PMTCT/Health Centers and Communities

This is a continuing activity from FY06. As of May 2006, the partner received 100% of FY06 funds and is on track according to the original targets and work plan. As of Sept. 2006, 145 health centers implemented PMTCT services. This activity relates to IntraHealth/ANECCA (10652) supporting pediatric case finding and post-partum follow-up, Food 10398 by Prescription (Palliative Care) and IntraHealth and JHPIEGO/Mothers to Mothers Support Groups (10633).

This activity is linked with: Prevention - Making Medical Injections Safer/JSI,(8094) inother/policy local voices (10381) Communication/IEC - InterNews; Care/Support - CT, TB/HIV, Palliative Care: BERHAN pallative care (10647) TB/HIV (10400)CT (10399) at health centers, support groups for HIV + women, PLWHA associations, Treatment Services -IMAI/WHO, LMIS/MSH for ARV (10534) and related commodities, Pediatric (10436)ART/Columbia University(10436), User Support Center for ART Service Outlets(10550)/Addis Ababa University.

COP06 Summary: Between 10/2005 and 6/2006, supported health centers served 11,408 pregnant women with counseling and delivered 315 women with single dose NVP. HIV prevalence in sites ranges from 3.1 to 12.5 percent in peri-urban health centers to 8.0 to 16 percent in urban health centers. Furthermore, a well-developed community-level mobilization campaign has reached households around 131 health centers and continues to be expanded. Partner invitations have improved male involvement in counseling and testing, labor and delivery. In Modjo health center, all HIV+ mothers returned for assisted delivery. In Soddo health center, all HIV+ mothers return monthly for post-partum follow up including infant provision of CTX. Significant involvement of regional health bureaus and district health offices led to joint analysis of service statistics, quantification of commodities, strengthened linkages with hospitals, and monitoring of quality of care. Pilot Mother to Mother support groups that have waiting lists due to popularity are being expanded in a new activity by IntraHealth. Additionally, ANECCA, based on strong experiences in East Africa, will provide this activity with experience sharing to rapidly expand pediatric case finding, post-partum follow up and pediatric care package delivery.

This activity will collaborate with USAID/Ethiopia's MCH and RH/FP programs. This activity supports wrap-arounds in food and nutrition with the World Food Program (OVC) and income generation activities with DAI's Urban Gardens (Palliative Care). To support coordinated outreach, this activity will collaborate with US University partners to improve access for health center attendees for hospital pediatric/adult care and treatment and laboratory services. This activity will continue to support the PMTCT Secretariat to support USG and non-USG partners and UNICEF to synchronize PMTCT assistance.

COP07 Proposed Activities: This activity has several components. One component will support 267 health centers to support clinical PMTCT services. In collaboration with the Care and Treatment RFP (i.e. BERHAN), IntraHealth will graduate sites falling within ART health networks to the new mechanism and expand to complement non-ART and non-network health centers. This is possible given standardization of trainings through IMAI, health center staffing size and intensive site-level mentoring and assistance provided through the new mechanism. The scheduled of assistance is noted: 9/2006 145 health centers 4/2007 267 health centers 6/2007 267 health centers (25 ART health centers graduate to Care/Treatment RFP, 25 new) 9/2007 267 health centers (50 ART health centers graduate to Care/Treatment RFP, 75 new) 12/2008 267 health centers (25 ART health centers graduate to Care/Treatment RFP, 25 new) 4/2008 267 health centers (50 ART health centers graduate to Care/Treatment RFP, 75 new)

Technical assistance will include: 1) Training to deliver elements of the adult and pediatric preventive care package at ANC, including referral to non-PEPFAR services (i.e. FP, CSH, Malaria); 2) Coordination of outreach services (lab and pediatric treatment) with US Universities at

health centers; 3) Supportive supervision for health providers to strengthen performance and referral patterns; 4) On the Job training of national PMTCT curriculum including opt-out CT, utilization of HMIS, implementation of PMTCT guidelines (including use of AZT/NVP and HAART), TB/CD4 screening procedures, and stigma reduction with health providers; 5) Provision of basic commodities such as gloves, goggles, smocks, privacy screens and non-monetary incentives schemes; and 6) Coordination with Crown Agents to synchronize renovations in health center MCH service areas.

The second component of this activity will include non-clinical support to health providers such as facility client flow solutions, training on provider stigma reduction, performance factors, target setting, root-cause analysis, non-monetary motivation schemes, improving facility environment for friendly services, and distribution non-clinical supplies and IEC materials. The third component of this activity will include community based mobilization efforts through a community action for behavioral change approach (CABC), a capacity strategy that empowers communities to explore and identify local resources and response to problems. This activity will implement CABC using community-level, family centered approaches. Firstly, 22 sub grantees will develop the capacity of community core teams (CCTs) and village facilitators to generate community-wide dialogue on key health themes including HIV prevention, ANC attendance and CSH. CCT's will be established around each health center. Each team will support 40 village facilitators who deliver messages to 250 households a year (total of over 66,750 households). In addition, partner involvement methods such as invitations to attend CT, LD, follow up activities and participation in Father to Father groups will continue.

The fourth component of this activity is advocacy based, focusing on the Ministry of Health and Regional Health Bureaus to place a greater emphasis on implementation of revised PMTCT guidelines, the uptake of ANC and PMTCT services by exploring pilot models such as the integration of ANC/PMTCT outreach with IMCI campaigns at the health post and PMTCT mobile services with preventative care package partners. In addition, IntraHealth will collaborate with USG partners to monitor ARV prophylaxis supply to HIV+ pregnant women via traditional birthing attendants.

This activity will continue to build joint Contractor/regional and district health office supportive supervision to health centers. This built greater ownership of the program among public health officials.

Target Development

Assumption: 85 percent uptake of CT by ANC attendees in new sites. 8 percent are HIV+. 80 percent uptake of ARV prophylaxis and infant CTX. 60 percent referral for CD4 screening.

Local subgrantees: BethaZatha Health Service; Anti Malaria Association (Bahir Dar, Adet and Woreta); Beza Youth, Yirgalem; Ethiopian Red Cross (Assosa, Bambassi and Arbaminch); Hiwot Ethiopia (Kebena, Selam and Bole branches); Ethiopian Evangelical Church (Hossaena, Butajira) Organization for Social Services for AIDS (Adama, Modjo, Wolenchiti and Dhera branches) Abebech Gobena (Fitche and Ginchi); Jember Art (Assaiyita); ISAPSO (Lideta, Teklehaimanot and Addis Ketema branches); Netsebrak Reproductive Health and Social Development Organization (Dessie, Bati, Haik and Kombolcha branches).

Psychosocial Counseling Services Support Groups for Mothers to Mothers to Be

This is a new activity.

During COP05, IntraHealth implemented a pilot Mothers to Mothers support group at four health centers under the activity PMTCT/Health Centers and Communities (10615). Two USG technical assistance visits, PMTCT and Food & Nutrition, recommended a broad expansion of Mothers to Mothers groups given positive impacts on psychosocial support and postpartum follow up options. In addition, a new Food by Prescription activity, outlined in PMTCT and Palliative Care will support HIV positive lactating women until weaning and exposed children until 24 months of age. The Mother to Mother support groups (M2M) are convenient methods to deliver post-partum follow up services. Community action initiatives also increase usage of related MCH services, such as family planning, improved nutrition practices, male involvement, combating stigma and discrimination, and strengthen referral systems for HIV+ women and families. Since the establishment of the M2M in November 2005, a total of 160 HIV+ women and 36 male partners have joined the group in the three health centers in Addis implementing the program. At the pilot sites the M2M group meetings also provide the opportunity to offer and deliver health services. The most direct services include OI prophylaxis for babies as well as starting and continuing ART treatment for mothers and children. Related services which are also provided immediately before, during, and immediately after Support Group meetings include family planning, partner involvement, and general immunization services. Most simple services are delivered by the Mother Mentors (e.g., Family Planning counseling) and require no additional health staff. In this way, the program leverages the small investment in supporting the M2M Support Groups to deliver a multitude of other services at no additional cost in human resources or physical infrastructure.

Proposed COP07 Activities: This activity, in partnership with JHPIEGO, will support a broad expansion of network-focused M2M support groups at the community level. This will prioritize networks of high client flow with above average HIV prevalence while accounting for newly decentralized ART services to health centers throughout the country. In addition, the activity will work closely with Regional Health Bureaus, IntraHealth sub-grantees and JHPIEGO to standardize implementation of Mother to Mother models.

M2M groups are formed as referrals from the PMTCT process. Mothers who are found HIV+ are encouraged to join an existing support group with other HIV+ mothers. Each group meets once a week for two hours. Meetings are led by Mother Mentors who receive five day training by IntraHealth.

The selection criteria for Mother Mentors include a willingness to be a mentor and disclose HIV status with peers; an ability to read and write (8th grade complete); and a willingness to spend at least 3 full days per week supporting HIV+ mothers at a determined location.

Training for the Mother Mentors includes general HIV-related primary and secondary prevention information, positive living, Pre-ART and ART, stresses adherence, discusses disclosure, provides nutritional counseling, and referral information on family planning. Mother Mentors receive volunteer stipends of approximately $20 per month. The stipend covers transportation and DSA for three day per week mentorship services.

In addition, during the congregation of HIV+ women and exposed children, specialized services such as pediatric care and treatment will be focused. In addition, partner involvement will be encouraged prioritizing the family unit. A menu of available health services will be developed by Mother Mentors in coordination with local health centers and hospitals. For each service, the Mother Mentor will either provide the service (i.e. secondary prevention lecture) or arrange for a health provider or USG contractor to assist. Likewise, a menu of educational topics will be developed, each backed up by supporting educational materials. With the help of the Mother Mentor, groups will select the educational topics which are most relevant. In addition to ongoing technical support through mentorship to Mother Mentors, the activity will cost share with district health offices to initiate support groups by procuring basic furniture, cassette players and IEC materials.

Activities during the support group meetings include: educational presentations on related health topics by the Mother Mentors, educational videos, guided discussions of topics of concern to the group members, and a chance for socializing and mutual support to other mothers in similar circumstances; mothers who are new to the program receive support and guidance from those with more experience. Demand for inclusion in the M2M has far exceeded capacity (availability of rooms and additional mentors). In one site, six groups are run per week, with 8-12 members per group, and currently 30 women are on a waiting list to be enrolled in the support groups.

Building on the early success of the M2M pilot sites, the activity will formalize the process for establishing and scaling up access to the M2M program to 50 ART health networks (i.e. community groups serving both hospitals and health centers) with high ANC client volume and relatively high HIV prevalence. This may include establishing several M2M groups where clients exceed existing capacity.

Several standard processes are required to scale up M2M: referral criteria, selection criteria for Mother Mentors, standard operating procedures, incentive structure of Mother Mentors, adapting existing curricula on adult communication and low literacy environments, HIV stigma, primary and secondary prevention, care and support, and treatment adherence and nutritional counseling. In limited instances, at risk mothers likely to drop from follow up will be tracked and encouraged to rejoin clubs for up to 24 months. This provides a critical junction to ensure referral for clinical care and CD4 screening. Furthermore, the delivery of pediatric and adult preventive care packages and food by prescription will support the PMTCT and palliative care programs achieve efficiencies in reaching individuals. A total of about 2300 HIV+ women are expected to be enrolled to the M2M program in one year.

In addition to standard indicators, the activity will track four additional indicators: 1) Number of M2M support groups established. 2) Number of HIV+ women enrolled in M 2 M program. 3) Number of HIV+ women linked to various treatments, care and support programs including ART, OI, FP, Pediatric care. 4) Number of Mother Mentors trained

Expansion of PMTCT to Private Health Facilities (New) This is a new activity in COP07. This activity relates to Abt Associates (TB/HIV) (10375)and Abt Associates (ART Services)(10379).

This activity will support the expansion of PMTCT services in Higher Clinics with ANC and delivery services and non-governmental MCH clinics in urban areas of Addis Ababa, Amhara, Dire Dawa, Harar, Oromia and Tigray. Building on several activities that are expanding HIV services (i.e. VCT, TB, ART) to private health providers, this activity will standardize regional policy on private provider involvement in PMTCT service provision, including training, reporting and delivery.

Based on several recommendations from the USG private sector technical assistance visit in August 2006, PEPFAR Ethiopia is expanding its approach to strategically target activities and audiences that may identify HIV+ persons and link them to care, utilize a broad range of private sector partners, including pharmacies and lower level clinics to identify pregnant women, and direct them to treatment.

According to the EDHS 2005, HIV prevalence is highly concentrated in urban and peri-urban areas among female populations in their reproductive years. In addition, place of delivery indicates a presence of private health providers who play important roles in delivery throughout Ethiopia. Although limited to approximately 0.5 percent of total deliveries in Ethiopia, approximately 11 percent of deliveries in Addis Ababa are within the private sector. In addition, those delivering in private facilities typically have a higher education and fall within a higher wealth quintile. Furthermore, 17 percent of all women (urban and rural) receive family planning services from the private sector. Regional capitals and large towns, such as Awassa, Bahir Dar, Dessie, Dire Dawa, Mekele and Nazareth, are key centers to expand the ART health network to capture those living with HIV/AIDS that will not initially attend services at public facilities.

COP07 Proposed Activities:

This activity will implement a private sector initiative in 75 private sector health care facilities in major urban areas of several regions. These private sector clinics cater ANC services to an estimated total of 120,000 pregnant women per year.

This activity has several components:

(1) Policy: Existing PMTCT guidelines will be operationalized in private sector settings. In addition, operational guidelines will set standards for professional training and qualifications of those practicing in private service outlets. Adaptations of some IEC materials will be necessary. This will be completed through stakeholder engagement. Private sector service outlets will use the same clinical protocols and performance standard for PMTCT as those in the public sector.

(2) Expanding PMTCT Services: Interest building meetings with selected private sector facilities will market PMTCT service delivery, financing mechanisms (i.e. acceptable service charges) and manage expectations of USG technical assistance among those interested in joining a broader network of providers.

(3) Training: Utilizing commercial training providers and pre-existing materials, the activity will adapt some curriculum delivery elements to accommodate professional learning. In addition, on-the-job trainings will last approximately seven days. As an added benefit to the sites, the supervision curriculum will include the supportive supervision skills that have been successful and widely accepted in the public sector health centers. Private providers will receive a similar package of technical assistance as public health centers.

The activity will engage faculty from prominent medical colleges and universities to support enhancements in pre-service training options for nurses, health officers and physicians. We anticipate this will be a major cost-sharing opportunity utilizing private faculty to expand the pool of nurses sensitized to PMTCT service delivery and ancillary subjects.

(4) Quality Control: This activity will support regional health bureaus and city

administrations monitor private sector quality of care. In addition, this activity will build on experiences from the Abt Associates Public Private Mixture DOTS activities in TB/HIV which has supported the concept of government stewardship among the Federal TB and Leprosy Control Program and regional health bureaus to facilitate private provision of services with regulatory oversight. Joint supportive supervision and quality inspection visits will be conducted with the appropriate health authorities during the course of the project.

5) Monitoring and Evaluation: This activity will integrate private providers into the national HMIS. At present, reporting is inconsistent and of poor quality. In addition, the activity will incorporate and analyze quality metrics and analysis to support government stewardship function.

Supporting activities in the private sector could (significantly) increase access to PMTCT services and increase the number of transmissions averted. This activity will implement a private-sector initiative in 75 private sector health care facilities in 4 regions (Addis Ababa, Oromia, Amhara and SNNPR) to complement the existing PMTCT services being delivered in public facilities in these regions. In this manner, a broader network approach will capture those with greater likelihood of living with HIV and support those individuals with PMTCT, care and treatment options.

TBA/HEW Involvement in PMTCT Services

This is a new activity in COP07. An exploratory analysis of traditional birth attendants (TBAs) and health extension workers (HEWs) was funded in a COP06 supplemental to IntraHealth International. This activity will collaborate with PMTCT partners IntraHealth (10637, 10615, 10633), Columbia University, (16452) and the University of Washington. In addition, this activity will collaborate with the Care and support contract (10647) (formerly called BERHAN).

According to EDHS 2005, 94% of all expectant Ethiopian women deliver outside health facilities. Over half (57%) of urban-based deliveries are in the home. Furthermore, 6 % of all births are assisted by health professionals, 28% by traditional birth attendants and 61% by relatives. Assistance by health professionals and traditional birth attendants during birth is segmented between urban (47% and 23%) and rural (3% and 29%). Furthermore, 94 percent of women do not return for a post-natal checkup. In urban areas less than one-third (31 percent) of women return for a post-natal checkup within two days compared to just 3% for rural women. A large proportion of the mothers who should benefit from this intervention are not being reached. With such a low proportion of pregnant women actually using health facilities for delivery, health facility-based efforts to deliver PMTCT could end up having far less impact on mother-to-child transmission of HIV than should ideally be the case.

In this context,TBA have traditionally assisted mothers in sub-Saharan Africa to deliver and have been trained in several midwifery skills. They are highly trusted and respected by communities, and could effectively administer PMTCT. In addition to TBA, HEW are a new cadre of health worker is placed at the community level to serve several villages (i.e. Kebele) in peri-urban fringe and rural areas. In total, we anticipate 30,000 HEW will be deployed by 2010. The HEW is the first point of contact at the community level for the formal health care system. The HEW reports to public health officers at the health center and is responsible for a full range of primary and preventive services at the community level. They function as a significant and new link in the referral system and will be able to, through community counseling and mobilization, move vulnerable and underserved populations into the formal health system.

Although PEPFAR Ethiopia has invested considerable support for facility-based PMTCT services, social and community issues affect the implementation and efficacy of current PMTCT interventions. In response to EDHS 2005 findings as well as PMTCT program performance, a re-structuring and re-orientation of programs to ensure a better "fit" between health systems and the needs of communities they serve is underway.

PEPFAR Ethiopia's focus on facilities within the ART health network did not adequately address the critical layer between the primary health care unit and the community level. In COP07, PEPFAR Ethiopia will support several activities that will strengthen the primary health care unit and community interface in urban and peri-urban areas. This activity will cluster technical assistance for PMTCT involvement to TBAs and HEWs in/around peri-urban/rural areas where HIV prevalence is projected to be above regional averages and where ART health networks are available.

This activity has three components: (1) Advocacy and Organization: This activity will utilize the IntraHealth exploration of TBA and HEW involvement in community PMTCT service delivery to be conducted in COP06. Utilizing this document, PEPFAR Ethiopia and PMTCT partners will collaborate with the contractor to engage regional health bureaus and the Ministry of Health to pilot several activities under close supervision. PSCMS will support deployment of Nevirapine to TBA and HEW's participating in the pilot.

(2) Recruitment and Training: This activity will mobilize senior TBAs and deployed HEWs to participate in the activity and train them on the following roles: provision of HIV/AIDS education to clients, mobilization of women for VCT, directly observed treatment supporters for HIV+ mothers who have received Nevirapine and deliver at home, client confidentiality, and referral of these mothers to health facilities postnatally to allow their infants to receive Nevirapine syrup. Additionally, TBAs and HEWs will be provided basic equipment (torches, gloves, aprons, clean gauze, safe delivery kits, etc.) and integrated

into the district's health information management system to record the number of women they deliver and provide PMTCT services. The contractor will devise non-monetary schemes to support TBA and HEW involvement in referrals for VCT and ANC, completion of delivery of NVP to mother infant pairs, reporting to the district health office or health center and referral for postpartum follow up. It is anticipated that TBA and HEW participants will refer pregnant women for counseling and testing. In some instances, pilot home-based counseling and testing may be utilized to determine uptake of service. (3) Quality Assurance and Supervision: The Contractor and appropriate regional health bureau and district health office staff will jointly facilitate and supervise the implementation. Routine analysis of TBA and HEW reports will permit a review of the overall approaches used in the activity. Several review workshops will be held with TBA and HEW participants, primary health care providers and regional bureaus.

Traditional birth attendants constitute an extensive network, potentially capable of expanding and simplifying access to comprehensive HIV care through various entry points. Most TBA are eager to collaborate but few have been involved as yet. Health Extension Workers, though recently deployed, will quickly become important figures in communities given access to medical commodities.

This activity's geographic coverage is anticipated to be in selected peri-urban/rural hotspots in Amhara, Oromia and Tigray based on ANC and EDHS analysis.

The projected deployment will be 50 TBA and HEW participate in each region Amhara, Oromia and Tigray. The overall HIV prevalence for these four regions is 2.5%.

Comprehensive OVC care through Mother to Mother programs

This is a new activity for FY07. This activity is linked to Food Support of PLWHA (5774), Prioritizing Pregnant Women for ART (6637), and PMTCT/Health Centers and Communities (5586).

FY07 PLAN: PEPFAR Ethiopia proposes that OVC program will link with an expanded PEPFAR supported "Mothers to Mothers" program to reach clinically malnourished OVC, especially those under 5, and their families with nutritional inputs (food-by-prescription (FBP)) as part of comprehensive support to OVC. The PEPFAR food and nutrition guidance recognizes the greater vulnerability of children born to HIV+ mothers, especially children under two years. With Ethiopia's low HIV prevalence and low PMTCT and ART uptake, identifying these children is challenging, especially doing so without generating stigma and discrimination. Many infants born to HIV+ mothers are part of households with other OVC. As the average household in Ethiopia has five children, World Food Program, with Title II inputs, will be leveraged to address the nutritional needs of other OVC in the family, whose mothers are in the support groups and receive FBP.

This activity provides an opportunity to link OVC with comprehensive care and support services through health facilities and community-based programming. The recipient will partner with IntraHealth, PEPFAR's lead PMTCT provider, and work closely with existing OVC PEPFAR partners to provide integrated services to OVC and their caregivers.

OVC programs, nearest to the 70 health centers hosting the Mothers-to-Mothers support groups, will partner with IntraHealth. This support group program is designed to assist women living with HIV and their families. Groups meet in health centers facilitating improved linkages to a continuum of HIV prevention, care and treatment services. OVC program partners will make referrals, especially of most vulnerable girls, to the program, follow up on the support received, and provide additional services to the children (e.g., education, psycho-social support, protection) of participating mothers. The connection with the health facility will increase access to child health services (immunizations, vitamin A supplementation, treated bed nets, treatment of childhood illnesses). OVC caregivers participating in the groups will receive training and support in nutrition and education, child feeding, child development, adherence counseling, health care, and the HIV/AIDS continuum of care. Linkages with OVC programs will provide access to economic strengthening activities for OVC caregivers in the support groups.

The Mothers-to-Mothers program fills a large gap in bridging health facilities with OVC programs. The intended result is strengthened referral networks in HIV/AIDS high prevalence areas that provide comprehensive care for the most vulnerable children due to HIV/AIDS. Young girls affected by HIV/AIDS, especially orphans, are more likely to be raped or forced into early marriage. Referrals to counseling and testing, ART, and PMTCT programs and related follow up are core features of the Mothers to Mothers program. OVC programs will reinforce these activities.

In partnership with other PEPFAR Ethiopia OVC partners, IntraHealth will work with the new PEPFAR APS recipient to coordinate activities to achieve most efficient use of resources for OVC in the highest HIV/AIDS prevalence areas. This includes harmonization on indicators, reporting, and OVC standards of care in line with Government of Ethiopia national guidelines and policies and OGAC OVC Program Guidance, as well as achieving quality assurance in OVC programming. Data from the EDHS 2005 and the results of USG Ethiopia mapping will inform priority areas for FY07 and may involve immediate phasing out of geographic areas not among those ranked highest for children affected by HIV/AIDS and service availability to meet their comprehensive needs.

Linking Pediatric Clients to Treatment

This is a continuing activity. The vulnerability of a child commences much earlier than has been recognized previously. To date, the partner received 100% of the FY06 funds and is on track according to the original targets and workplan.

The impact of a parent's illness, long before they are eligible for ART, may result in decreased household income and their need for care, both of which could affect a child's ability to continue in school, availability of food in the household and social isolation due to the high level of stigma associated with HIV and AIDS. Due to increased death rates among adults of reproductive age, the long appreciated Ethiopian traditional system of family members stepping in to care for orphans is declining.

HIV exposed children living with care givers experience many negative changes in their lives and can start to suffer in many areas including: neglect long before the death of a parent(s); distress and emotional trauma following the death of a parent; difficult to access food, shelter, health, clothing, education, responsibility for their siblings; social isolation due to stigma resulting in denied access to school, health care and even socialization with other children; inability to benefit from their inheritance and property. For children who lost their parent(s) due to AIDS, many of them can be presumed to be HIV+ causing even greater stigma, reducing their future opportunities, and affecting their access to health care.

There is little explicit recognition that children, in particular OVC, are in need of screening for pediatric ART. These children, exposed to HIV, face additional barriers and often lack access to adequate primary health services due to their parent's illnesses. This activity will enable PEPFAR Ethiopia to further increase pediatric HIV case detection and treatment through family focused approaches by linking with existing partners working in ART and palliative care services.

Ethiopia has over 800,000 orphaned due to AIDS. The national IMR and CMR of 97 and 144 respectively demonstrate the high vulnerability for most children throughout the country. Given such overall fragility of children and the need those who are HIV positive, Intrahealth will expand their FY06 activities to solicit new partners, specifically, indigenous grassroot NGO to provide community and family level identification of children in vulnerable circumstances specifically as a result of their parent(s) illness and, in particular, sick children from households affected by HIV and AIDS.

Although ART pediatric services have not been given sufficient recognition in the proceeding PEPFAR Ethiopia COP, they are now recognized as a critical service to be provided. The treatment will be provided in the health centers and hospitals that are USG supported sites.

Intrahealth will utilize NGO, FBO and CBs to ensure the training of staff in the identification of exposed children and to refer those children for care and treatment services. It is with this understanding that the selection and involvement of indigenous organizations is key in facilitating ART services to pediatric cases.

NGOs, FBO and CBO will not provide pediatric services; rather, because of close ties with communities, they will identify children in vulnerable situations and households with a high probability of HIV and AIDS and refer them to social and facility-based services psycho-social and HIV screening. The nascent pediatric ART experience in Ethiopia and the COP07 Country Operational Plan target for pediatric patients calls for innovation and targeted outreach. The ability of PEPFAR Ethiopia to rapidly scale up pediatric treatment will require active case finding at the household level through communities in which the children reside.