PMTCT Services at Hospital and Health Center Level by Region

This is a continuing activity from FY07. In FY07, the University of Washington/I-TECH-supported PMTCT

services in 35 health facilities in Afar, Amhara, and Tigray regions. Building on programs initiated by other

implementing partners in FY05-FY06, I-TECH 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, I-TECH will extend these services to a total of 50 health 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 Afar, Amhara, and Tigray. I-TECH will provide PMTCT services at two hospitals

and 16 health centers in Afar, 17 hospitals in Amhara, and 12 hospitals and three health centers in Tigray. I-

TECH uses antenatal care (ANC), maternal/neonatal/child health (MNCH), and PMTCT programs as entry

points to HIV care and treatment for women, children, and families. The Government of Ethiopia has revised

the National PMTCT Guidelines that was published in 2001, and issued the new PMTCT Guidelines in July,

2007. I-TECH in collaboration with JHPIEGO will support roll out of the new PMTCT Guidelines in these

regions. Major areas of emphasis include: integration of PMTCT with MNCH 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.

I-TECH 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, I-TECH will contribute to the

development of training material, clinical support tools, guidelines, formats and standards. I-TECH will

continue to provide technical input and guidance to the FMOH and Regional Health Bureaus (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 facility level, the I-TECH supported package of PMTCT Plus/family-focused care includes:

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

PLWH organizations, to promote uptake of antenatal and PMTCT services and to support follow up of

infants enrolled in early infant diagnosis (EID) programs. I-TECH will continue to work on referral linkages

by using case managers at hospitals, and enhance this system through partnership with other USG

partners. It will continue to strengthen the patient referral/linkage network through the development of tools,

training of health professionals, and on-site mentorship

2) Enhanced linkages between ANC, MNCH, PMTCT, family planning (FP), 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) 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 in coordination with the Global Fund to Fight AIDS, Malaria, and

Tuberculosis (Global Fund) 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 (MVI) 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 MNCH staff (including traditional birth attendants) on safe infant-feeding practices in the

context of HIV, developing infant-feeding support tools, and establishing infant-feeding MSG

12) Linkages of all infants born to HIV-positive women to the HIV-Exposed Infant Clinic to ensure EID by

DNA PCR using dried-blood spot (DBS) 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-management information systems (HMIS)

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 of age 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 and the JHPIEGO-supported

Standard-based Management Program

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

18) Provision of 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, refurbishing, and repair (as needed) of ANC, labor and delivery rooms, and maternity

wards at JHU-supported sites

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

communication (IEC/BCC) materials in local languages to enhance public awareness and use of ANC,

MNCH, PMTCT and HIV care & treatment services.

Additional narrative to COP08 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. ITECH will be

involved in the expanding outreach PMTCT services in Amhara, Tigray and Afar regions.

Addition 10/7/08:

This funding will be used to strengthen the existing prevention intervention by University of Washington.

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

care and treatment programs.

University of Washington 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.

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, I-TECH has taken full responsibility for supporting STI activities at 35 sites found in

Operational Zone 1 (Afar, Amhara, and Tigray regions). The support includes training healthcare providers

in prevention and syndromic management of STI, and providing technical assistance to implement the

syndromic approach at hospital level. I-TECH has hired an STI technical officer to spearhead this effort and

begin the developing an action plan to initiate the training and assistance that will be needed to affect

heightened awareness and treatment of STI by clinical practitioners at all I-TECH hospital sites.

FY08 activities at the regional level will include:

Coordination with regional health bureaus (RHB) will help facilitate and coordinate linkages between STI

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

community service organizations (CSO), faith-based organizations (FBO) 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) Expansion of STI services to three additional sites, for a total of 38 sites supported by I-TECH (including

30 public hospitals, two private hospitals, and six health centers)

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. The focus will be 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 on 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 services, promoting a provider-initiated, opt-out

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

positive

8) Providing 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. There

will be a special focus on MARPs.

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

educated about STIs (including education on preventing STI during pregnancy) and provided with

necessary, according to national STI management and antenatal care guidelines

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

prevention and early/complete treatment in communities surrounding I-TECH-supported ART sites

I-TECH will also focus on:

12) Establishing criteria to ensure that follow-up of patients on treatment is successful

13) Close collaboration with the RHB to ensure that those persons at highest risk of STIs from all publicly

supported STI clinics are included in the protocols for HIV testing

14) Developing appropriate protocols and tools at each site to ensure that all partners of those persons

testing positive for any STI are notified of their exposure and of the need for STI evaluation, treatment, and

HIV screening, as per the national guidelines

15) Evaluating STI/HIV referral services that will be provided quarterly to both hospital staff as well as the

RHB

16) Providing appropriate training and support for hospital staff to routinely evaluate patients for STI at

antenatal, family planning, and ART units and out-patient departments, as well as to offer routine HIV

testing

17) Support sites in documenting and reporting STI syndromic

Palliative Care

In this continuing FY08 activity, two I-TECH FY07 palliative care programs (i.e. basic care and support-

10501) and prevention with positives (10629), are merged into one activity.

In FY06, the University of Washington/I-TECH introduced a basic palliative care approach to 31 ART

facilities. In FY07, they expanded this activity to 35 sites in Operational Zone 1 (Afar, Amhara, and Tigray

regions). Initial work included baseline assessment of the palliative care activities at sites, development of

pain management guidelines, and development of palliative care training curriculum in collaboration with

relevant government stakeholders. They also conducted regular supervision of palliative care activities at

site level. The palliative care curriculum developed by I-TECH was integrated as part of the basic

comprehensive HIV training, including ART. Training and supervision focused on identification of pain and

discomfort among HIV patients, ensuring cotrimoxazole prophylaxis (pCTX) for all eligible patients,

tuberculosis (TB) screening for HIV-positive patients, and targeted elements of the preventive care package

(e.g., multivitamins, nutrition assessments, condoms, and links to programs that distribute insecticide-

treated bed nets (ITN).)

As a lead partner in palliative care among US-based university partners, I-TECH, in collaboration with the

Ethiopian Drug Administration and Control Authority and PEPFAR partner organizations, has developed the

National Pain Management guideline to aid proper assessment and management of pain at all levels of

healthcare. As an active member of the National Palliative Care Task Force, I-TECH is working with other

stakeholders in the development of the National Palliative Care Guideline and coordination of palliative care

program implementation at the national level.

In FY07, 5,417 persons have received palliative care, and 60,000 tablets of cotrimoxazole (CTX) and 1,000

bottles of CTX have been provided to ART sites in the Afar region as emergency support.

In FY08, I-TECH will support palliative care activities at 38 sites that provide HIV/AIDS care and treatment

(hospitals and emerging region health centers), 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 prevention of opportunistic infections for people living with HIV (PLWH), slowing

disease progression and reducing morbidity and mortality.

I-TECH will assist hospitals in Afar, Amhara, and Tigray to provide the preventive care package,

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

Health, and other PEPFAR Ethiopia-funded activities when possible. I-TECH will focus on provision of the

preventive care package, which for adults includes: pCTX; micronutrient (multivitamin) and nutrition

supplements and counseling; ITN, through links with the Global Fund malaria control program; point-of-use

water disinfectant (wuha agar) at hospital level and health education about safe water use; condoms and

education for prevention among positives; and screening of partners and family members of PLWH, as well

as TB screening and isoniazed (INH) preventive therapy. The preventive care package for children includes:

pCTX to prevent serious illnesses like Pneumocystis carinii pneumonia, TB, and malaria; prevention and

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

programs.

I-TECH will work closely with PEPFAR Ethiopia's other US-based university partners to ensure

complementarity of activities in the implementation of national pain management guidelines and the

palliative care training curriculum.

I-TECH's 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

the 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.

I-TECH will ensure that all supported sites have reliable stocks of CTX tablets and syrups as well as

promote TB screening and provide INH prophylaxis for HIV-positive adults and children. (See also the

activity section on TB/HIV activities.) Supportive supervision and mentorship will be strengthened to ensure

that standard operating procedures and national guidelines for the provision of CTX and INH prophylaxis

are being followed. Attention will be given to the issue of HIV/malaria co-infection, and the routine provision

of ITN in HIV/AIDS and PMTCT programs in collaboration with the Global Fund. Facility and lay staff will

provide health education and behavior-change communication for HIV-positive individuals, complementing

Global Fund and other USG-funded activities. Health education, counseling, and support will encourage

positive living to forestall disease progression, and promote prevention among positives to prevent further

HIV transmission.

In FY08, I-TECH will continue its national-level support through active participation in the National Palliative

Care Task Force and through organizing workshops to advocate for the integration of palliative care

(including the preventive care package) in the overall healthcare system. I-TECH will also address the

Activity Narrative: human resource issue by increasing healthcare worker training through the standardized palliative care

curriculum.

I-TECH will implement prevention-with-positives activities which include: promotion and education on the

use of condoms; partner and family screening; education and counseling on positive living; and addressing

the full spectrum of transactional sex, particularly in urban settings. Along with these efforts, some

opportunities may exist for more strategic access to condoms, condom distribution and condom education.

In addition to standardized training, coordination, and evaluation, strategies will include peer education and

outreach programs through the case managers and outreach workers at each facility (given the human

resource constraints in Ethiopian health facilities). Many of those programs will include PLWH. In addition,

the lessons learned from FY07 prevention-with-positives activities will be used to enhance and refine the

approach to this intervention, as well as to strengthen prevention-with-positives activities throughout

PEPFAR Ethiopia's palliative care programs.

TB/HIV Support at Hospital Level

In FY07, Washington University/I-TECH has been supporting tuberculosis (TB)/HIV collaborative activities

in 35 hospitals in Operational Zone 1 (Afar, Amhara, and Tigray regions). I-TECH has been providing

technical assistance to sites through: on-site clinical mentorship for counseling and testing TB patients for

HIV; linkage to care and treatment services; routine screening of HIV patients for TB; isoniazid preventive

therapy (IPT); cotrimoxazole preventive therapy (CPT); monitoring and evaluation (M&E) of TB/HIV

activities; and TB infection control. In addition, during the first quarter of FY07, 30 healthcare providers were

trained and certified on TB/HIV collaborative activities.

In FY08, I-TECH will continue to strengthen and expand TB/HIV activities in Operational Zone 1 at a total of

38 sites. I-TECH will support improved access to high-quality HIV counseling and testing services among

patients at TB clinics by training both providers and on-site lay counselors, as well as providing support for

on-site, rapid HIV testing. In addition, I-TECH will continue to support sites to implement routine, provider-

initiated HIV counseling and testing (with an opt-out approach) for all TB patients in I-TECH-supported

hospital and health-center settings. I-TECH will also offer prevention counseling, education, and referral to

HIV care and treatment services.

I-TECH will introduce intensified, active case-finding for TB in HIV-positive clients by incorporating

screening for TB symptoms into post-test counseling in a number of venues: voluntary counseling and

testing (VCT) centers, sexually transmitted infections (STI) clinics, and antenatal clinics (ANC). Clients with

symptoms will be linked to the newly trained case managers and peer educators to ensure proper TB

diagnosis and treatment. Case managers and peer educators will also encourage family members of their

HIV-positive clients to be tested for HIV and screened for TB, and will offer home visits to do screenings. In

addition, I-TECH will support efforts to improve adherence to TB therapy through case managers and peer

educators. Through its region-based, clinical mentoring teams, I-TECH will sensitize ART-adherence nurses

to the importance of adherence to TB treatment. I-TECH will collaborate in regional and national

interventions related to multidrug-resistant TB (MDR-TB) treatment and containment.

As part of their routine activities, region-based ART clinical mentoring teams will continue working with sites

on appropriate diagnosis and treatment of active TB in HIV-positive persons. I-TECH will also ensure that

HIV-positive patients are appropriately provided with isoniazid preventive therapy (IPT), through regular

supportive supervisory visits by field-based clinical mentoring teams to all 38 hospital sites. ITECH will

support sites in the provision of cotrimoxazole preventive therapy (CPT) for all TB/HIV co-infected patients.

I-TECH will establish and strengthen the multidisciplinary care teams in each facility, with representation

from the TB service to facilitate referral and linkage to care and treatment services. I-TECH's M&E unit

(both field- and Addis-based) will support facilities in monitoring the referral system for co-infected patients,

and regularly evaluate/analyze referral data to inform efforts to improve the current system. As part of its

M&E activities, I-TECH will also offer supportive supervision of ART-clinic-based data clerks and data

managers, and on-site training and mentoring in data collection using TB/HIV data-collection forms. I-TECH

will also support the Federal Ministry of Health (MOH), the HIV/AIDS Prevention and Control Office

(HAPCO), and CDC efforts to improve the TB/HIV information system by hiring a TB/HIV M&E expert who

can work closely with CDC and MOH.

I-TECH will support laboratory TB diagnosis through regular mentoring visits to TB clinics and labs by

laboratory technicians and quality-assurance experts who have experience in TB diagnosis with smear

microscopy. These laboratory-mentors will provide on-site troubleshooting and training, as well as a link to

the regional referral laboratories. I-TECH will support the initiative by MOH, CDC and EHNRI to establish

TB culture facilities at regional levels and facilitate the transport of specimens to regional labs for TB culture

once capacity is available.

I-TECH will also work on developing information, education, and communications materials, and/or reprint

and distribute existing materials on TB prevention and symptom screening at the hospital level.

In 2007, I-TECH assessed the feasibility of TB/HIV collaboration and the prevalence of HIV in TB patients in

pastoralist areas of the country. In FY08, the result of the assessment will be used to improve the

implementation of TB/HIV collaboration in those areas.

I-TECH will introduce infection control and provide supplies required for infection control, work closely with

regional health bureaus (RHB), MOH, implementing sites, and CDC on prevention and management of

MDR-TB, and on improving the recording and reporting of TB/HIV data. I-TECH will support the MOH,

HAPCO, and CDC efforts to purchase and install chest x-ray machines for hospitals in ICAP- CU regions.

Finally, I-TECH will support feasibility studies (targeted evaluations) planned by CDC and other partners

and will work closely with RHB, hospital ART committees, regional TB/HIV working groups, and MOH in its

focus regions to ensure that TB program representatives are included in program-planning activities and

policy development that addresses the co-morbidity of HIV/AIDS and TB.

This is a continuing activity.

In FY07, the University of Washington/I-TECH has been providing technical assistance for the

implementation of both client-initiated and provider-initiated HIV testing and counseling services, as well as

training of healthcare providers in the same area for 35 hospitals found in Operational Zone 1 (Afar,

Amhara, and Tigray regions). So far, during the first quarter of 2007, 57 healthcare professionals have been

trained on HIV counseling and testing (HCT)—both client and provider initiated—according to national and

international standards. In addition, 34 sites are providing voluntary counseling and testing (VCT) and 30

sites are providing provider-initiated counseling and testing (PICT) services. In the same quarter, we have

provided HCT services to 16,965 and PICT services to 1,901 individuals.

In FY08 the following activities will be supported by I-TECH :

Considering that HCT is the entry through which the general population can access appropriate HIV

prevention, care, and treatment services, I-TECH would intensify complementary interventions to ensure

quality, client HCT services at 38 health facilities (30 public hospitals, two private hospitals and six health

centers in Afar) within Operational Zone 1 (Afar, Amhara, and Tigray), including referrals of HIV-positive

clients from community-based VCT programs.

In line with the family-centered care approach, which includes testing pediatric age groups, couples would

be encouraged to be counseled, tested, and receive test results together. The notification of partners will be

encouraged in cases where one partner receives positive test results, regardless of the setting in which the

person was tested. Efforts will be made to ensure privacy and autonomy of both individuals and couples.

Informed decisions shall be encouraged among discordant couples to protect the HIV-negative partner and

support the HIV-positive partner, while, at the same time, trying to assure testing of the untested partner.

Appropriate child counseling and testing, as appropriate, would be assured as part of diagnostic testing, and

family and couples' counseling.

Considering the high prevalence of HIV among youth and women, efforts also would be made to promote

routine premarital and preconception HCT to family-planning clients.

In FY08, I-TECH will consolidate ongoing efforts to ensure that both client-initiated and PICT services are

readily available at all 35 hospitals in the three I-TECH operation regions. We will continue to expand

counseling and testing cadres and same-hour result models through HIV testing points. It will be the norm at

all I-TECH sites to offer routine HIV testing for sexually transmitted infections (STI), tuberculosis (TB), and

family planning (FP) clients and to patients in the inpatient and outpatient departments. Appropriate intra-

facility referral tools will be implemented to ensure functional linkage among the different units within a

hospital: VCT, ART, STI, TB, FP, inpatient, and out-patient.

In addition, PICT will be expanded in pediatric inpatient and outpatient departments, as well as in

immunization outlets.

I-TECH will fully assume responsibility for training healthcare providers as fulltime counselors and in the use

of rapid HIV testing in the three operational regions. Gondar and Mekele Universities will continue to be

supported as training sites for counselors. A pool of trainer-of-trainers for healthcare provider training in

HCT techniques would be ensured to sustain local needs to include Health Center staffs as necessary and

to assure regional ownership of the program.

Furthermore, taking into account that the nation suffers most from a severe shortage of trained healthcare

providers, I-TECH will fully support and complement the national effort in scaling up the lay counselors

initiative. I-TECH will also involve people living with HIV/AIDS (PLWH) in this effort throughout the three

operation regions (based on the piloting of lay counselors by JHPIEGO in 2006).

Through coaching and mentoring visits to hospitals, I-TECH's field-based clinical teams would make sure

that quality of HCT services (client- and provider-initiated) are in place in both adult and pediatric service

outlets. Functional hospital HIV committees would be encouraged to foster adherence to quality HCT

standards and enhance the formation of multidisciplinary care teams for all testing sites within the facility.

Hospitals and health centers will be supported to establish functional referral mechanisms and linkages with

private-sector facilities.

efforts will be made to launch outreach and mobile VCT services in high-risk corridor areas like the Addis

Ababa - Djibouti route in Afar area and the Humera region in western Tigray where there are migrant

mobile work forces and commercial sex workers are found. This will be done in close partnership with

PEPFAR implementing partners in the area.

Since there is limited space for HCT, and a shortage of human resource because of high turnover of

hospital staff (especially trained counselors), it is important to increase timely access to HIV care and

treatment services. I-TECH will continue to expand counseling and testing services by supporting weekend

VCT services in all of the major hospitals within the regions.

I-TECH provides support to sites implementing outreach services as necessary, in line with the Millennium

AIDS Campaign and local initiatives.

I-TECH supports establishing peer-support groups at site level for burnout management and skill building,

and also organizes other burnout-management programs in collaboration with partners.

Furthermore, I-TECH will give support to the Regional Health Bureaus and sites in terms of technical

assistance in launching National HIV Testing days.

I-TECH will also continue to work closely with national and regional partners and USG agencies to promote

HCT services, training of healthcare providers, and sharing of best practices.

In FY06, I-TECH-supported facilities enrolled over 15,000 new patients on ART (96% of target) and enrolled

2,560 new patients in the first two months of FY07, ensuring it would meet its target for new patients in

2007. This activity continues in FY08 and will enroll a projected total of 18,000 new patients on ART, with a

better quality of care.

I-TECH will provide intensive technical support to all 30 public hospitals and two private hospitals in Afar,

Amhara, and Tigray regions, in partnership with the regions. This support will also extend to up to six health

centers in Afar region for comprehensive support through established regional and field-based teams. To

meet 2008 targets in Afar, I-TECH anticipates continuing comprehensive support of the six health centers.

The expanded regional ART teams include a physician coordinator, pediatrician, a lab technician, a

program assistant, and a monitoring and evaluation coordinator and a data manager for each of the three

regions. These teams will continue to work in close collaboration with the Regional Health Bureaus (RHB).

There will also be an enhanced focus on the quality of all services in our continuing efforts to strengthen

and focus on positive clinical outcomes. The teams will identify the training needs of the multidisciplinary

teams at the 38 sites in the I-TECH supported regions.

I-TECH will provide periodic entry-level training on: providing ART; tuberculosis (TB)/HIV collaborative

activities; and voluntary counseling and testing (VCT), PMTCT and sexually transmitted infections services.

(This will also extend to the post-basic nurse training under the I-TECH Nursing Initiative). In addition to this

training, HIV/ART modules for pre-service training, begun in FY07, will be completed in FY08 in

collaboration with major university sites within the I-TECH regions (i.e., Gondar and Mekele) and will

continue to be supported.

Advanced training for ART clinicians will continue to be provided through an ongoing relationship with

Hadassah Medical Center in Jerusalem, Israel. Ten healthcare providers have completed this advanced

training and we will be sending another 11 healthcare providers in FY07. The advanced training has proved

very valuable for Ethiopian ART practice and the development of ART expertise. In 2008, I-TECH will

design an evaluation tool to assess the performance of the trainees on site and try to measure the impact.

1) In addition to developing "Centers of Excellence" for HIV and infectious disease training at Gondar and

Mekele Universities, I-TECH will continue to support and give technical assistance in upgrading ALERT

Hospital as a demonstration training center by assisting with training curriculum development and modeling

the HIV practice set-up. The establishment of these three centers of excellence in FY08 will provide the

framework for shifting advanced ART clinical training currently conducted in Israel to Ethiopia.

2) In FY08, I-TECH, in collaboration with Hadassah University, will conduct advanced training in Israel for

nurses working in health centers supported by I-TECH and other USG universities.

3) Trainings of trainers (TOT) will continue to be used for multidisciplinary training and their roles will be

expanded for training and mentoring at all levels of practice within the hospital setting, including the ART

clinic and the key programs including the VCT, PMTCT and TB programs. During FY08, each health facility

in I-TECH-supported regions will have at least one skilled trainer who would be able to train on at least one

area.

4) In collaboration with the Ethiopian Ministry of Health (MOH) and USG partners, I-TECH is already in the

process of developing revised training curricula for comprehensive ART training and refresher courses for

ART practice that will be piloted and evaluated to address the major changes in treatment.

5) In FY08, I-TECH will continue to work with its USG partners and the MOH in the primary role of ART

training-related activities, including curriculum review and development, advanced nurse practice training

and certification, and development of new or innovative ART team members. I-TECH will train and certify 60

additional TOT and train 300 health providers (physicians, nurses and pharmacists) on comprehensive HIV

training.

6) As the demand for HIV Advanced Nurse Specialists (HANS) has increased, I-TECH will train 200 HANS

in FY07. In the first quarter of 2007, 80 nurses received this training. As a continuation of this activity and to

conduct this training on a broader scale, I-TECH will train offer TOT for HANS in 2008, and work with USG

universities throughout the country to prepare them to mentor their own HANS in 2008. I-TECH will also

work with Management Sciences for Health (MSH) to ensure that the advanced-practice nurse trainings and

curricula are made available to the nurse cadre seeing patients at health centers including the development

of TOT for that segment. In addition I-TECH will assure that standardized site visits to all regions through

mentoring of mentors will be conducted in collaboration with MOH, HIV/AIDS Prevention and Control

Offices, and USG universities.

7) I-TECH has a national mandate to develop an ART case-management model. In FY07, the National ART

Case Management Model was finalized, an ART case-management curriculum was developed, and six

case managers were hired in order to pilot case-management services at six major hospitals in Amhara,

Tigray, and Afar regions. I-TECH will be training more ART case managers before the end of FY07, and will

work in FY08 with the MOH, HAPCO and USG universities on TOT to ensure that it is endorsed as a

national program. I-TECH will train case managers for all the facilities it supports in FY08 and will conduct

targeted evaluations to see the impact of their activity. It will also provide the training curricula and TOT to

MSH in order to assure that a standard model of case management exists at both hospitals and health

centers supported by USG.

8) In FY08 I-TECH will continue to support MOH and Federal HAPCO in the development and

harmonization of training materials for primary healthcare providers working at health centers, and will

assist HAPCO in the development of different guidelines and mentoring training manuals in response to

HAPCO's request to lead these activities. As a national technical lead on training, I-TECH will continue to

give TA to organizations that implement the ART program at health centers, particularly in development of

curricula and TOT.

Site level:

I-TECH site mentors, consisting of a physician for ART support, lab technologist, nurse, and monitoring and

evaluation staff teams, will regularly visit all 38 regional ART sites to: provide system support for clinics,

laboratories, and pharmacies; identify and provide multidisciplinary team training; provide regular mentoring

and case consultation to physicians and nurses; and address issues that are identified as barriers to the

efficient and effective care of ART patients. These mentors will be part of a regional ART team for each of

the three regions and each team will be assigned to assist 3-4 health facilities per team. The ART team will

work in close collaboration with the RHB but will report to the I-TECH medical and country director as

appropriate.

Activity Narrative: 1) An I-TECH laboratory technician will routinely visit the ART laboratory staff to provide additional

resources and capacity by addressing issues of training, equipment maintenance, and reagent

procurement. The technician will work closely with the RHB and the national agency for laboratory support

for ART (through the Ethiopian Health and Nutrition Research Institute). This expert will link with the CDC

and other university partners in order to standardize laboratory practices and capacity, and work closely

with other laboratory trainers, agencies, and suppliers to strengthen support and capacity in the hospital

setting.

2) In addition to adult ART support and training, I-TECH will concentrate on the support for pediatric

treatment and expand to other major sites including Dupti Hospital in Afar. The need to expand routine

treatment of children, which was a focus point in FY07 and addressed by the hiring of three pediatricians,

will be further expanded in FY08 through working with the sites, RHB, and MSH to assure referral from

health centers to hospitals as appropriate.

I-TECH will also integrate a post-exposure prophylaxis (PEP) protocol and approach for both government-

employed clinicians, as well as its own staff at all I-TECH sites in FY08. I-TECH will also provide protocols

and training for victims of sexual assault, and ensure that PEP-related drugs are in place in all of its sites in

2008. Victims have virtually no access to information on HIV/AIDS or the preventive services such as PEP;

the need for information, services, and trained practitioners will be met both by site-level training and by

including the training in I-TECH's basic ART and HANS trainings.

Local Universities Support: As part of its continuation of the FY07 plan, in FY08, I-TECH will further

strengthen the two demonstration sites at Gondar and Mekele Universities as venues for training and

clinical preceptorship for health providers in the Amhara, Tigray and Afar regions. To strengthen human

resource capacity of these two universities, their staff will be recruited and enrolled as TOT, and given

advanced ART trainings in Israel. These demonstration centers will also provide the continuum of care for

ART services beyond the hospital, extending to the community through case managers, palliative care

providers, and linkages to health centers in the major hospital catchments. I-TECH will also strengthen their

laboratory capacities, including resistance testing, in collaboration with the ongoing laboratory training with

Hadassah Medical Center and the University of California, San Diego.

Site-level laboratory Support

In FY07, I-TECH (Washington University) provided comprehensive high-quality HIV/AIDS services,

including ART, at public and private hospital networks in the Amhara, Tigray, and Afar regions.

Comprehensive technical assistance (TA) and implementation support has strengthened essential elements

of the laboratory system, and improved service quality and consistency. I-TECH has helped to conduct

assessment of laboratory services and train laboratory staff (via offsite and on-site trainings on equipment

operation, preventive maintenance, and HIV-related laboratory test procedures). I-TECH has also helped to

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

implementing standard operating procedures (SOP), developing log books and improving documentation

and recording; and providing technical and logistic support for specimen referral linkages between testing

hospitals and referring hospitals and health centers.

In FY07, I-TECH provided major infrastructure support to hospital laboratories, including: improving 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, I-TECH, in collaboration with the

International Center for AIDS Care and Treatment Programs at Columbia University, has provided key

technical and implementation support to Early Infant Diagnosis (EID) programs at regional and site levels. I-

TECH supported 393 blood sample transfers from health centers to nearby hospitals in Tigray and 1,643

samples in Amhara regions in FY07.

In FY08, I-TECH will expand its support to 32 hospital networks (30 government and two private) in the

Amhara, Tigray, and Afar regions, enabling each to provide comprehensive, high-quality HIV/AIDS services.

In addition, I-TECH will support six health centers in Afar region. Intensive site-level laboratory support is an

essential component of I-TECH'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 38 sites. I-TECH will work

directly with the regional labs, hospital labs, and health center personnel to implement and monitor QA

programs at the 38 sites. Procurement and distribution of laboratory equipment and supplies for these sites

will be handled by the CDC, the Ethiopian Ministry of Health, the Ethiopian Health and Nutrition Research

Institute (EHNRI), and the Supply Chain Management System (SCMS), as will equipment maintenance. I-

TECH will continue to provide TA for the rollout of HIV-1 DNA PCR tests for infant diagnosis at regional

levels.

I-TECH's laboratory support activities in FY08 will include:

(1) Strengthening site-level laboratory quality systems, with emphasis on initiating and enhancing QA

programs in partnership with EHNRI and Amhara, Tigray, and Afar 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. I-TECH will also support the preparation and provision

of standard documentation and recording formats, including QC forms, lab request forms, and registers. I-

TECH 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 38 ART site 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 capability, 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 I-TECH regional laboratory advisors will work closely with the regional lab

associates of SCMS.

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

I-TECH 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. I-TECH 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. I-TECH will support preventive maintenance of essential HIV-related

equipment and equipment care and management at the facilities and facilitate the major equipment

maintenance; and support for national laboratory reporting systems. In FY08, I-TECH will continue to

facilitate upgrading laboratory infrastructure to improve the service in ten 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) Providing 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 diagnosis of common

opportunistic infections (OI). I-TECH 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 I-TECH, in collaboration with regional labs, will evaluate the quality of services rendered

by lab personnel after training in different disciplines.

(5) I-TECH will continue to provide 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. I-TECH will also support: 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 standard guidelines and procedures are followed. I-TECH will facilitate

EHNRI's expansion of the Laboratory Information System (LIS) to the sites.

Activity Narrative: (6) I-TECH will continue to provide key TA to EID programs in the region. Working at the national, regional,

and site levels, I-TECH will support not only HIV DNA PCR testing capacity in laboratories, but the clinical

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

infants and families. Support will be given to establish HIV DNA PCR testing capacity at three more I-TECH-

supported sub-regional and hospital laboratories (Dessie and Afar regional labs and Gondar University

hospital laboratory). This will include minor renovations, epoxy painting of floors, and furnishing with

standard laboratory furniture.

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

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

(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 of the three regional laboratories

and hospital laboratories for EID; support for health center laboratories in emerging regions; and integration

of OI diagnosis.

Support for site-level use of data

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 Afar, Amhara,

and Tigray regions.

In FY07, University of Washington/I-TECH supported 26 sites in Operational Zone 1 to collect, manage,

analyze, and use HIV/AIDS services-related data generated at site level for decision-making to improve

clinical and program management. In addition, I-TECH has trained 45 health professionals and data clerks

in monitoring and evaluation (M&E) and assisted regional health bureaus (RHB) to organize experience-

sharing workshops.

In FY08, I-TECH 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 I-TECH 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. I-TECH

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

provided to enhance collection of accurate and complete data. I-TECH 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, I-TECH 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.