services including ART. The purpose of this reprogramming request is to facilitate expansion of ART at health centers, and to support the transition of technical assistance from Family Health International to a TBD contractor under the Care and Support Contract. This activity will be coordinated through RHBs, Zonal Health Departments, where available and Woreda Health Offices. US Universities will support Health Center laboratory needs including the transportation of specimens, training, supportive supervision and stocking labs with appropriate supplies.