PMTCT Implementation Support at Uniformed Services Health Facilities

This is a continuing activity from FY07. In FY07, UCSD supported PMTCT services in 24 health facilities

nationally. Building on programs initiated by JHPIEGO, UCSD 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, UCSD will extend these services to a total of 45 health facilities, working to dramatically reduce the

number of infants born with HIV in collaboration with the Defense Health Department and Command Health

Services. UCSD will provide PMTCT services at 38 hospitals and seven health centers. UCSD uses

antenatal care (ANC), maternal-child health (MCH), and PMTCT programs as entry points to HIV care and

treatment for women, children, and families.

In July 2007, the Government of Ethiopia issued new PMTCT guidelines. UCSD, in collaboration with

JHPIEGO, will support rollout of the new PMTCT guidelines in these health facilities. 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, labor and delivery;

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.

UCSD will work to support PMTCT programming at the national, regional, and facility levels. At the national

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

development of training material, clinical support tools, guidelines, formats, and standards. UCSD will

continue to provide technical input and guidance to the Federal Ministry of Health (MOH) and Uniformed

Health Services, 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 facility level, the UCSD-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/AIDS. 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 testing and counseling at ANC, labor and delivery according to national guidelines

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 to encourage retention in care. In collaboration with JHPIEGO, implementation of

peer-educator programs and mothers' support groups (MSG) 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) Providing 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, 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 providing 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-months postpartum period

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

11) Promoting 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 MSG for infant feeding

12) Linking all infants born to HIV-positive women to the HIV-exposed Infant Clinic to ensure early infant

diagnosis (EID) by DNA PCR using dried-blood spot (DBS). 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 management information 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) Determining infection status at 18 months for HIV-exposed infants not found to be HIV-positive via EID

15) Facilitating availability of supplies for PMTCT services

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

Standards-Based Management Program

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

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

levels, and appropriate use of collected data

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

and maternity wards at UCSD-supported sites.

23) Supporting the Military Women's Anti-AIDS Coalition, an organization composed of military and civilian

women working on educating and increasing awareness about HIV/AIDS, with a focus on PMTCT. This

association will continue to do community mobilization, advocacy on safe infant feeding, and PMTCT-Plus

Activity Narrative: activities.

24) Linking the PMTCT service with the Modeling and Reinforcement to Combat HIV/AIDS (MARCH)

prevention interventions

25 Establish pre-service training through strengthening the curriculum of Defense Health Sciences College

and Police Nursing School

Addition: 10/7/08

This funding will be used to strengthen the existing prevention intervention of UCSD with in the military.

UCSD has assisted the NDFE Training Department in the establishment of Voluntary Counseling and

Testing (VCT) centers and education for new military recruits at only a few training sites. In recent

discussions with the Training Department Officers, the need for expansion and strengthening VCT centers

and of the military training curriculum to incorporate better HIV/AIDS and STIs education was emphasized.

Thus, this activity will involve Capacity building and system strengthening of the NDFE and Federal Police

Training Departments/colleges for new recruits in HIV/AIDS/STIs education and expansion of VCT services

for the new recruits.

Strengthening STI services for MARPS

During FY07, the University of California, San Diego (UCSD) initiated a new activity for the prevention and

control of sexually transmitted infections (STI). Major accomplishments in FY07 include: the development of

a workplan and an assessment tool to identify the sources of STI treatment and prevention activities at

health-facility level; participation in CDC-funded trainings; and coordination of training for health providers

from the uniformed services. In FY07, UCSD supported expanded access to STI prevention and treatment

services and improved STI service quality at 43 uniformed-services health institutions.

During FY08, UCSD will support expanded access to STI prevention and treatment services and improved

quality of STI services at 76 facilities. Prevention of STI among uniformed service members, prisoners, and

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

the epidemic among these population groups. Complete and appropriate treatment of STI is also a key

element of UCSD's multidisciplinary, client- and partner-focused approach to prevention, care, and

treatment.

In FY08, UCSD will work with commands and divisions of the military to help facilitate and coordinate

linkages between STI and HIV/AIDS services.

FY08 activities at the hospital/facility level include:

1) Expansion of STI services to 33 additional sites, for a total of 76 sites supported by UCSD

2) Continuing collaboration with uniformed-health-services coordinating offices to conduct needs

assessments of the capabilities of hospital-based STI services. This will be 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) Provision of on-site technical assistance to improve STI diagnosis and treatment following national

syndromic management guidelines

4) Training, supportive supervision, and mentorship of 152 providers, including 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 STI symptoms and the need to seek care

6) Development of 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) Development of linkages to HIV counseling and testing services, promoting a provider-initiated, opt-out

approach, for all STI patients, and 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) Provision of condoms to patients enrolled in care and treatment and education on how to use them.

There will be a special focus on most at-risk patients/populations (MARPs).

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

educated about STI (including STI prevention during pregnancy) and provided with necessary treatment,

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 UCSD-supported ART sites

UCSD will also focus on:

12) Strengthening STI services for MARPs

13) Support for sites for STI syndromic data documentation and reporting

14) Establishment of an STI surveillance program within the uniformed services' health-delivery structure

Palliative Care Assistance at Uniformed Service Health Facilities

This is a continuing activity from FY07. In FY07, the University of California, San Diego (UCSD) introduced

basic palliative care and preventive care services to 30 more facilities, in addition to the 13 ART facilities it

supported in FYO6. This included: initial assessment of the palliative care activities at sites; development of

training modules in collaboration with I-TECH; training of trainers and providers; and supervision and

mentoring of palliative care activities. UCSD also introduced HIV counseling and testing of family members

and contacts, and prevention for positives. Relief of pain and discomfort among HIV patients was also

addressed through available analgesics, anti-motility, and anti-emetic drugs.

UCSD worked closely with other partners, ensuring the delivery of complementary activities, such as links to

services outside the facility and to community resources after discharge (e.g. OVC) through implementation

of referral systems, forms, staff support, and review meetings. UCSD also provided job aids and patient

education materials related to palliative care and positive living.

UCSD is an active member of the National Palliative Care Task Force, which is working with other

stakeholders to facilitate the development of national palliative care guidelines, coordinate palliative care

program implementation at the national level, and advocate the integration of palliative care and

standardized pain management in the healthcare system with policy makers and health professionals.

UCSD, in collaboration with the CDC, has conducted baseline assessments of palliative care service

delivery at facility level.

In FY08, UCSD will continue to support palliative care activities via multidisciplinary, family-focused

approaches to providing the preventive care package, pain and symptom management, and end-of-life

care. In addition, UCSD will initiate palliative care activities at 33 new sites, bringing the total number of

sites to 76 uniformed services health facilities providing HIV/AIDS care and treatment. UCSD will focus on

provision of the preventive care package to adults, which includes: active tuberculosis (TB) screening;

cotrimoxazole prophylaxis; symptom management; micronutrient (multivitamin) and nutrition

supplementation and counseling (see below); insecticide-treated mosquito nets (ITN) through links to the

Global Fund; condoms; positive living strategies; prevention with positives; active TB screening; case-

finding; counseling and testing of family members and contacts, and promoting safe water usage through

the provision of safe home water disinfectant vessels at all UCSD-supported hospitals. The preventive care

package for children includes: prevention of serious illnesses like Pneumocystis carinii pneumonia, TB, and

malaria via appropriate prophylaxis and use of ITN; symptom management; prevention and treatment of

diarrhea; and nutrition and micronutrient supplements and links to national childhood immunization

programs. 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.

UCSD support to facilities will be continued or expanded as follows:

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, and 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 related to the 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.

UCSD will continue its national level support by assisting in the national policy review and participating in

the development of national strategies to ensure palliative care is well addressed in the overall HIV/AIDS

control program implementation plan. UCSD will mount its commitment, in collaboration with partners, to

support the Federal Ministry of Health and the national HIV/AIDS Prevention and Control Office (HAPCO) in

their efforts to implement sustainable a national hospice care initiative through:

1) Initiating efforts to increase access, coverage, and integration of services to improve quality of life of

terminally-ill patients and their families via affordable and culturally appropriate "end-of-life" care or hospice

services.

2) Initiating mental health and spiritual care services to PLWH at the facilities of the uniformed services and

using this as an experience to expand services nationally.

3) In collaboration with partners working at the community, coordinate the integration of currently ongoing

home based care activities at the community level with newly initiated hospice services at the facility level

4) Collaborate with HAPCO and other partners in organizing and sponsoring trainings at the national level

for physicians, nurses, and lay people as advocates and trainers of trainees abroad and within the country

to facilitate the capacity building efforts.

5) Establishing, within the uniformed services, a model center for ‘end of life'/hospice care so that it will be a

training and center of excellence for duplication nationally.

6) Partnering with the Ministry of Health and Education of Ethiopia and the Defense Health Sciences

College to introduce elements of palliative care in general, and end-of-life care in particular, into the national

curriculums of health professional training institutions of Ethiopia.

TB/HIV at the Uniformed-Services Health-Facility Level

The University of California San Diego (UCSD) has been providing tuberculosis (TB)/HIV support to the

National Defense Forces of Ethiopia (NDFE), Federal Police of Ethiopia (FPE) and the Federal Prison

Administration (FPA) since 2006. In FY07, that activity continued and the number of supported sites was

expanded from 13 to 43.

In FY07, working with other US universities, UCSD implemented a package of interventions, including: (1)

expansion of provider-initiated HIV counseling and testing for TB patients; (2) referrals of HIV-positive TB

patients for HIV-related care , including cotrimoxazole therapy and ART; (3) regular TB screening of HIV

patients in care and treatment; (4) isoniazid preventive therapy (IPT) for eligible, HIV-positive patients; (5)

improving TB diagnostic services; and (6) strengthening monitoring and evaluation (M&E) of the TB/HIV

collaborative activities.

UCSD initiated support to strengthen the TB diagnostic capacity of the uniformed-service laboratories in

several ways. The laboratory personnel were given on-site trainings on direct-smear microscopy and on the

new smear microscopy guidelines.

Moreover, concentration of sputum smears, which was proved to increase sensitivity of detection of

mycobacterium, was also introduced to all 24 sites using the simple, cheap, and less-contaminating step of

liquefying and decontaminating with bleach and concentrating through flotation in xylene. This was done

through on-site theoretical and practical trainings to the lab personnel and has proved to be effective in

increasing the yield of direct microscopy in all the sites.

Safety for laboratory personnel was also given due attention through supply of simple exhaust fans to

increase air flow and protect them from fumes. One of the hospitals was also supplied with dead air hoods

and a UV light for decontamination to allow for preparation of acid-fast bacilli smears.

A FY06 pilot project, in which fluorescent microscopy was introduced into one of the biggest military

hospitals, was scaled up to two more sites in FY07 through the supply of the objective lenses with built-in

barrier and excitation filters. These can be added to any microscope and widely available halogen bulbs

were used as a light source. This procedure was found to increase the sensitivity of detection of

mycobacteria without affecting the specificity.

In FY08, UCSD plans to strengthen activities that have already been initiated and implement the program in

33 more sites, including the 15 regional prisons where the incidence of TB is high. Therefore, a total of 76

uniformed-service sites will have TB/HIV collaborative services in FY08.

With the overall objectives of reducing the burden of TB in people with HIV and reducing HIV among people

with TB, UCSD will strengthen and continue activities initiated during FY07. The activities included were:

1) Intensified TB case-finding: This will be done through regular screening of all people with, or at-risk of,

HIV for symptoms and signs of TB, referring them for prompt diagnosis and treatment, and doing the same

for their household contacts. A simplified standardized cheklist will be used to screen patients for TB

symptoms and identify the majority of the TB suspects. UCSD will continue to work on improving the TB

diagnostic capacity of laboratories and personnel through continuous on-and off-site trainings and regular

supportive supervision to give direct, technical, site-level support. The use of fluorescent microscopy to

diagnose TB will also be scaled up from three to six sites, as the relatively low cost and ease of use of these

microscopes has made fluorescent microscopy feasible. UCSD will also support the Federal Ministry of

Health (MOH), the Federal HIV/AIDS Prevention & Control Office (HAPCO), and CDC efforts to improve TB

diagnosis by purchasing and installing new chest x-ray machines. In addition, UCSD will support a venture

between the Ethiopian Health and Nutrition Research Institute (EHNRI) and CDC to establish culture

facilities at regional levels.

2) Treatment of latent TB infection with IPT. Treatment with IPT will be given to both adult and pediatric

patients with HIV and TB latent infection, according to the national guideline to prevent progression to active

disease.

3) Implementation of facility-level TB infection-control programs. UCSD will help sites establish infection-

control strategies based on good work practices and administrative measures, which will include: a written

infection-control plan for each facility; technical and financial support for procedures in the plan including

quality assurance, staff training, education of patients, and increasing community awareness; and providing

supplies required for infection control. UCSD will also work with MOH, CDC and other partners on

prevention and management of MDR -TB.

In FY08, UCSD will expand to a total of 76 sites and support activities to reduce the burden of HIV among

people with TB. The following activities will be included:

1) HIV testing and counseling: UCSD will be expanding provider-initiated testing and counseling not only to

all TB patients, but also to all TB suspects, to increase the yield. This will be done through continuous on-

site training, and clinical ,mentoring, and supportive supervision activities.

2) Implementing HIV preventive methods: UCSD will introduce and implement comprehensive HIV-

prevention strategies for patients in TB clinics. This will be done through training and steady supply of

materials (e.g., information-education-communication materials, condoms).

3) Providing cotrimoxazole prophylaxis (CPT): CPT will be provided to all TB-HIV co-infected patients.

UCSD plans to support the uniformed services through the supply of Dapsone for those patients for whom

cotrimoxazole is contraindicated.

4) HIV/AIDS care and treatment, including ART: Ongoing support will be provided to co-infected patients

through counseling and other psychosocial support. Special attention will be given to the adherence status

of these patients, as they will have a high pill burden, which can greatly compromise adherence.

In addition to the efforts that will be made to lessen the burden of TB on HIV and vice versa, UCSD will be

carrying out a number of activities to improve TB/HIV collaborative activities:

Activity Narrative: 1) Renovation of clinic physical space: USCD will renovate TB clinics, including waiting areas and

laboratory infrastructure, in a way that is consistent with infection-prevention strategies.

2) Improvement in medical informatics for health-data management and information systems. This will make

it possible to capture data on: the number of TB patients offered counseling and testing for HIV; the number

of HIV patients screened for the presence of active TB; the number of TB patients supplied with palliative

care packages; and other parameters. UCSD will also support MOH, HAPCO, and CDC efforts to improve

the TB/HIV information system by hiring an expert on M&E for TB/HIV who can work closely with CDC and

MOH.

3) Awareness campaign for TB/HIV using military and police media services

4) Collaboration with EHNRI to evaluate the sensitivity of isolates of mycobacterium tuberculosis to

antimicrobial agents

5) Close collaboration with facility representatives to set up a coordinating body for TB/HIV activities and

help sites have joint TB/HIV planning and M&E.

Counseling and Testing Support at Uniformed Services Health Facilities

In FY07, the University of California San Diego (UCSD) supported client and provider-initiated HIV

counseling and testing (HCT) services in 58 military and police hospitals as well as prison health facilities.

This included an initial and follow-up site assessment, site-level training, refurbishment of sites, improving

data collection and reporting systems, and supervision of HCT services. The site-level support aimed at

improving performance to deliver quality HCT services for uniformed personnel, their families, prisoners,

and the community around military facilities ( civil-military alliance program).

During FY07, HCT programs in the uniformed services were continued through collaboration between

UCSD and JHPIEGO, who provided training-of-trainer (TOT) sessions and training materials. During this

period, UCSD supported these activities by supporting the implementation of HCT programs at 38 military,

nine police, and 11 prison clinics. Overall the scope of assistance of UCSD to the uniformed services was

focused on:

1) Training of counselors on relevant skills, capacity building, staff educational programs, and outcomes

assessment

2) Laboratory enhancement of capacity for HIV-testing in the voluntary counseling and testing (VCT) sites

and strengthening of laboratory quality assurance

3) Advocacy activities, including drama and advertising, through the support of military media and the CDC-

sponsored MARCH programs in the defense and police forces

Major HCT interventions by UCSD have been in:

1) Adopting PICT and opt-out strategies for CTR hospitals and outpatient clinic settings

2) Assessment of current capacity for care, laboratory testing, and nursing support of VCT

3) Support for the sites to provide same-hour HIV testing at VCT sites

4) Strengthening of the referral link between counseling and testing with post-test services

5) Support for site-level refresher trainings and mentoring for HCT personnel with UCSD experts

6) Support for minor renovation of physical space to ensure infrastructure which is consistent with the

standard

7) Providing necessary laboratory supplies for the VCT labs

8) Improved data management system of HCT and reporting

9) Establishing a quality-assurance system for HCT services for both client- and provider-initiated HCT

In FY08, UCSD will continue all activities related to HCT, including technical support and training for

healthcare professionals working in the uniformed services. The focus of this activity is making HCT

accessible at all sites and to high-risk groups, and linking all HIV-positive people to chronic HIV care and

treatment services.

UCSD's reach will increase from 58 to 91 service outlets, all of which will have HCT trained staff,

infrastructure, and the capacity to offer same-hour testing service. The service outlets will provide HCT to

an estimated 151,875 additional clients. Besides focusing on facility-based HCT, the funding will also cover

the provision of counseling and testing services to remote peripheral regions through mobile, outreach, and

community-based HCT.

To expand and enhance this program in FY08, UCSD will establish regular trainings with special attention to

opt-out PICT, couples counseling, and provider training for non-health personnel. UCSD will also conduct

site assessments and regular supportive supervisions, mentoring of counselors to ensure quality of service

and supporting lab workers through training by both local staff and visiting UCSD experts.

UCSD will continue its support in FY08, increasing the reach of HCT at the regimental level, by supporting

the military's mobile VCT services as well as by providing HCT at all prison sites (Federal and regional), to

prison guards, and prisoners around the country. UCSD will continue to assist the regional prison clinics'

efforts to establish a strong referral linkage with the nearby civilian hospital to send all HIV-positive

prisoners for chronic care and support, including ART.

In FY08, UCSD plans to further expand the HCT program and strengthen the existing services through:

1) Conducting site-level basic and refresher training on VCT for service providers, and training non-health

professional uniformed personnel by following the standard protocol. Moreover, counselors at all sites will

be given training on counseling couples, so that they will be able to provide quality service. By giving

emphasis to discordant results, counselors will be supported to address the challenges clients face in

dealing with their results.

2) Consolidating the existing HCT services to increase the uptake of individuals receiving counseling and

testing in healthcare settings, while expanding the service to 38 new HCT sites. Moreover, child testing will

be promoted and supported at all sites by facilitating family-centered counseling.

3) Collaborating with the CDC MARCH Program for outreach education, drama, and advertising, and

developing and disseminating military and police-specific information- education-communication/behavior-

change communication (IEC/BCC) messages to promote HCT-seeking behavior among high-risk groups

and increase demand for the service

4) Supporting sites to provide outreach/community-based HCT services to uniformed personnel and their

families. In collaboration with PEPFAR, UCSD will organize a mobile service for hard-to-reach camps in the

periphery of the country.

5) Involving people living with HIV (PLWH) as peer advocates for HCT and ART promotion and peer

support for positives. This will include peer support groups and experience-sharing through uniformed

services media.

6) Improving monitoring and evaluation system of the HCT service by using the UCSD-developed data

capturing software and timely reporting of data in all sites through training and mentoring of the staffs

7) Working with police forces at Federal and regional levels, UCSD will help strengthen and expand HCT

services in the 11 regional police clinics.

8) Expanding HCT to customs services, fire-brigade clinics, and access refugee communities through

mobile VCT to strengthen civil-military alliance

9) Commemorating National Annual Testing Day in all sites, thereby transmitting HIV messages to

uniformed personnel and their families

10) Strengthening the referral network between HCT and other services such as ART, PMTCT, and other

services

Activity Narrative: 11) Strengthening the quality-assurance system of counseling services through refresher training,

mentoring, review meetings, and peer and group counseling supervision systems.

12) Consolidating and expanding civil-military alliance programs for communities around military facilities

13) Supporting burnout management programs for service providers

14) Developing a retention program for service providers. This will be done in collaboration with the Ministry

of Defense, the police commission, and prison administration.

All activities will be closely monitored by UCSD office staff and clinical advisors. The university will support

the administrative and technical coordination mechanism to improve the management system of the

service. The activity will help to reach PEPFAR Ethiopia targets for care and treatment.

Military ART Support

This is a continuing activity from FY05, FY06, and FY07. University of California San Diego (UCSD) has

played a critical role as the lead for Military-Public Alliance and has supported implementation of ART in

Operation Zone 4 (Defense and Police and Prison Forces). The Ethiopian Ministries of National Defense

and Health, the National Defense Forces of Ethiopia (NDFE), the Federal Police of Ethiopia (FPE), and the

Federal Prison Administration (FPA) have committed to building capacity to care for their members and to

provide free ART.

PEPFAR Ethiopia provides the support to build on an ongoing collaboration between NDFE and physicians

at USCD. Since 2005, UCSD, in cooperation with Washington University/I-TECH, has assisted the NDFE,

FPE, and FPA with: (1) assessment of current capacity to support ART; (2) training and mentoring for

clinical, laboratory, and infection-control personnel through regular conferences in each facility and via

teleconferencing with UCSD experts; (3) support for physical space and equipment and reagents by

providing technical assistance and coordinating with other implementing partners; and (4) improvement in

medical informatics for health data management and information systems.

In 2007, UCSD established a program of site assessments, training and mentoring of military health care

workers to support expansion of ART. UCSD has been training medical staff since 2005, and the activity

has been systematically expanded to regional military hospitals and police and prison clinics, totaling 24

facilities in 2007. UCSD will increase its technical support from 24 ART sites in FY07 to 39 ART sites in

FY08. To ensure sufficient trained staff for expansion of sites, UCSD has partnered with Defense

University's Health Science and Police Nursing School to build capacity through pre-service training. In

2006, UCSD assisted these colleges in revision of their curricula. The support continued through 2007 to

integrate major competencies of HIV/AIDS prevention, care, and treatment programs into college curricula.

The monitoring and evaluation of this program will continue in FY08 to measure the outcome of the whole

process.

To improve coordination and integration of the program with the military and police administrations, UCSD

has provided workshops for high-ranking non-medical military, police, and prison administration leaders to

familiarize and involve them in prevention and treatment program. UCSD has worked with PEPFAR

partners to raise awareness of availability and utility of ARV services through uniformed-services media.

These sensitization workshops will continue, one of which will be through commemoration of World AIDS

Day with the different high-ranking officials of defense and police, involving the various associations for

people living with HIV/AIDS in the process. Civil-military alliances were also strengthened through the

training of more than 10,000 military reservists who are respected community members and/or leaders.

These trained reservists returned to their communities to serve as community-based peer leaders for

HIV/AIDS issues, and are having a wide geographical impact. This activity will be continued in FY08 for

additional 20,000 military reserve recruits. UCSD has also implemented educational programs on HIV/AIDS

for more than 200 non-medical uniformed trainees of Defense University College schools (non-medical), to

help them protect themselves and become effective leaders in the integration of HIV prevention and care

program into their institutions.

USCD strengthened capacity building for healthcare workers (HCW) by introducing an electronic, case-

based learning approach—TheraSim Clinical Simulator for 35 HCW at six uniformed-service hospitals.

UCSD also strengthened and continued the program aimed at protecting medical personnel from

occupational exposures by distributing infection prevention (IP) materials on a quarterly basis. Appropriate

post-exposure prophylaxis (PEP) was also implemented. Some activities of promoting PEP for women and

children who were victims of sexual assault were also carried out among the community of dependents of

military and police personnel.

In FY08, UCSD's assistance will expand its activities in a number of directions which will require a budget

increment of more than 20%:

(1) Initiation of an additional 15 new ART and 33 new HCT sites for staff and prisoners of the Federal

prison, military, and regional police clinics. These are hospitals and health centers which are found in

remote and hard to reach areas of the military, making implementation of the program more costly in terms

of accessing the sites for baseline assessment, regular mentoring, and supportive supervision activities.

The cost required to deploy data personnel to these sites is also expected to be high, as UCSD will be

forced to supplement these people with hardship allowances and retention.

(2) Protection of medical personnel from occupational HIV exposure and PEP. UCSD will ensure availability

and use of basic IP materials to the HCWs of all 39 sites and follow-up on the implementation of the

program at site level. PEP will be made available to those who have occupational exposure to HIV infection

and to victims of sexual assault, as outlined in the guidelines and protocols. All the necessary trainings,

protocols, and arrangements will be made to provide the service in all the sites that are being supported by

UCSD. This will be a continuation of the activity initiated by Johns Hopkins University as a lead in FY07.

(3) Training for undergraduate and newly trained medical personnel. The support includes pre-placement

comprehensive HIV training for all health officer and nurse graduates of the Defense Health Sciences

College and Police Nursing School. UCSD also plans to support the Defense Junior Nurses Training

Institute, which is the only training center that trains nearly 400 junior nurses each year.

(4) Offer clinical mentoring activities to ensure program sustainability through capacity building of command

health departments, command referral hospitals, as well as the Defense Health Sciences College. This will

facilitate clinical mentoring within their commands and catchments by creating a pool of clinical mentors. As

most HCW in the defense forces are Health Officers, training this group of HCW to become capable

mentors would require the provision of intensive theoretical and practical trainings; this would have financial

implications.

(5) Work with teams of Central Defense Health Department, Command Health Departments, and Division

Health Departments of the NDFE to build their supportive supervisory capacity after training them in HIV

program management. Provide the necessary technical and logistical support to conduct regular and

sustainable supervisory site visits.

(6) Improve inter- and intra-facility referral linkages to minimize the number of patients lost to follow-up

between different service clinics of the hospital by printing and duplicating referral tools and following up to

ensure proper implementation.

(7) Continue to collaborate with the Twinning Center to identify qualified professionals who can augment

Activity Narrative: local clinical and system mentoring activities at the uniformed-services health facilities.

(8) Address the human resource shortage by supporting the government's plan to shift tasks by level and to

highlight a nurse-centered care model. UCSD also plans to work on innovative retention plans to decrease

human resource attrition in the uniformed services; that attrition is becoming a continuing threat at all levels

of health facilities.

(9) Continue human capacity-building activities at the existing 24 and 15 new ART sites through building an

HIV/AIDS resource center. Expand TheraSim clinical simulator program to other sites.

(10) Support the Military Women's Anti-AIDS Coalition, an organization comprised of military and civilian

women working to educate and increase awareness about HIV/AIDS. (11) Promote ART via media

campaigns. (12) Support PLWH and others as peer advocates for ART: UCSD will help to organize and

support military unit- and hospital/clinic-based support groups to provide care, psychological support, and

peer advocacy.

In FY08, UCSD has planned to focus on strengthening pediatric ART services in the 39 ART sites through

continued collaboration with Columbia University's International Center for AIDS Care and Treatment

Programs. UCSD will have four major elements in expanding pediatric ART in the uniformed services: (1)

increasing access to pediatric ART, (2)ensuring comprehensive care and treatment services for HIV-

exposed and HIV-infected infants and children, (3)increasing availability of infant HIV diagnostics using

dried-blood spot DNA PCR testing and (4)enhancing pediatric case-finding and referral to care and

treatment services. The model pediatric ART center established at one of the defense referral hospitals in

FY07 will also be used as center of excellence and will be replicated by phases at the other pediatric

treatment centers.

To provide technical support to the country, UCSD will assist the ART health networks to follow

standardized clinical procedures and use of tools that have been agreed upon by all partners. In its lead

area of training, military-civil alliance in ART delivery, UCSD will coordinate joint planning and

implementation.

Site-level laboratory Support

This is a continuing activity which was handled by CDC in FY06; University of California, San Diego (UCSD)

continued to work on it in FY07.

In FY07, UCSD was funded to support nine hospitals, but UCSD increased support to 24 ART hospitals and

performed a number of activities, including direct laboratory support for the six hospitals with ART-

monitoring machines and support of referral testing for 18 sites without the machines.

Site-level laboratory support in FY07 included renovation of physical space to improve infrastructure; on-site

as well as off-site trainings on laboratory monitoring tests of ART, rapid testing of HIV, tuberculosis (TB) and

other opportunistic infection (OI) diagnosis; preventive maintenance and repair of equipment; specimen

management; sample transport; and implementation of laboratory quality assurance (QA) through preparing

and disseminating laboratory standard operating procedures (SOP) for different activities, which were all

done through regular follow-up and supportive supervision activities.

The collaboration between UCSD and Columbia University's International Center for AIDS Care and

Treatment (ICAP-CU) continued in FY07 to strengthen early infant diagnosis (EID) using dried-blood-spot

(DBS) and DNA PCR tests at the 24 ART sites. They offered on-site training on sample collection and

transport, site renovation, and material and furniture support for the sites.

Infection prevention was also implemented in all the 24 laboratories through a number of activities including

supply of infection-prevention materials like gloves, face shields, and exhaust fans, as well as preparation

and follow-up for implementation of safety manual and regular on-the-job trainings on infection prevention in

the laboratory.

As part of the effort in improving site-level TB diagnostic capacities, UCSD has scaled-up the pilot project of

TB diagnosis using fluorescence microscopy from one military hospital to thee more uniformed-service ART

hospitals. USCD did so by supplying the fluorescence microscope objective lens that helps change an

ordinary microscope into a fluorescent microscope, as well as by training lab personnel on the use of the

microscope.

UCSD, in collaboration with CDC Ethiopia, also established a model laboratory at one of the military central-

referral hospitals, which will be used as center of excellence and training center especially for practical

attachments of the different lab trainings. This will be replicated by phases to the other uniformed-service

laboratories in FY08.

Scale up of quality ART depends on quality laboratory services. UCSD's FY08 activity encompasses

laboratory-support activities needed at 39 (24 existing and 15 new) sites for scaling-up of ART, voluntary

counseling and testing, PMTCT, and TB services.

In 2008 UCSD will support the following activities:

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

QA programs, in partnership with the Ethiopian Health and Nutrition Research Institute (EHNRI). 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/QC programs. UCSD will also support the preparation and provision of standard

documentation and recording formats, including QC forms, lab request forms, and registers. UCSD 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 39 ART site networks. This includes:

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

ART site 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 capability; and supporting human resources by facilitating the availability of

adequately trained laboratory personnel at all sites. These activities will be coordinated with the Supply

Chain Management System and EHNRI

(3) Capacity building and minor renovation of facility-level laboratories:

UCSD 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. UCSD 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. UCSD will support: preventive maintenance of essential HIV-related

equipment, as well as equipment care and management at the facilities. UCSD will also facilitate major

equipment maintenance and provide support for national laboratory reporting systems. UCSD will

technically assist in laboratory services and instrument calibration (i.e. centrifuges, pipettes, Timers and

Thermometers).

(4) Provision of 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); laboratory training on integrated diseases including common OI

diagnosis. UCSD will provide on-site training on the new algorithm and monitor and evaluate use of the new

algorithm. A total of 120 laboratory personnel will be trained and UCSD, in collaboration with EHNRI, will

evaluate the quality of services rendered by lab personnel after training in different disciplines.

(5) UCSD will continue to provide technical assistance 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. UCSD will also support EHNRI to

establish systems for: specimen collection at uniformed-services health facilities and/or peripheral hospitals;

Activity Narrative: transportation to appropriate hospital and regional laboratories; tracking of patient samples; reporting of

results; and implementing and ensuring that standard guidelines and procedures are followed. USCD will

also support the expansion of the TB fluorescence microscope study from three to six sites to improve TB

diagnostic capacities of laboratories. UCSD will support EHNRI in expanding the laboratory information

system (LIS) at selected sites.

(6) USCD, in collaboration with ICAP-CU, will continue to provide key technical assistance to the EID

program at uniformed-services health facilities by facilitating DBS sample collection and referral. UCSD,

working at site levels, 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. UCSD will support access to EID services at all 39 ART sites through facilitation and

coordination of referral linkages.

(7). Integration of OI diagnosis in the HIV/AIDS laboratory support: UCSD 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 in budget was necessary to expand the comprehensive laboratory support to the

more than 15 sites, for the integration of OI diagnosis in HIV/AIDS laboratory support and introduction of

fluorescent microscope in some selected sites.

Site Level Data Support among Uniformed Services Health Facilities

The Federal Ministry of Health (MOH) has established a chronic-disease record-keeping system for the

national ART program. MOH has also developed standardized data collection and reporting tools for HIV

counseling and testing (HCT), PMTCT, tuberculosis (TB)/HIV, sexually transmitted infections (STI) and

Laboratory activities in a move to collect data in a standardized manner and put a national HMIS in place.

As such, this activity will strengthen the implementation of the national HMIS by harmonizing the data

collection and reporting system. The University of California at San Diego (UCSD) will also actively

collaborate with Tulane University in its effort to support the MOH/HAPCO in strengthening the HMIS and

M&E system.

As this activity was new in FY07, efforts were made during this year to establish a unit at UCSD with two

appropriate M&E personnel.

One of the major problems identified during FY07 was underused site-level data, and the following activities

were undertaken to improve the situation:

1) Appropriate data personnel were recruited for 24 health facilities, who provide support to all HIV/AIDS

programs including ART and PMTCT. This makes the total number of data personnel to be 38, together with

the 14 previously hired data personnel.

2) Eleven trainings were conducted for all the data personnel and more than 300 healthcare workers

actively involved in recording and reporting activities drawn from 58 health facilities. They were trained on

the basics of M&E, basic computer skills, PEPFAR and MOH indicators, data-collection and reporting tools

of the different programs, and site-level data use.

3) Support was provided through information technology (IT) infrastructure, data recording, and handling

materials for all the 58 uniformed-service health facilities. An electronic database was developed that serves

all levels of data handling and use for the uniformed services. The database encompasses program areas

for ART, PMTCT, HCT, TB/HIV, STI and information on Laboratory activities. The database was designed

to improve patient management, patient monitoring, site-level data use, and program monitoring, by

capturing core PEPFAR and MOH/HAPCO indicators.

In FY08, UCSD will provide technical support to 39 ART, PMTCT and Laboratory service sites, 76 STI,

TB/HIV and palliative care sites, 91 HCT sites (of which 33 are new ), and the Defense Health Science

College and Police Nursing School to assess and monitor HIV/AIDS services coverage, quality and

process. All the 91 health facilities will receive IS-related technical assistance and emphasis will be given to

the new sites through recruiting data personnel, trainings on basic M&E, data collection and reporting tools

of UCSD-supported programs, site-level data use, data quality, and other evidence-informed planning and

decision-making methods.

ART and other UCSD-supported programs will be strengthened further by increasing the capacity of health

facilities, health departments and health science colleges, and higher level decision-making departments

within the uniformed services, which provide treatment, care, and support to collect, store, analyze, and use

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

Despite the multiple efforts to expand sites, scale up services, and systematically collect, analyze, and use

data at different levels, insufficient attention is given to data and service quality, documentation and sharing

the information with stakeholders at all levels (i.e. healthcare personnel at facility level, health managers at

division and command level). Due to this, limited information is available on quality of services, barriers to

utilization of services, and documentations on best practices in PMTCT, HCT, TB/HIV, STI, palliative care

and ART services.

Therefore, in FY08 more emphasis will be given to data quality, ways to find information on service quality

and improve accordingly, and documentation of best practices and sharing information with all stakeholders.

Data use will be supported at all levels to enable service providers to manage data and use data. Sites will

be further enabled to appropriately tabulate and visualize their data through tables, charts, line and bar

graphs, and other standard methods. Appropriate options for tabulation include aggregation of data by

patient, clinic, and command levels.

Specific activities include: training and updating of data personnel and healthcare providers on the data

collection and reporting tools; training on basic computer skills; more frequent data-quality checks;

generation of more qualitative data through training and development of tools; training on documentation of

best practices: and presentations of findings and experiences both at local and international scientific and

programmatic forums for priority setting and decision making; assessment of service quality, barriers to

utilization of services; and tracking of lost-to-follow up clients and also strengthening the HIV drug-

resistance surveillance activities.

Implementation mechanisms for this activity will include providing the necessary modeling at site and

command levels within the uniformed services.