HIV Community Planning for Community ART Treatment Adherence

According to the Government of Ethiopia (GOE), ART implementation guidelines, program management,

and coordination mechanisms should be in effect at all levels, including district and community venues. The

Ethiopian National Social Mobilization Strategy also emphasizes the need to promote community ownership

of the HIV epidemic. It lays out sequential activities necessary to mobilize the community, including training

of trainers (TOT) for regional, zonal, and district representatives, and subsequent community-planning

activities.

In FY07, PEPFAR Ethiopia and the National Alliance of State and Territorial AIDS Directors (NASTAD)

worked together in response to these national guidelines to promote community support for people living

with HIV/AIDS (PLWH) and ART treatment adherence, through refinement of existing HIV community-

planning materials and delivery of TOT for all regional HIV/AIDS Prevention and Control Offices (HAPCO).

Through such trainings, district- and ward-level AIDS committees learn how to develop action plans for

community ART adherence, uptake of services (including PMTCT), and positive living. NASTAD technical

assistance (TA) providers are US state AIDS directors and their staff responsible for planning and delivering

community-planning training and support in the US; they travel to Ethiopia to provide "real-time" TA to their

counterparts in regional HAPCO.

In FY07, NASTAD supported two full-time TA providers in Addis Ababa to ensure delivery of community

ART adherence, to provide TOT in five regions for 10,800 people, and to provide one-on-one follow-up

assistance to staff in regions around implementation of the National Social Mobilization Strategy and ART

community mobilization activities in local wards. Also, in FY07, NASTAD initiated twinning relationships

between three regional HAPCOs (Oromiya, Amhara, SNNPR) and three US state health department

HIV/AIDS programs (Minnesota, New Jersey, and Maryland). Twinning provides the opportunity for one-on-

one, ongoing, and tailored TA to support Social Mobilization Strategy implementation and program

management, with a focus on community mobilization for ART treatment adherence.

In FY 08, NASTAD proposes to maintain and strengthen existing programming:

1) Continue to support two full-time TA providers in Addis Ababa

2) Collaborate with Federal HAPCO to harmonize the Community ART-adherence TOT with the national

Community Conversations TOT

3) Provide three regional community ART-adherence TOT, including representatives from regional and

district HAPCO of Gambella, Somali, Benishangul-Gumuz , Oromiya, Dire Dawa, and Harari

4) Provide one-on-one follow-up assistance. NASTAD will work with each of the regional HAPCO listed

above to assist in developing a plan to cascade the community ART adherence TOT to their districts—

and/or assist at least 25% of individual participants attending regional trainings to modify and integrate the

training into existing district social-mobilization efforts.

5) Maintain existing twinning relationships between Oromiya/Minnesota, Amhara/New Jersey, and

SNNPR/Maryland. Assess quality and outcome of twinning relationships, and use findings to direct the

establishment of two additional twinning relationships in Dire Dawa and Addis Ababa.

6) Through HAPCO mentioned above, work with PLHW associations and include members in the

Community ART-adherence TOT to engage their support for ART adherence activities

This is a new activity involving reprogramming of fund from USAID to HHS/CDC and from SCMS to

NASTAD. With this activity it is planned to support regional and sub-regional HAPCO/Health offices to help

them in planning, coordination and management. In response to the growing complexity of PEPFAR

Ethipoia, the USG proposes to place key professionals staff to support key host country platform at regional

and sub-regional level in all regions, focusing on regions of high HIV prevalence and density of HIV/AIDS

services supported by USG. these staff would be placed with our existing partner, NASTAD and would work

on regional and sub-regional (woreda) planning, supporting intra PEPFAR and comprehensive planning

with all partners.

In FY08, the USG will establish joint planning mechanism with regional and sub-regional authorities through

the placement of professionals in regional HAPCO/Health Bureaus as well as at district (woreda) levels to

support the planning processes. The USG will utilize its implementing partner the National Alliance of State

and Territorial AIDS Directors (NASTAD) to place regionally and, in parallel build organizational capacity of

local authorities to implement complex HIV/AIDS program. These activities will be managed by national

level CDC and USAID technical staff specializing in Community Planning and Health Resources.

In Ethiopia, as in other countries, there are multiple indigenous, bi-lateral and multi-lateral donors and other

organizations operating on HIV/AIDS at national and regional levels. While support from all agencies is

welcomed, multiple organizations present regional HIV/AIDS administrations with categorical funding

allocations that do not necessarily reflect regional priorities, with less coordination, multiple monitoring and

evaluation protocols, and a critical need to develop effective regional communication, networking and

referral systems. Therefore, NASTAD seeks to support PEPFAR Ethiopia to 1) enhance coordination

among PEPFAR partners at the regional level, focusing on joint planning, communications, and referral and

networking between prevention, and care and treatment providers, as well as between facility and

community based partners; 2) strengthen regional capacity to plan for, coordinate and monitor all regional

HIV program activities regardless of funding source. Specific capacity building needs have been identified in

the following areas:• Need for institutionalized and ongoing development of annual regional and sub-

regional level comprehensive plans of action by regional HIV/AIDS Prevention and Control Offices

(HAPCOs) and woreda administrators using participatory processes involving USG and other partners

working in the region. • Need for enhanced coordination, management and implementation of regional

HAPCO plans, in collaboration with USG and other partners, to result in more efficient utilization of available

resources/funds. • Need for standardized and consistently implemented monitoring and evaluation protocols

in accordance with annual plans.

The main goal of this activity is to achieve sound joint plans, improved coordination, management, and

oversight by regional HIV/AIDS administrations of the multiple HIV program activities occurring at the

regional and woreda levels The objectives include: 1. Conducting operational assessment at the regional

level to determine specific HIV program coordination and management technical support needs; 2.

Establishing or improving existing annual regional and sub-regional/woreda comprehensive work planning

processes, involving all partners and stakeholders; 3. Strengthening implementation of national initiatives at

regional and woreda levels through joint planning and monitoring; 4. Strengthening regional and woreda

capacity to coordinate and oversee implementation of annual work-plans; 5. Strengthening regional and

woreda capacity to document, monitor and report implementation of HIV program activities at the regional

level; 6. Establishing or improving existing referral and networking protocols between regional and woreda

level HIV program activities; 7. Initiating and/or strengthening ongoing communication between donor and

all other stakeholders within the region, between regions, and nationally.

Implementation of Regional and Woreda Support NASTAD proposes placing a total of 32 staff in ten

regional offices. Two offices will be established in Oromia, one office will coordinate work in Dire Dawa,

Harar and Somali, one office will be in Addis Ababa, and one regional office will be established in each of

the remaining six regions. There will be a designated lead regional coordinator housed either within a

regional PEPFAR partner organization or within the RHB or regional HAPCO who will provide daily

oversight of other regional/woreda staff. The remaining staff will be assigned to specific zones to oversee

activities with and within specific woredas under the zone. The exact number of staff to be placed in an area

will be determined by criteria such as the number of woredas and burden of disease, but in general, we

expect to assign 4-6 zonal staff to Amhara, SNNPR, Oromia, and Addis Ababa, and 1-2 zonal staff to the

remaining 6 regional offices. All staff will be hired as contractors and have their salaries paid by NASTAD. It

is anticipated that the RHB/RHAPCOs and/or host PEPFAR partner will provide space and use of available

office infrastructure (e.g., copiers, fax machines) at their office for the staff hired by NASTAD. NASTAD will

pay rental costs for use of these facilities, and in addition provide internet connections, phones, lap top

computers for all staff. Each regional office will be allocated one double cab pick-up truck, and each

zonal/woreda staff person will be allocated a motorcycle, since staff will be expected to be in the field

conducting observations of planning activities, and providing technical assistance and training for planning,

coordination, and monitoring on a regular basis. Other office supplies will also be purchased and distributed

for use in the field. Within the regions, NASTAD contractors will assist RHB/RHAPCO and woreda

administrations in developing and monitoring implementation of annual work plans as well as in developing

and implementing structures to promote networking and referral between HIV partners at the regional level.

The primary focus will be on facilitation of communication and coordination with all partners. Examples of

activities to be conducted by field staff include:• Assisting in convening and facilitating stakeholder

coordination and planning meetings • Assisting in developing regional and woreda work plans• Assisting in

the development of standardized monitoring and evaluation processes, and standardized referral

mechanisms• Promoting coordination and communication between donor funded activities• Assisting in

harmonizing regional, national, and donor-initiated monitoring and evaluation requirements NASTAD

proposes a staged implementation of this project over time, allowing for an assessment of placement

strategies and coordination activities to make any necessary adjustments and assure subsequent

expansion in a more efficient and successful manner.

Thus, in the first three months of the project NASTAD will place one regional coordinator in each of the

regions where NASTAD has already established strong working relationships: Addis Ababa, Oromia,

SNNPR, Amhara, and Dire-Dawa/Harar/Somali.. NASTAD will subsequently place coordinators in the

remaining regional offices, and finally begin the process of hiring staff to work in selected woredas in all

regions by the end of the year.

Capacity Building and Support for National Social Mobilization Strategy

In FY07, the National Alliance of State and Territorial AIDS Directors (NASTAD) worked to enhance the

capacity of more than 42 HIV/AIDS program coordinators and officers in districts and wards to

operationalize the country's HIV/AIDS Social Mobilization Strategy Guidelines. This work has been

conducted using previous experience with district-level and ward-level HIV/AIDS committees, and in close

collaboration with federal HIV/AIDS Prevention and Control Office (HAPCO).

According to the "Ethiopian Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response, 2004" support

for ward-level HIV/AIDS activities is provided by the district health desk, which is assigned the responsibility

of linking facilities, wards, and the community. Its primary role includes supporting community ART activities

and encouraging mobilization among community-based and faith-based organizations working in OVC

activities. District health desks have the responsibility to respond to facility needs and report monitoring and

evaluation data back to the regional health bureaus (RHB). There is a need for HAPCO to provide technical

assistance (TA) and support to build the capacity of RHB and district health desks, and similarly, for the

district health desk staff and health extension workers to provide support to ward administrators. NASTAD

has worked to strengthen this chain of technical support and expertise by developing and delivering a

central training of trainers (TOT) and five zonal cascade trainings by the NASTAD team, in collaboration

with the three major US-based university partners supported in Ethiopia (University of Washington/I-TECH,

Columbia University, and JHPIEGO).

These trainings focused on:

1) AIDS activity management: how to design an AIDS activity plan, monitor its implementation, manage

budgets, and account for expenditures

2) Training and quality assurance: how to provide training for effective HIV/AIDS interventions to activity

implementers, and provide TA and oversight to ensure interventions are implemented appropriately

3) Monitoring and evaluation needs: what kinds of information to collect from activity implementers, how to

collect it, who to report it to, and in what format

4) Coordination and communication: how to integrate ward-level AIDS activity plans into overall ward

development plans, and assure coordination and communication between multiple ward activities

In FY 08, NASTAD will:

1) Present one additional zonal cascade training to assure that staff from all regional health boards/HAPCO

have participated in training between FY07 and FY08

2) Provide one-on-one ongoing support to regional health board/HAPCO staff from five regions (Addis

Ababa, Amhara, Dire Dawa, Oromiya, and SNNPR). NASTAD will work with each of the five regional

HAPCO through CDC Ethiopia's existing twinning program--assisting them to develop and implement plans

to deliver training and ongoing support and mentorship to regional and district staff in their roles as technical

assistants to ward administrators. NASTAD trainers will follow up with trainees in the course of

implementation and provide close assistance and intermittent monitoring.

3) Collaborate with federal HAPCO to design national TOT for regional HAPCO on the collection and

reporting of data in accordance with the National Monitoring and Evaluation Guidelines of the Social

Mobilization Strategy. In addition, deliver one central and four cascade trainings to assure participation by

all regional HAPCO.

4) Sponsor a national HAPCO meeting to facilitate exchange of skills and experiences related to

implementation of the National Social Mobilization Strategy Guidelines