This is a continuing activity from FY07. In FY07, the International Center for AIDS Care and Treatment,

Columbia University (ICAP-CU) supported PMTCT services in 42 hospital networks in Operational Zone 3

(Dire Dawa, Harari, Oromiya, and Somali regions). Building on programs initiated by other implementing

partners in FY05-06, ICAP-CU expanded and enhanced interventions to prevent perinatal and postpartum

transmission, and to link HIV-positive pregnant women and their families to comprehensive HIV care and

treatment services.

In FY08, ICAP-CU will extend these services to a total of 52 facilities, working to dramatically reduce the

number of infants born with HIV in collaboration with the Federal Ministry of Health (MOH)and regional

health bureaus (RHB) of Dire Dawa, Harari, Oromiya, and Somali. It will provide PMTCT services at two

hospitals and six health centers in Dire Dawa, three hospitals and two health centers in Harari, 29 hospitals

in Oromiya, and six hospitals and four health centers in Somali. ICAP-CU utilizes antenatal care (ANC),

maternal-child health (MCH), and PMTCT programs as entry points to HIV care and treatment for women,

children, and families. Major areas of emphasis include: integration of PMTCT programs with HIV care and

treatment programs; implementation of more potent and complex PMTCT regimens; prompt clinical and

immunologic staging of HIV-positive pregnant women and rapid initiation of ART for eligible patients;

enhancing the quality of infant feeding initiatives; strengthening systems for PMTCT service delivery; and

supporting human resources by providing high-quality training and clinical mentoring.

The Government of Ethiopia issued new PMTCT guidelines in July 2007. ICAP-CU, in collaboration with

JHPIEGO, will support rollout of the new guidelines in these regions. Major areas of emphasis include:

integration of PMTCT with MCH services and HIV prevention, care, and treatment programs; provider-

initiated, routine, opt-out HIV testing and counseling at ANC and labor and delivery venues; implementation

of more potent and complex PMTCT regimens; prompt clinical and immunologic staging of HIV-positive

pregnant women and rapid initiation of ART for eligible patients; enhancing the quality of infant-feeding

initiatives; strengthening systems for PMTCT service delivery; and supporting human resources by

providing high-quality training and clinical mentoring.

ICAP-CU will work to support PMTCT programming at the national, regional, and site levels. At the national

level, as a member of the National Technical Working Group on PMTCT, ICAP-CU will contribute to the

development of training material, clinical support tools, guidelines, formats, and standards. ICAP-CU will

continue to provide technical input and guidance to the MOH and RHB, supporting initiatives to: expand

PMTCT beyond single-dose nevirapine (SD-NVP) where appropriate; enhancing PMTCT-Plus training; and

supporting links between PMTCT programs, HIV care and treatment programs, and pediatric services.

At the site level, the ICAP-CU-supported package of PMTCT Plus/family-focused care includes:

1) Support for linkages between healthcare facilities and community-based implementing partners, including

organizations for people living with HIV (PLWH). This will promote uptake of antenatal and PMTCT services

and support follow-up of infants enrolled in early infant diagnosis (EID) programs.

2) Enhanced linkages between ANC, MCH, PMTCT, family planning, sexually transmitted infections (STI)

and HIV care and treatment clinics at the facility level

3) Promotion of partner testing and a family-centered model of care, using PMTCT as an entry point to HIV

services for mothers, children, and families

4) Routine, opt-out HIV counseling and testing at ANC, family planning, and STI clinics (as well as

tuberculosis (TB) clinics and inpatient wards

5) Active case-finding within families and households using a simple validated tool (the Family Enrollment

Form)

6) Adherence and psychosocial support and enhanced follow-up and outreach services for pregnant women

testing positive for HIV, which will encourage retention in care. Implementation of peer-educator programs

and mothers' support groups at selected sites, to maximize adherence to care and treatment among

pregnant HIV-positive women, and to strengthen their links to psychosocial support and community

resources.

7) Provision of a basic care package for all HIV-positive pregnant women, including: patient education; TB

screening; prophylactic cotrimoxazole (CTX) when indicated; nutritional support (see below); insecticide-

treated bed nets; condoms; and safe water. This will be done in coordination with the Global Fund for AIDS,

Malaria, and Tuberculosis and other partners.

8) Routine assessment of all HIV-positive pregnant women for ART eligibility using clinical staging and CD4

testing, and provision of prophylaxis and treatment as appropriate, including ART when indicated

9) Nutritional education, micronutrient supplementation, and "therapeutic feeding" for pregnant and

breastfeeding women in the six-month postpartum period

10) Enhanced postnatal follow-up of HIV-positive mothers and HIV-exposed infants

11) Promotion of infant-feeding initiatives and healthy infant-feeding practices by facilitating on-site trainings

and mentoring of MCH staff (including traditional birth attendants) on safe infant-feeding practices in the

context of HIV. Developing infant-feeding support tools, and establishing mothers' support groups for infant

feeding.

12) Providing access to EID by DNA PCR/dried-blood-spot testing. Enhanced laboratory capacity for infant

diagnosis at selected facilities and strengthened linkages with regional labs at remaining facilities (see the

laboratory narrative). Initiation and expansion of the clinical and health-information management systems

needed to implement EID services.

13) Ensuring that HIV-exposed infants are enrolled in care and receive prophylactic CTX, immunizations,

nutritional support, careful clinical and immunologic monitoring, monitoring of growth and development, and

ongoing assessment of eligibility for ART

14) Determination of infection status at 18 months for HIV-exposed infants not found to be HIV-positive via

EID

15) Facilitate availability of supplies for PMTCT services

16) Support for site-level staff to implement national performance standards, the JHPIEGO-supported

Standards-Based Management Program, and ICAP-developed Standard of Care.

17) Providing PMTCT-Plus training to multidisciplinary teams at the facility level

18) Providing ongoing clinical mentoring and supportive supervision in partnership with RHB

19) Ongoing development and distribution of provider job aids and patient-education materials

20) Routine monitoring of PMTCT-Plus programs, reporting of progress against targets, and ongoing

assessment of linkages within facilities (from PMTCT to ART clinics, for example) and uptake of services by

family members

21) Support for the availability and correct usage of PMTCT registers and forms, HIV-exposed infant

Activity Narrative: registers and follow up cards, timely and complete transmission of monthly reports to regional and central

levels, and appropriate use of collected data

22) Minor renovation, refurbishment, and repair (as needed) of ANC, labor and delivery rooms, and

maternity wards at ICAP-CU supported sites.

23) Radio and TV outreach campaigns and use of information and education/behavior-change-

communication materials in local languages to enhance public awareness and use of ANC, MCH, PMTCT

and HIV care & treatment services

The funding level for FY08 has increased from FY07, in part because ICAP-CU has taken additional

responsibilities for continuing PMTCT implementation formerly carried out by IntraHealth at health centers in

emerging regions (Dire Dawa, Harari, and Somali regions), and in part because ICAP-CU will expand

services from 42 to 52 sites. In FY07, additional PMTCT funds ($75,000) reprogrammed from medical

transmission, are being applied to support social marketing and branding of PMTCT to improve knowledge

and create demand for ANC and PMTCT services, which will also continue in FY08. Therefore, the total

FY07 budget (including the additional PMTCT funds) should be considered as the base for the FY07 budget

to justify the increase in the FY08 budget request.

Additional narrative to existing COP narrative: This activity will provide support for outreach ANC/PMTCT

services. It will train health care workers to provide ANC and PMTCT services to the hard-to reach rural

communities. Trained nurses based at a hospital and health center and Health extension workers will be

involved to provide outreach PMTCT services. Community level PMTCT activities will be linked to the near-

by Hospital or Health center PMTCT programs through referral linkages and establishment of catchments

area networks. Experiences elsewhere and in Ethiopia (JHU and IntraHealth) have shown that outreach

PMTCT services can effectively be utilized to improve the uptake of PMTCT services. ICAP will be involved

in the expanding outreach PMTCT services in Oromia, Harreri, DireDawa, Somali regions.

This funding will be used to strengthen the existing prevention intervention by Columbia University. Mainly

the program will focus on mainstreaming IEC and Behavioral Change Communication programs with care

and treatment programs.

Columbia University in collaboration with regional health bureaus, regional HAPCO's, US University

partners and CDC-Ethiopia will establish a national and respective regional taskforce to research, design

and develop, produce and mounting billboards centrally and regionally on new thematic areas that will be

endorsed by the task force. These billboards will replace the central and regional billboards which were

mounted in 2004 and 2005 under the theme "the Role of Leadership in the fight against HIV/AIDS". JHU-

CCP will provide the necessary technical assistance in the production processes of the educational

billboard. University of Washington will mainly work with three regional health bureaus in this regard.

Strengthening STI Services for MARP

Prevention of sexually transmitted infections (STI) among most-at-risk populations (MARPs) and people

living with HIV (PLWH) is a critical activity in preventing new HIV infections and slowing the pace of the

epidemic.

During FY07, Columbia University's International Center for AIDS Care and Treatment Programs, (ICAP-

CU) has taken full responsibility for supporting STI activities at 42 public and private health facilities found in

Operational Zone 3 (Dire Dawa, Oromiya, Harari, and Somali regions). The support to date has included an

assessment of current services and development of a workplan.

FY08 activities at the regional level will include:

1) Coordination with Regional Health Bureaus (RHB) to help facilitate and coordinate linkages between STI

and HIV/AIDS services, and strengthen external referral linkages between hospitals, health centers, and

community service organizations, faith-based organizations, and PLWH support groups and associations.

Regional linkages will be supported so that patients who do not respond to syndromic management of STI

symptoms at the health-center level are referred to appropriate care at the hospital level.

FY08 activities at the hospital/facility level will include:

1) Expanding STI services to ten additional sites, for a total of 52 sites supported by ICAP-CU

2) Continuing needs assessments of the capabilities of hospital-based STI services, 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, antenatal care, etc.)

3) Providing on-site technical assistance to improve STI diagnosis and treatment following national

syndromic management guidelines

4) Training, supportive supervision, and mentorship of physicians, health officers, and nurses on STI

prevention, diagnosis, and treatment, with a focus on the linkages between STI and HIV infection, as per

national guidelines

5) Training of facility-based peer educators on STI prevention and treatment for PLWH and their partners,

as well as community education regarding the symptoms of STI and the need to seek care

6) Developing linkages with the Global Fund for AIDS, Malaria, and Tuberculosis and other PEPFAR-

funded partners to ensure adequate supplies of STI drugs at all facilities

7) Developing linkages to HIV counseling and testing (HCT) services, promoting a provider-initiated, opt-out

approach for all STI patients, and developing linkages to care and treatment services for those who are HIV

-positive

8) STI education focused on risk reduction, screening, and treatment for patients enrolled in HIV/AIDS care

and treatment at the hospitals

9) Providing condoms, and education on how to use them, to patients enrolled in care and treatment, with a

special focus on MARPs

10) Integration of STI services into antenatal and PMTCT services to ensure that all pregnant women are

educated about STI and given necessary treatment, and are educated on STI prevention during pregnancy

(according to national STI management and antenatal care guidelines)

11) Development of linkages to community-based organizations that promote risk reduction and HIV/STI

prevention and early/complete treatment in communities surrounding ICAP-CU-supported ART sites

ICAP-CU will also focus on:

12) Exploring the feasibility of extending targeted STI prevention, diagnosis, and treatment services to

MARPs, including commercial sex workers

Palliative Care Support at Hospital Level

Care and treatment of HIV is the centerpiece of the activities of the International Center for AIDS Care &

Treatment Programs-Columbia University (ICAP-CU). In FY07, ICAP-CU supported basic palliative care

services at 42 facilities. These included: an initial assessment of site-level palliative care activities, training

of the multidisciplinary team, site-level clinical mentoring, enhancement of data collection and reporting,

minor renovations, and supportive supervision of palliative care activities. Training and supervision focused

on identifying and managing symptoms, pain, and discomfort among HIV-positive patients, and on providing

cotrimoxazole prophylaxis (pCTX), tuberculosis (TB) screening, and key elements of the preventive-care

package, such as multivitamins, nutritional assessments, and prevention for positives. This program was

introduced to the hospitals in Operational Zone 2 (Dire Dawa, Harari, Oromiya, and Somali regions).

In FY08, ICAP-CU will support palliative care activities at 52 facilities providing HIV care and treatment via a

multidisciplinary, family-focused approach to providing 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 people living with HIV (PLWH), slowing disease progression and reducing

morbidity and mortality. ICAP-CU will play the lead role in pediatric care and treatment among PEPFAR

Ethiopia's US university partners and will spearhead the development of national guidelines and standard

operating procedures for pediatric HIV care.

ICAP-CU will assist 52 facilities in Operational Zone 2 to provide the preventive care package,

complementing the Global Fund for Aids, Tuberculosis, and Malaria (Global Fund), the Federal Ministry of

Health, and other USG-funded activities when possible. ICAP-CU will focus on provision of the preventive

care package for adults, which includes: active TB screening; pCTX; symptom management; micronutrient

(multivitamin) and nutrition supplementation and counseling (see below); insecticide-treated mosquito nets

(ITN) through links with Global Fund; condoms; positive-living strategies; prevention with positives;

counseling and testing of family members and contacts; and home water disinfectant and vessels at all

ICAP-CU-supported hospitals.

The preventive care package for children includes: appropriate prophylaxis and ITN to prevent serious

illnesses like Pneumocystis carinii pneumonia, TB, and malaria; symptom management; prevention and

treatment of diarrhea; nutrition and micronutrient supplements; and linkage to national childhood

immunization programs. ICAP-CU will also ensure that all HIV-positive children receive careful and

consistent clinical, developmental, and immunologic monitoring to promptly identify those eligible for ART.

OVC enrolled in care and treatment will be prioritized for palliative care services and linked to community-

based OVC care programs in order to receive a continuum of care.

ICAP-CU will work closely with other PEPFAR Ethiopia US-based university partners (e.g., University of

California, San Diego) to ensure complementarity of activities on implementation of national pain

management guidelines. As member of the National Technical Working Group on Palliative Care, ICAP-CU

will contribute to the development of guidelines, formats, and standards. More details on delivery of these

aspects of the preventive care package are outlined below.

ICAP-CU support to facilities will be continued or expanded as follows. ICAP-CU will:

1) Strengthen the internal and external linkages required at facility level to identify HIV-positive individuals

and provide them with access to care. Internal linkages include referrals to the HIV/AIDS/ART clinic from

antenatal clinics, TB clinics, under-5 clinics, inpatient wards, out-patient departments, as well as voluntary

counseling and testing. 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 multidisciplinary teams.

4) Provide clinical mentoring and supervision to multidisciplinary teams for care of PLWH, including those

who do not qualify for or choose not to be on treatment, in partnership with regional health bureaus 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 to palliative care, to the importance of adherence to both

care and treatment for PLWH, and to the palliative care services available at the facility level.

7) Improve nutrition assessment at health facilities.

8) Promote interventions (pharmacologic and non-pharmacologic) to ease distressing pain or symptoms.

9) Continue patient management after hospital discharge if pain or symptoms are chronic.

10) Link patients with community resources after discharge.

ICAP-CU activities will promote prophylaxis and treatment for opportunistic infections in accordance with

national guidelines. Appropriate use of pCTX is an essential element of care for HIV-positive adults and

children, and for HIV-exposed infants, and will be an important component of ICAP-CU's implementation

activities, especially at those sites not yet providing ART. ICAP-CU will ensure that all supported sites have

reliable stocks of CTX tablets and syrup, and will provide emergency supplies when absolutely necessary to

ensure quality and continuity of care. Similarly, TB screening and isoniazid prophylaxis (IPT) will be

promoted and provided for HIV-positive adults and children. (See TB/HIV narrative). Supportive supervision

and the institution of standard operating procedures will improve the use of CTX and IPT. Attention will be

given to the issue of HIV/malaria co-infection and routine provision of ITN to all HIV patients, in collaboration

with Global Fund. Pregnant patients in HIV/AIDS and PMTCT programs will have priority.

Health education and behavior-change communication for HIV-positive 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. At least five hospitals will provide "therapeutic feeding-by-

prescription" for patients who qualify based upon criteria agreed upon by PEPFAR Ethiopia (i.e., HIV-

positive pregnant or breastfeeding women, HIV-exposed or infected infants who are no longer

breastfeeding, malnourished patients). Johns Hopkins University, the lead for hospital-level nutrition

programs, will provide guidance. Clear criteria will be established for patient selection, and an exit strategy

developed when therapeutic feeding support is initiated. Health education, counseling, and support will

encourage positive living to forestall disease progression and promote prevention among positives to

Activity Narrative: prevent further transmission of HIV.

TB/HIV Linkage at Hospital Level

The International Center for AIDS Care and Treatment Programs, Columbia University (ICAP-CU) has

extensive experience strengthening linkages between tuberculosis (TB) and HIV programs in Ethiopia. In

FY08, ICAP-CU will expand its activities at the national, regional, and local levels to improve the vital

linkages between these closely related services. These activities will also establish programmatic

components that will enhance the diagnosis and management of TB/HIV co-infected patients.

At the national level, ICAP-CU will continue to give technical support to Ethiopia's Federal Ministry of Health

(MOH) and coordinate its TB/HIV activities. This will include maintaining ICAP-CU's clinical resources

website, and assisting the MOH to update, reprint, and distribute national TB/HIV implementation

guidelines, registers, and reporting formats. CU-ICAP will also be involved in the development of guidelines

on management of multidrug-resistant TB (MDR-TB), training of physicians on MDR-TB, and the selection

of MDR-TB treatment centers. ICAP-CU will also support the design and production of relevant information,

education, and communication (IEC) materials.

ICAP-CU is a member of the National TB/HIV Technical Working Group, and in that capacity will continue to

support the MOH and Federal HIV/AIDS Prevention and Control Office (HAPCO) in the development and

revision of policies related to TB/HIV. ICAP-CU, together with CDC Ethiopia and MOH, will host the 2nd

National TB/HIV workshop/conference to update and standardize TB screening practices and Ethiopia's

guidelines for the management of latent TB infection (LTBI).

In FY08, ICAP-CU will also second a TB/HIV integration expert on a full-time basis to MOH/HAPCO. This

advisor will have access to the expertise of ICAP-Ethiopia's TB/HIV advisors, to ICAP-CU regional technical

advisors, and to the extensive resources of the ICAP-CU Clinical Unit in New York. ICAP-CU will also

support MOH, HAPCO, and CDC efforts to improve the TB/HIV information system by hiring a TB/HIV

monitoring and evaluation expert who can work closely with MOH and CDC.

In addition to providing technical assistance with guidelines, conferences, and training materials, ICAP-CU

will provide systems-strengthening and implementation assistance in TB/HIV integration. Activities will

include: 1) support to MOH to create and expand integrated TB/HIV programs for adults and children; 2)

development of standardized screening tools and diagnostic algorithms; and 3) development of effective

referral mechanisms among facilities providing TB and HIV services.

At the regional level (in Operational Zone 3), ICAP-CU will:

1) Support regional TB/HIV technical advisors to liaise with regional health bureaus (RHB) in Dire Dawa,

Harari, Oromiya, and Somali regions.

2) Collaborate with Jimma and Haramaya Universities, and with other partners (e.g., JHPIEGO) on pre-

service TB/HIV curricula and in-service training initiatives. This will develop local capacity to train healthcare

professionals.

3) Assist RHB to establish regional TB/HIV coordinating bodies that will conduct joint supportive supervision

with regional TB/HIV focal persons

4) Develop tools and checklists to facilitate program management, supervision, and site visits

5) Develop regionally-appropriate (IEC materials in local languages

6) Support the initiative by MOH, CDC, and the Ethiopian Health and Nutrition Research Institute to

establish TB culture facilities at the regional level

At the facility level, ICAP-CU will:

1) Directly assist 52 health facilities in four regions (Dire Dawa, Harari, Oromiya, and Somali) to provide

integrated TB/HIV services. ICAP-CU initiated support for 42 of these hospitals in FY07 and will expand its

hands-on implementation assistance to an additional ten facilities in FY08, enabling them 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-infected patients, with special

emphasis in children and pregnant women. The activity will focus on ICAP-CU supported ART sites, but

ensure 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-

positive 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 to HIV-positive patients in whom active disease has been ruled out

6) Provide cotrimoxazole preventive therapy to all TB/HIV co-infected patients

7) Design, implement, and evaluate systems for referral of HIV-infected TB patients to HIV care and

treatment services

8) Provide close clinical monitoring for TB/HIV patients who have started on ART, to identify and manage

immune reconstitution reactions

9) Support strategies to engage families into care when TB patients are found to be HIV (e.g., home visits to

screen for HIV infection and disease in the household)

10) Work closely with sites on improving TB/HIV recording and reporting

11) Develop and share clinical support tools for TB/HIV management, including TB-symptom screening

questionnaires, job aids, posters, and clinical algorithms

12) Support TB/HIV refresher trainings and ongoing supportive supervision and clinical mentoring for site

staff

13) Support radiology services at TB and ART clinics to improve diagnosis and management of TB in HIV-

infected patients

14) Renovate and refurbish TB and ART clinics as needed to minimize nosocomial transmission of TB

15) Introduce infection control and provide supplies required for infection control

16) Support transport of specimens to regional labs for TB culture, once capacity is available

17) Support MOH, HAPCO and CDC efforts to purchase and install chest x-ray machines to hospitals in

ICAP- CU regions

18) Support feasibility studies and technical evaluations planned by CDC and other partners

Activity Narrative: TB/HIV Linkage at Hospital Level

In FY07, the International Center for AIDS Care and Treatment, Columbia University (ICAP-CU) supported

HIV counseling and testing services at 42 hospitals, providing comprehensive HIV services (including ART)

in operational regions (Dire Dawa, Harari, Oromiya, and Somali regions). ICAP-CU's technical assistance

and implementation support included initial site assessments, site-level training in collaboration with

JHPIEGO, refurbishment of sites, enhancement of data collection and reporting, and supervision of

counseling and testing services. These activities assisted hospitals to deliver quality HIV counseling and

testing services to their patients and communities.

During FY08, ICAP-CU will support expansion of voluntary counseling and testing (VCT) and provider-

initiated counseling and testing (PICT) services to an additional ten sites, bringing the total number of ICAP-

CU supported counseling and testing (C&T) sites to 52, and enabling provision of quality C&T services and

enhanced linkages between C&T and care and treatment services. ICAP-CU will coordinate the required

increase in the number of C&T sites in collaboration with PEPFAR Ethiopia, other donors, and PEPFAR

partners, and will work with sites to support and manage the necessary increase in C&T staff. As member of

the National Technical Working Group on HIV Counseling and Testing, ICAP-CU will also contribute to

development of guidelines, formats, and standards.

ICAP-CU will continue to promote the use of innovative testing strategies, including PICT, in inpatient wards

(adult and pediatric) and outpatient settings. It will offer a particular focus on TB, family planning, under-5,

sexually transmitted infections (STI), and other clinics, to identify HIV-positive patients and to facilitate their

enrollment into C&T programs. Active case-finding within families and households will also be ICAP-CU

priority. C&T cadres will be expanded and point-of-service testing models will be implemented—making it

possible to get same-day results. External referral linkages between hospitals and nongovernmental

organizations (NGO), faith-based organizations (FBO), and support groups/associations for people living

with HIV (PLWH) will be strengthened. ICAP-CU staff will work closely with PEPFAR Ethiopia partners and

USG agencies to develop and distribute promotional materials on PICT and VCT services.

HIV Counseling and Testing activities will include:

1) In collaboration with regional health bureaus (RHB), the Federal Ministry of Health (MOH), CDC-Ethiopia,

and JHPIEGO, ICAP-CU will support training and deployment of lay counselors in the four ICAP-CU

supported regions. ICAP-CU will work closely with the MOH and RHB and other partners in the selection,

training, and supportive supervision of this new cadre to expand C&T services.

2) ICAP-CU will support the implementation of additional mobile C&T service in addition to the one started

in FY07. These services are critically needed to serve hard-to-reach nomadic populations, particularly in the

Borena zone of Oromiya Region.

3) In collaboration with Jimma and Haromaya Universities and other institutions of higher learning, ICAP-CU

will support "Know your status" campaigns for students and staff. ICAP-CU will also support VCT services

for students and staff, as well as access to care and treatment.

4) Supported hospitals will expand the use of the Family Enrollment Form, a validated tool for active case-

finding within families at multiple points of entry to HIV services.

5) ICAP-CU will play a major role in developing and implementing infant diagnostic strategies and services

at the national, regional, and facility level (see Lab and ART narratives).

6) ICAP-CU will support sites to extend C&T services to the most vulnerable groups (e.g., prisoners) in

selected regions, providing education, C&T, and linkages to prevention, care, and treatment services.

7) Strengthening stress- and burnout-management programs for service providers. This may be done by

establishing peer-support programs at site level, refresher trainings, and case conferences.

8) Supporting sites to provide outreach and weekend services in line with Millennium AIDS Campaign and

other local initiatives

Other specific activities include: ensuring establishment of quality-assurance systems for HIV counseling

and testing; supporting the development of tools and job-aids; and supporting refurbishment and minor

renovations to ensure privacy when needed. ICAP-CU will coordinate with relevant implementing partners

to help ensure the availability of C&T supplies, such as test kits and laboratory supplies and equipment.

ICAP-CU's C&T activities will be harmonized with all PEPFAR Ethiopia partners operating in the same

regions. This will strengthen linkages for better impact for the program.

All activities will be closely monitored by ICAP-CU regional office staff and central office Clinical Advisors,

who will provide technical assistance and implementation support to strengthen service delivery and

program management. This will help PEPFAR Ethiopia and MOH reach FY08 targets for care and

treatment.

ICAP-CU is requesting a funding increase from $375,000 in FY07 to $600,000 in FY08 for Counseling and

Testing activities (i.e., a 60% increase). The expansion of services to include an additional 24 sites, and the

introduction of mobile VCT service to provide access for the hard-to-reach pastoralist population of Borena

Zone, Oromiya region necessitated increasing the budget by 60% from the level of the FY07 budget.

Technical Support for ART Scale-up

Care and treatment of HIV in adults and children is the centerpiece of the International Center for AIDS

Care and Treatment Programs-Columbia University (ICAP-CU) activities in Ethiopia. In FY07, ICAP-CU

supported full-spectrum HIV prevention, care, and treatment services at 42 hospital networks: ICAP-CU is

the technical lead in pediatric HIV services, tuberculosis (TB)/HIV integration, malaria/HIV integration, family

-focused care and treatment, and involvement of people living with HIV/AIDS (PLWH). In FY08, ICAP-CU

will expand services to 40 hospitals and 12 health center networks, continue and expand its central- and

regional-level support, and initiate additional clinical mentoring and twinning projects.

At the national level, ICAP-CU will continue to support the Ethiopian Federal Ministry of Health's (MOH)

National Pediatric HIV/AIDS Care and Treatment Program, by continuing and expanding the following

activities:

1) Assist the Government of Ethiopia (GOE) to update national policies and guidelines on pediatric HIV

2) Assist the GOE to develop a national capacity-building plan for pediatric care and treatment and support

to achieve national pediatric treatment targets

3) Support National HIV Pediatric Care and Treatment

4) Expand the national pediatric care and treatment training curriculum and continue widespread distribution

of pediatric support materials developed by ICAP-CU

5) Assist with the integration of pediatric monitoring and evaluation into existing care and treatment tracking

systems

6) Continue a partnership with the Ethiopian Pediatric Society to provide training on pediatric HIV/AIDS care

and treatment to every pediatrician in Ethiopia

7) Continue a partnership with Stellenbosch University to support access of Ethiopian clinicians to the

successful South-2-South training program in South Africa

8) Provide technical input into the development/revision and implementation of forms, registers, and

charting tools for pediatric care and treatment

9) Support radio and TV campaigns and the use of Information, Education and Communication and

Behavior Change Communication (IEC/BCC) materials in local languages to enhance public awareness of

pediatric HIV care & treatment services

10) Assist the GOE to establish a national system and support direct implementation of pediatric care and

treatment at 52 facilities in four regions, and provide central-level TA to implementing partners working in

other regions

ICAP-CU will continue to provide technical support in the areas of family-centered HIV care and treatment,

and will work with the National ART Program to ensure that the growing Ethiopian PMTCT program is linked

to care and treatment services. ICAP-CU will contribute its extensive experience with treatment of HIV-

exposed and infected infants and children and assist with the expansion of national pediatric treatment

guidelines, work to improve access to infant HIV diagnostics, and work with partners to expand pediatric

training materials.

At the regional level, ICAP-CU will work with Dire Dawa, Harari, Oromiya, and Somali Regional Health

Bureaus (RHB) and other partners to build their capacity to effectively design, implement, and evaluate

HIV/AIDS programs. ICAP-CU will formally partner with RHB and support provision of quality and

comprehensive HIV services. ICAP-CU will work with RHB to assess new sites, evaluate the clinical,

infrastructural, management, and informatics needs of facilities and develop implementation strategies to

enable each facility to meet required national standards; and to provide assistance to support the

implementation of national treatment guidelines. ICAP-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 on stable patients or initiate ART services in some cases.

"Up referral," in which health centers refer complex cases to hospitals, will also be facilitated.

ICAP-CU will continue to build the capacity of Jimma and Haramaya Universities to provide TA, supportive

supervision, and mentoring to their respective RHB and catchment health networks. These universities will

eventually assume the responsibilities of providing TA to the health networks in the four regions, enabling

external partners to exit smoothly. In FY08, ICAP-CU will host a clinical mentoring retreat for ICAP staff

from around sub-Saharan Africa, strengthening south-to-south linkages and sharing resources and lessons

learned with regional universities and RHB.

At the facility level, following Ethiopian National Guidelines, ICAP-CU will support provision of

comprehensive high-quality HIV services, including ART, at 52 public and private facilities in the four

regions. Specific activities include:

1) Support for hospital HIV/AIDS Committees and multidisciplinary ART Teams to ensure facility ownership

of service implementation

2) Training and quality improvement activities for physicians, nurses, and pharmacy personnel

3) Ongoing supportive supervision and clinical mentoring of facility staff (ICAP-CU will enhance clinical

mentoring skills and strategies by sending a team of clinical advisors to the Stephen Lewis Foundation

mentoring workshop in Uganda)

4) Linkages with entry points to care and treatment, including counseling and testing services, antenatal

clinics and PMTCT programs, TB clinics, Under-5 clinics, and adult and pediatric inpatient wards, as well as

support for staff at these entry points

5) Linkages to services for family planning, TB/HIV, sexually transmitted infections, and the full package of

palliative care services (see Palliative Care narrative)

6) On-site implementation assistance to strengthen systems, including: medical records; referral linkages;

patient follow-up and adherence support; ART clinic management; integration of prevention into care and

treatment; involvement of PLWH; appointment systems and defaulter tracing mechanisms; and facilitating

access to laboratory services and ARVs

7) Standardized health-management information systems and on-site assistance with data management

and monitoring and evaluation to guide quality improvement

8) Hiring of data clerks at all hospitals, in coordination with Tulane University and RPM+

9) Renovation of facilities will be supported in coordination with RPSO and Crown Agents where needed

10) Implementation of post-exposure prophylaxis (PEP) activity for occupational exposure of healthcare

providers and for victims of sexual assault in the 52 hospitals supported. This includes: establishing a

Activity Narrative: functional Infection Prevention/PEP committee in all facilities; organizing forums to create awareness in the

facilities; ensuring full availability of ARV drugs for PEP; developing and distributing standard operating

procedures (SOP), wall charts, and brochures that indicate steps to be taken after accidental occupational

or sexual assault exposures.

ICAP-CU will support ART training, according to national guidelines and curriculum. Additional training,

including training on program management skills, will be provided to all new sites initiating ART in FY08 and

to sites already providing ART services to fill the gaps created by high staff turnover. This will be

supplemented by refresher trainings, focusing on an integrated multidisciplinary team approach to care and

treatment. In FY08, ongoing site-level clinical mentoring and supportive supervision will be carried out at all

ART hospitals in ICAP-CU supported regions.

ICAP-CU will support internet access for ART hospitals, enabling staff to use web-based resources,

including ICAP websites, and e-mail case consultation services, as well as to obtain information from the

national program. ICAP-CU will expand provider reference tools on ART, including pocket guides, ART

dosing cards, posters, and ART SOP, as well as client educational materials in local languages (i.e.

Amharic, Oromiffa, and Somali).

Under the ART health network, ICAP-CU will work to establish and strengthen links between hospital

services, different levels of facilities and PLWH groups, nongovernmental and faith-based organizations,

and communities with other partners working at these levels. This will facilitate patient access to, and use

of, comprehensive care and support and continuity of care and treatment.

In FY08, ICAP-CU will continue to support PLWH associations to involve their members in HIV/AIDS

program activities. ICAP-CU will:

1) Support and facilitate PLWH involvement at different levels

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 PLWH involvement workshop and national peer educators' review meeting

5) Provide facility-level assistance to expand involvement of PLWH as peer educators. ICAP-CU will expand

its peer educator program from 18 hospitals to 52 facilities in FY08. As part of multidisciplinary ART teams,

peer educators play a key role in patient education on prevention for positives, positive living, adherence

counseling and support, defaulter tracing, and linkages to community resources, such as food and

psychosocial support.

As part of its human capacity development scheme, ICAP-CU will collaborate with the International

Twinning Center to expand the voluntary healthcare corps by recruiting retirees with experience in clinical or

project management.

Site-level laboratory Support

In FY07, the International Center for AIDS Care and Treatment Programs, Columbia University (ICAP-CU)

is providing comprehensive high-quality HIV/AIDS services, including ART, at 42 public and private hospital

networks in the Oromiya, Somali, Harari, and Dire Dawa regions. Comprehensive technical assistance (TA)

and implementation support has strengthened essential elements of the laboratory system, and improved

service quality and consistency.

ICAP-CU has helped to: conduct assessments of laboratory services; train laboratory staff (both offsite and

on-site)on equipment operation, preventive maintenance, and HIV-related laboratory test procedures;

establish and strengthen quality assurance (QA) programs via on-site mentorship and by developing and

implementing 29 standard operating procedures (SOP); develop log books and improve documentation and

recording; and provide technical and logistic support for specimen-referral linkage between 17 testing

hospitals and 48 referring hospitals and health centers.

In FY07, ICAP-CU is doing major infrastructure support to six hospital laboratories, including: improvement

of space in the rooms within existing footage; epoxy painting of floors and walls in testing rooms; standard

furnishing of labs; and improving electric lines and drainage systems. In addition, ICAP-CU has provided

key technical and implementation support to Ethiopia's Early Infant Diagnosis (EID) program at the national,

regional, and site levels. ICAP-CU has helped to: lead the "technology transfer" of HIV-1 DNA PCR testing

services to the national laboratory at the Ethiopian Health and Nutrition Research Institute (EHNRI);

supported decentralization by providing capacity building for HIV-1 molecular testing at two regional

laboratories; and spearheaded the first phase of facility-level implementation.

In FY08, ICAP-CU will extend its support to 52 hospital networks in the Oromiya, Somali, Harari, and Dire

Dawa regions, enabling each to provide comprehensive high-quality HIV/AIDS services. These networks

will include 50 public and two private facilities and health centers at emerging regions. Intensive site-level

laboratory support is an essential component of ICAP-CU's plans, as the availability of consistent and

reliable laboratory services will ensure quality HIV prevention, care, and treatment services. Ongoing

training, supervision, and mentoring of laboratory staff and hands-on implementation support will be

provided to all 52 sites. ICAP-CU will work directly with the regional labs, hospital labs, and health center

personnel to implement and monitor the quality assurance programs at the 52 sites. Procurement and

distribution of laboratory equipment and supplies for these sites will be handled by CDC, the Ethiopian

Ministry of Health, EHNRI, and the Supply Chain Management System (SCMS), as will equipment

maintenance. ICAP-CU will continue to provide TA to the rollout of HIV-1 DNA PCR tests for infant

diagnosis at national and regional levels.

ICAP-CU's laboratory support activities in FY08 will include:

(1) Strengthening site-level, laboratory-quality systems, with an emphasis on initiation and enhancement of

QA programs in partnership with EHNRI and Oromiya, Harari, and Somali regional reference laboratories.

These activities will include the preparation, revision, and implementation of standard operating procedures

(SOP) for HIV disease monitoring (hematology, clinical chemistry, and CD4), specimen management,

laboratory safety, and QA and quality control (QC) programs. ICAP-CU will also support the preparation and

provision of standard documentation and recording formats, including QC forms, lab request forms, and

registers. ICAP-CU technical advisors will provide ongoing supportive supervision and mentorship at all

sites, ensuring the delivery of high-quality laboratory services, as well as systems strengthening, skills

transfer, and capacity development.

(2) Technical support for uninterrupted laboratory services at all 52 hospital networks. This includes:

assisting with the development, implementation, and enhancement of laboratory inventory systems in the

hospital networks and ensuring availability of continued and sufficient reagent supplies; supporting timely

preventive and troubleshooting maintenance services; building regional capacity for essential laboratory

equipment maintenance; and supporting human resources by facilitating the availability of adequately

trained laboratory personnel at all sites. These activities will be coordinated with SCMS and regional

laboratories, and ICAP-CU regional laboratory advisors will work closely with the regional lab associates of

SCMS.

(3) Capacity building and minor renovation of facility-level laboratories. ICAP-CU will provide regular

mentorship of site-level staff, focusing on improving laboratory management, laboratory organization, layout

and work flow, specimen management, testing procedures, standard documentation, record keeping and

reporting, and stock and inventory management. ICAP-CU will also conduct periodic site assessments and

will provide necessary and appropriate support, including minor renovations and refurbishing of site labs

and laboratory accessories needed for the day-to-day delivery of HIV-related laboratory services. ICAP-CU

will support preventive maintenance of essential HIV-related equipment and equipment care and

management at the facilities. ICAP-CU will also facilitate major equipment maintenance; and support for

national laboratory reporting systems. In FY08, ICAP-CU will continue to facilitate the upgrading of the

infrastructure of the laboratories to improve the service in 15 selected high-patient-burden hospital

laboratories. This will help to improve the capacity to support more patients, to maintain quality, and to

provide standard laboratory service at ART facility laboratories supported by PEPFAR.

(4) Standardized trainings using nationally approved curricula, in collaboration with CDC, PEPFAR

implementing partners, EHNRI, and regional laboratories. These site-level and regional-level trainings will

include: HIV diagnostics (HIV serology testing, rapid testing); HIV disease monitoring (hematology, clinical

chemistry, and CD4); and laboratory training on integrated diseases, including common opportunistic

infections (OI) diagnosis. ICAP-CU will provide continued on-site training on the new HIV rapid-testing

algorithm and monitor and evaluate the use of the algorithm at facilities. A total of 300 laboratory personnel

will be trained, and ICAP-CU, in collaboration with regional labs, will evaluate the quality of services

rendered by lab personnel after training in different disciplines.

(5) TA and implementation support to referral laboratory services. This will strengthen the functioning of the

reference labs as they supervise QA activities at lower-tier labs and provide access to more sophisticated

diagnostic assays. ICAP-CU will also provide support for: EHNRI/regional labs to establish: systems for

specimen collection at health centers and/or peripheral hospitals; transportation to appropriate hospital and

regional laboratories; tracking of patient samples; reporting of results; and implementing and ensuring that

Activity Narrative: standard guidelines and procedures are followed. ICAP-CU will support EHNRI's expansion of the

Laboratory Information System (LIS) at facilities.

(6) Key TA to the nationwide EID program. Working at the national, regional, and site levels, ICAP-CU will

support not only HIV DNA PCR testing capacity in the laboratory, but the clinical systems, health-

management information systems, and linkages needed to provide high-quality services to infants and

families. ICAP-CU will continue to support the national EID program by providing TA to the national EID

Technical Working Group and to EHNRI. Support will be given to establish HIV DNA PCR testing capacity

at two more ICAP-CU-supported, sub-regional laboratories, and 52 ICAP-CU-supported ART facilities will

offer access to EID services through dried-blood-spot sample transfer.

(7). Integration of OI diagnosis in the HIV/AIDS laboratory support. ICAP-CU, in collaboration with other

stakeholders working in the laboratory area, will establish common OI and sexually transmitted infections

(STI) diagnostic-testing services at regional labs and hospitals. This includes training of lab personnel on

common OI and STI diagnosis, providing TA in setting up of the test services, and providing some critical

reagents and diagnostic kits.

The significant increase of budget was necessary to support: upgrading the two sub-regional laboratories

for EID; hospital laboratories in the three regions and health-center laboratories in emerging regions; and

integration of OI diagnosis.

Site-Level Data Support for Hospitals/Strengthen the HIV/AIDS Information System at Hospital level

This is a continuing activity from FY07. The major purpose of this activity is to strengthen the

implementation of the national Health Management Information System (HMIS) for comprehensive

HIV/AIDS services and to optimize the use of data for service and program strengthening in Dire Dawa,

Harari, Oromiya, and Somali regions.

In FY07, the International Center for AIDS Care and Treatment Program, Columbia University (ICAP-CU)

supported 42 sites in Operational Zone 3 to collect, manage, analyze, and use HIV/AIDS services-related

data generated at site level for decision-making to improve clinical and program management. Additionally,

ICAP-CU has trained 92 health professionals and data clerks in monitoring and evaluation (M&E) and

assisted regional health bureaus (RHB) to organize experience-sharing workshops.

In FY08, ICAP-CU will expand its site-level capacity building in M&E to further improve quality data

collection and maximize data use for continuous service quality improvements. ICAP-CU will:

1) Intensify support for efforts to fully document information for pre-ART and ART patients on the national

HIV care/ART follow-up by:

a) Continuing routine, data-quality assurance exercises to measure completeness and accuracy of

information on follow-up forms

b) Providing support to clinical teams for accurate completion of follow-up forms

c) Supporting efforts to fully document information for PMTCT, tuberculosis (TB)/HIV, voluntary counseling

and testing (VCT), and provider-initiated counseling and testing (PICT) clients on the appropriate national

HMIS forms

d) Supporting the integration of HIV/AIDS care and treatment data with national comprehensive HMIS

through technical support at site level in archiving, retrieving, and report aggregation, supported by routine

data-quality assurance assessments

e) Train healthcare providers, data clerks, and HMIS personnel on database use, including how to enter

records, query the databases, and produce routine reports

2) Provide support for M&E support tools developed for the national M&E systems and equipment. ICAP-

CU will work to ensure availability of computers, computer peripherals, and storage equipment and an

uninterrupted supply of the national M&E tools at all the sites

3) Strengthen supportive supervision and mentorship. On-site supervision and mentorship will be provided

to enhance collection of accurate and complete data. ICAP-CU will also work with site-level staff to build

capacity in data analysis, and in the use of data to manage and improve program delivery.

4) Support institutions to manage and use data fully and effectively. Sites will continue to be assisted in

tabulating and visualizing their data using tables, charts, line and bar graphs and other standard methods;

optional tabulations will include aggregation of data by patient, clinic, and regional levels. Continued FY08

activities will expand the number of facility-based health providers with basic computer skills and data

management skills, including data entry, data analysis, technical paper writing, and presentations.

5) Support the national laboratory information systems to ensure communication of patient results in an

efficient manner. There will be particular emphasis on communicating results to patients whose specimens

were transported to the hospital from another facility, such as a health center. Furthermore, ICAP-CU will

assist sites in tracking specimens of patients who need more specialized tests, such as viral load, which are

currently performed only at regional labs.

6) Support biannual, regional review meetings to provide fora where facilities can present their data and

share lessons learned. This activity will also continue to support and strengthen the national HMIS

implementation, document best practices, and present findings and experiences at local and international

scientific and programmatic forums. Implementation mechanisms will consist of necessary modeling at site

and RHB levels.