PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Subdivisions of Program Areas, these track general higher level sub-classifications of expenditure.
Subdivisions of Major categories, these are the most detailed expenditure data.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008
Model Center for Maternal and Family ART/Care
In FY07, the Johns Hopkins University-Bloomberg School of Public Health (JHU-BSPH), with collaborative
assistance from JHPIEGO, proposed to develop a Maternal and Family HIV Center of Excellence to model
delivery of PMTCT and ART services, and to facilitate care for family members of HIV-positive persons. The
proposed site was Gandhi Hospital in Addis Ababa, a specialized facility known for excellent maternal care,
which has not functioned to full potential due to severe material and staff shortages. However, Gandhi has
provided excellent antenatal (ANC) and PMTCT care. In FY06, a model voluntary counseling and testing
(VCT) center opened, and currently serves pregnant women, their partners, and children with a full-time
general practitioner to care for HIV patients and a pediatrician to care for HIV-exposed infants. Great efforts
are underway to further develop Gandhi Hospital as a model center providing integrated PMTCT, VCT, and
To date in FY07, JHU-BSPH has: developed a workplan for this activity in collaboration with Gandhi and the
Addis Ababa regional health bureau (RHB); conducted an on-site PMTCT training for all ANC and labor and
delivery personnel; hired a PMTCT case manager and nurse assistant to facilitate the extra workload
involved in this project; and worked with the facility to relieve perceived work burden for overstretched
In FY08, Gandhi Hospital will continue to take the lead in solidifying the implementation of the revised
national PMTCT guidelines, which support opt-out HIV counseling and testing and aggressive referral of
family members. In the ANC setting, the opt-out approach will continue to include group education and rapid
testing by trained lay counselors. HIV-positive women will be encouraged to have partners and children
tested. JHU-BSPH will support an innovative, family-focused approach at Gandhi using PMTCT as the entry
point. Gandhi pioneered starting HIV-positive pregnant women on ART within the same clinic, and now
plans to expand services to provide care for the entire family. Moreover, Gandhi will provide screening for
other family-focused clinical problems, such as TB. Evidence shows that referring a pregnant woman from
PMTCT to an ART clinic for treatment is inefficient in the Ethiopian context; in reality, most eligible women
do not receive evaluation or ART until after delivery. Other pregnant women are never properly screened for
therapy, or are referred back to PMTCT programs, due to clinician inexperience in treating pregnant
mothers with ART. Referrals may also over-burden ART providers, contributing to burn-out and attrition.
JHU-BSPH proposes to optimize delivery of ART to pregnant women who meet treatment criteria. Based on
preliminary data from the Nigat Project, a PMTCT clinical-trial collaboration between JHU-BSPH and Addis
Ababa University, approximately 30% of HIV-positive pregnant women have CD4 counts <200/mm3.
Pregnant women with advanced clinical AIDS, or with CD4 counts <200/mm3, are at greater risk of
transmitting infection to their infants and at greater risk of serious morbidity or death. Maternal illness and
death have been shown to affect neonatal/infant health and survival adversely, even when mothers have no
HIV infection. Women with more advanced HIV require ongoing combination ART for their own health. Use
of single-dose nevirapine (SD-NVP) for lower CD4 counts is associated with increased NVP resistance,
which has the potential to affect community rates of nonnucleoside reverse transcriptase inhibitor (NNRTI)
resistance and reduce future maternal treatment options.
As part of the training programs of the Gandhi Hospital center of excellence, JHU-BSPH will continue to
train ANC providers and OB/GYN in ART management during pregnancy, clinical staging, and CD4
interpretation. JHU-BSPH will implement the revised Ethiopia PMTCT guidelines, which include extended
ARV prophylaxis options. These range from full ART to AZT during pregnancy, NVP and combivir
intrapartum and combivir postpartum, to SD-NVP, where facilities do not permit more complex regimens.
This transition in regimens will continue to require intensive staff training and measures to ensure
medication accessibility for pregnant women. In FY08, JHU-BSPH and Gandhi will share their experience in
training healthcare workers (HCW) on the extended regimens, and will use their experience in implementing
the revised guidelines to develop training materials and as a basis to develop a training-center program to
train HCW from other hospitals.
PEPFAR feels that the continuum of care for positive pregnant women starts at the ANC visit, followed by
HIV counseling, testing, and appropriate ARVs throughout pregnancy, as recommended by the MOH, with
the goal of reducing HIV transmission to the infant. As ART is scaled up in many low-resource settings,
providing highly active antiretroviral therapy (HAART) to HIV-positive pregnant women will benefit both
mothers and infants. HAART has been associated with the lowest rates of MTCT and has become standard
care for infected mothers in the US and abroad. Improvement in maternal health with ART will result in
healthier infants and reduced neonatal/infant mortality. General obstetrical antenatal practices will also be
strengthened, focusing on those most relevant to PMTCT (e.g., malaria prophylaxis in endemic areas,
syphilis screening, prevention/treatment of anemia, antenatal discussion of family planning). JHU-BSPH will
partner with the JHPIEGO-supported ACCESS Program at Gandhi Hospital that aims to improve maternal
The center of excellence will also provide general postpartum and newborn/infant care, including family
planning, counseling/monitoring of infant-feeding options, growth monitoring, and child immunizations. After
18 months, care for mother and family will be transferred to the nearest ART clinic. Pediatricians will be
trained in infant diagnosis and will provide infant management. The center will co-manage the partners of
the HIV-positive women, as treatment of the family as a unit has been shown to help keep the households
together, which in turn, minimizes mother and infant morbidity and mortality.
Care and treatment burden-sharing among a wider range of medical specialties will be a great strength of
this center and a marker of quality comprehensive care for the entire family unit. It is expected that this will
also have a positive influence on the retention crisis for trained health providers and the human resource
shortage challenges plaguing ART provision. Quality of services will be guaranteed when reliable
consultative linkages to internal medicine and infectious-disease services are established at Tikur Ambassa
or Zewditu Hospitals for complicated or advanced cases. JHU-BSPH plans to facilitate the transfer of
knowledge through international subject-matter-expert exchanges, supportive supervision and mentoring,
distance learning, and scheduled in-service training in the management of HIV-positive pregnant mothers.
In FY08, JHU-BSPH will continue to support the model site at Gandhi Hospital and will expand certain
activities, such as developing a training center and training capacity for practical PMTCT and ART
Activity Narrative: attachments, and involving family-focused cases in the ongoing telemedicine case conferences supported
by JHU-BSPH. If the model center proves successful in improving follow-up of infants, timely initiation of
ART for pregnant and postpartum women, and inclusion of all members of the family in HIV screening and
care, JHU-BSPH aims to extend this model to additional sites within its operational zone.
Proposed activities for FY08 include:
1) Annual assessment and review of activities: number of pregnant HIV-positive women seen in ANC clinic
and referred to ART clinic and number of pregnant women seen in ART clinic
2) Training of ANC providers to do clinical staging and perform and interpret CD4 counts
3) On-site and practical training for other hospital-based PMTCT programs; support to develop local training
4) Telemedicine for complicated HIV-positive pregnant cases
5) Training of ANC/labor and delivery physicians in ART management and follow-up
6) Introduction of counseling and testing at ANC and labor and delivery using the opt-out strategy
7) Introduction of counseling and testing to postpartum women who missed HIV testing in the prepartum
8) Early infant diagnosis with dried-blood-spot DNA PCR testing
9) Creation of the exposed infant clinic for all children born to HIV-positive mothers
10) Strengthening and increased functionality of referral linkages between ANC, labor and delivery wards,
exposed infant clinics, ART clinics and the HIV laboratory
11) Support for mothers' support groups at Gandhi
12) Support for case managers and nurse assistants at site level to ensure proper follow-up, tracking, and
comprehensive care for the entire family
13) Introduction of this model to another site in the JHU-BSPH-supported operational zone
14) Assistance for two US-based university partners to establish model centers at Jimma and Gondar
This is a continuing activity from FY07. In FY07, Johns Hopkins University/ Technical Support for the
Ethiopia HIV/AIDS ART Initiative (JHU TSEHAI) supported PMTCT services in 30 hospital networks in
Addis Ababa, Benshangul- Gumuz, Gambella and the Southern Nations, Nationalities, and Peoples
Regions (SNNPR). JHU TSEHAI expanded and enhanced interventions to prevent prenatal and
postpartum transmission, and to link HIV-positive pregnant women and their families to comprehensive HIV
care and treatment services. In FY08, JHU will extend these services to a total of 42 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 target areas.
Accordingly, JHU will provide PMTCT services at five hospitals in Addis Ababa, two hospitals and 11 health
centers in Benshangul-Gumuz, one hospital and six health centers in Gambella, and 17 hospitals in
SNNPR. JHU 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
recently issued revised national PMTCT guidelines, and JHU, in collaboration with JHPIEGO, will support
the rollout 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 and 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
JHU 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, JHU will contribute to the development
of training materials, clinical support tools, guidelines, formats, and standards. JHU will continue to provide
technical input and guidance to the MOH and RHB, supporting initiatives to expand PMTCT beyond single-
dose nevirapine (SD-NVP) where appropriate, enhancing PMTCT-plus training, and supporting links
between PMTCT programs, HIV care and treatment programs, and pediatric services. At the facility level,
the JHU-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
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
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
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) 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
In FY07, JHU-TSEHAI also implemented an initial pilot program to support infant-feeding practices in the
postpartum period. In FY08, this activity will continue as before, but will incorporate the following expanded
activities: (1) Expansion to SNNPR by linking with Intrahealth/JHPIEGO to introduce MSG at hospital level
Activity Narrative: for ongoing feeding support; (2) Supporting institutions to become baby friendly hospitals that promote
exclusive breastfeeding; (3) Training counselors and nurses in this activity; and (4) Training HIV-positive
mothers and family members in optimal feeding at all hospital sites.
JHU, in collaboration with Addis Ababa University, had followed more than 1,000 HIV-positive women and
their infants who were in a clinical trial for PMTCT. Review of feeding practices showed that although good
infant-feeding counseling was provided by trained healthcare staff, less than 50% of those who chose to
breastfeed were exclusively breastfeeding beyond three months. Appropriate ongoing counseling by
healthcare providers, mother-to-mother support groups, and involvement of family members would provide
a vehicle to promote and support optimal breastfeeding practices for mothers who are breastfeeding. The
proposed FY08 continuation activities include: (1)Assessment and improved current breastfeeding
counseling practices; (2) Targeting pregnant women in the antenatal period to counsel on infant-feeding ;
(3) Collaborating with partners on revising and updating current infant-feeding guidelines and manuals; (4)
Assessing and supporting factors that promote optimal breastfeeding such as maintaining breast health and
appropriate breastfeeding (positioning, attachment, etc.), developing IEC materials on exclusive
breastfeeding, ensuring maternal health and nutrition status, and family support; and (5) Training MSG to
ensure ongoing support for optimal infant-feeding and support for exclusive breastfeeding. JHU proposes
to train 150 counselors and nurses and 300 mothers and family members on optimal feeding options.
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. JHU will be involved
in the expanding outreach PMTCT services in Addis Ababa, Gambella, Benishangul and SNNPR regions.
Strengthening STI Services for MARPs
This funding will be used to strengthen the existing prevention intervention by Johns Hopkins University
Bloomberg School of Public Health. Mainly the program will focus on mainstreaming IEC and Behavioral
Change Communication programs with care and treatment programs.
Johns Hopkins University Bloomberg School of Public Health 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
During FY07, Johns Hopkins University Bloomberg School of Public Health (JHU-BSPH) has taken full
responsibility for supporting STI activities at 44 sites found in Operational Zone 2 (Addis Ababa,
Benishangul-Gumuz, Gambella, and Southern Nations, Nationalities, and Peoples (SNNPR) regions). The
support includes: development of a workplan and an assessment tool to identify the sources of STI
treatment and prevention activities at the hospital level; participation in PEPFAR-funded trainings; and
communication with Population Services International (PSI) regarding accessing and deploying pre-
packaged STI treatment doses at the hospital ART site level.
FY08 activities at the regional level will include:
1) Coordination with Regional Health Bureaus (RHB) to help facilitate and coordinate linkages between STI
and HIV/AIDS services, and strengthen external referral linkages between hospitals, health centers, and
community service organizations (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
FY08 activities at the hospital/facility level include:
1) Expansion of STI services to six additional sites, for a total of 76 sites supported by JHU-BSPH (including
hospitals and emerging region health centers)
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 300 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 (HCT) services, promoting a provider-initiated,
opt-out approach for all STI patients, and linkages to care and treatment services for those who are HIV-
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, and education on how to use them, to patients enrolled in care and treatment, with
a special focus on MARPs
10) Integration of STI services into antenatal and PMTCT services. This will ensure that all pregnant women
are educated on and/or treated for STI, and receive education on STI prevention during pregnancy
(according to national STI management and antenatal care guidelines)
11) Development of linkages to community-based organizations that promote risk reduction and HIV/STI
prevention and early/complete treatment in communities surrounding ART sites supported by Columbia
University's International Center for AIDS Care and Treatment Programs.
Palliative Care and Nutrition Support at Hospitals
In FY06, Johns Hopkins University - Bloomberg School of Public Health (JHU-BSPH) introduced a basic
palliative care approach to 20 ART facilities and then in FY07 expanded this activity to 44 sites in
Operational Zone 2 (Addis Ababa, Benishangul-Gumuz, Gambella, and SNNP). Initial work included: a
baseline assessment of the palliative care activities at sites; development of site-level training materials for
palliative care and the prevention care package in cooperation with the national leadership; development of
national pain management guidelines and training materials; and supervision of palliative care activities.
Training and supervision focused on identifying pain and discomfort among HIV patients, ensuring
cotrimoxazole (CTX) prophylaxis (pCTX)for all eligible patients, conducting tuberculosis (TB) screening for
HIV-positive patients, and targeting elements of the preventive care package (e.g., multivitamins, nutrition
assessments, condoms, and links to programs that distribute insecticide-treated bed nets (ITN) to HIV-
positive patients. To date in FY07, this project has provided palliative care to 3,995 people, and has
distributed 22,000 condoms, 1.2 million tablets of CTX, 33,000 bottles of cotrimoxazole and 630,000
multivitamins to ART sites. Four programs have linked ART clinics with the regional ITN distribution,
reserving 1,200 nets for HIV-positive persons of all ages. As the lead for nutritional programs among
university partners, JHU-BSPH has initiated collaborative meetings with Food and Nutrition Technical
Assistance (FANTA) and the HIV/AIDS Prevention and Control Office (HAPCO) to facilitate the introduction
of "food by prescription" programs at hospital level. Initial site visits have been conducted at St. Peter's
Hospital by JHU with FANTA.
In FY08, JHU will support palliative care activities at 50 sites providing HIV/AIDS care and treatment
(hospital and emerging regional 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 the prevention of opportunistic infections for people living with HIV
(PLWH), slowing disease progression and reducing morbidity and mortality.
JHU will assist the 50 facilities to provide the preventive care package, complementing the Global Fund for
AIDS, Tuberculosis, and Malaria (Global Fund), the Federal Ministry of Health, and other PEPFAR Ethiopia-
funded activities when possible. JHU will focus on providing the basic care package for adults, which
includes: pCTX; micronutrient and nutrition supplements and counseling; ITN (through linkage with the
Global Fund malaria control program); water disinfectant at community and hospital level; condoms and
education for prevention among positives; and TB screening and pain management for all patients. The
basic 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 supplement;
and links to national childhood immunization programs.
JHU will work closely with other university partners to ensure complementary of activities with, for example,
the implementation of national pain management guidelines and the development and implementation of
the Palliative Care Training curriculum.
JHU 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.
JHU will: ensure that all supported sites have reliable stocks of CTX tablets and syrups; provide emergency
supplies when essential for quality and continuity of care; promote TB screening; and provide and promote
INH prophylaxis for HIV+ adults and children. (See also the activity section on TB/HIV activities.) Supportive
supervision and the institution of standard operating procedures and national guidelines will improve the use
of CTX and INH prophylaxis. 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 Global Fund. Health education and
behavior-change communication for HIV-positive individuals will be provided by facility and lay staff,
complementing Global Fund and other USG-funded activities. 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, JHU will continue to support and expand nutritional activities to:
1) Assist in development of guidelines for nutrition assessment.
2) Improve dietary and nutrition assessment at the point of care and evaluate the effectiveness of the
3) Improve nutrition counseling by assessing current practices and implementing identified best practices for
4) Assess and address micronutrient supplement needs and examine and address therapeutic and
supplemental feeding needs.
5) Integrate therapeutic "food-by-prescription" with ART and PMTCT programs.
6) Support implementation of "food-by-prescription" in at least 20 hospitals, based on criteria agreed upon
by PEPFAR Ethiopia.
Activity Narrative: 7) Evaluate therapeutic and supplementary feeding programs with adaptation of WHO criteria for eligibility
and exit criteria for programs.
8) Support dietary assessment and supplementation of micronutrients to pregnant and lactating women and
9) Assess and recommend effective ways to improve dietary intake in patients with weight loss due to
appetite loss and inadequate intake.
10) Integrate infant feeding counseling and maternal nutrition in PMTCT programs.
11) Assess effect of ART in chronically malnourished populations.
12) Develop capacity and skill of hospital staff in nutritional assessment.
13) Examine the use of lay counselors (i.e., PLWH) to assist with nutritional counseling so that clinic staff is
14) Share information regarding nutritional assessment guidelines and experiences gained through pilot
implementation programs with the other university partners.
TB/HIV Linkage Support at Hospital Level
An integrated tuberculosis (TB)/HIV program is an essential component of the comprehensive HIV care
preventive package. With this program, Johns Hopkins University-Bloomberg School of Public Health (JHU-
BSPH) aims to strengthen the linkages between TB and HIV services in hospitals of operational zone 2
(which encompasses Addis Ababa, Benishangul-Gumuz, Gambella, and Southern Nations, Nationalities,
and Peoples Region (SNNPR).
In FY07, JHU-BSPH was funded to support and expand activities to 40 ART sites. To date, in FY07, JHU-
supported sites have provided HIV counseling and testing to 1,305 TB patients, treated or screened 393
HIV patients for TB, placed 165 persons on isoniazid preventive therapy (IPT) and trained 34 persons in
TB/HIV collaborative activities. Sensitization has been initiated at St. Peter's TB Hospital to serve as a
training and demonstration site, and plans are underway to review the TB curriculum, conduct a review of
multi-drug-resistant (MDR) TB cases, establish culture activity at St. Peter's laboratory, and implement
infection control measures in the inpatient setting. On-site trainings are planned for the second through
fourth quarters of FY07.
In FY08, JHU-BSPH will continue with all previous activities, supporting 50 sites in Operational Zone 2
(hospitals and emerging region health centers), and will focus on expanding activities to improve monitoring
and evaluation (M&E) and improved use of the current and revised TB/HIV recording system. Widespread
on-site training for TB/HIV activities will address the human resource attrition in the field. Improved TB
diagnostics (e.g., chest x-ray (CTX), concentrated acid-fast bacilli (AFB) staining methods, fluorescent
microscopy, fine-needle aspirations, culture and sensitivity, and—eventually—molecular diagnostics) will
improve site-level capacity to diagnose active TB. JHU-BSPH will support the phased implementation of
World Health Organization guidelines on smear-negative disease and extra-pulmonary TB, and will assess
TB relapse and failure rates as a proxy for resistance (MDR-TB).
JHU will further expand TB/HIV collaborative activities to those private-sector hospitals providing free ART
and PPM-directly observed therapy services and also expand IPT and cotrimoxazole preventive therapy
(CPT) to co-infected pediatric patients. In FY08, JHU-BSPH will work with Columbia University and the
MOH to assess training needs and curricula related to family-focused TB/HIV activities, including provider-
initiated counseling and testing (PICT) guidelines for children. With ICAP-Columbia University as the lead
TB-implementing partner among university partners, current didactic materials will be modified to reflect
current needs. JHU-BSPH will also support the Federal Ministry of Health (MOH), the HIV/AIDS Prevention
and Control Office (HAPCO), and CDC's efforts to improve the TB/HIV information system by hiring a
TB/HIV M&E expert who can work closely with CDC and MOH.
In FY08, JHU-BSPH will continue to implement previous interventions such as expansion of PICT for TB
patients, referral of HIV/TB patients for HIV-related care including CTX and ART, TB screening in HIV care
and treatment settings with improved documentation of these activities at the HIV clinic, IPT for HIV-positive
patients in whom active disease has been safely ruled out, and support at site level for improved ability to
rule out active TB by providing CXR capacity in rural areas and in network/referral hospitals.
These activities, initiated in FY07, will continue to be closely coordinated with the national TB and HIV
control programs and regional health bureaus (RHB) in the operational zone covered by JHU-BSPH. JHU-
BSPH will continue to work closely with the RHB in strengthening the TB/HIV working groups and review
meetings at regional level, along with providing strategies for: joint supportive supervision for TB/HIV
activities; M&E of TB/HIV activities; programs to improve prevention, diagnosis, and treatment advocacy for
MDR-TB; and human resources training and retention. JHU site-support teams will continue to provide
monthly supportive supervision and clinical mentoring in the field of TB/HIV, and teams will work closely
with the RHB to solve implementation road blocks.
In FY06 and FY07, JHU-BSPH initiated support to strengthen TB diagnostics among HIV-positive patients
through improvement of smear microscopy services, quality assurance of laboratory networks, and support
for regional referral. JHU-BSPH laboratory personnel assisted in the review of new smear microscopy
guidelines, trained on concentrated AFB methods, and disseminated this information to JHU-supported
TB/HIV sites. JHU-BSPH will continue to support improved smear microscopy but will expand this
laboratory support to labs providing culture and sensitivity testing at regional and federal levels, in
collaboration with the Plus-Up fund activities. The goal will be to increase ease of referral and improve
information feedback to patients and efforts to assess the situation of MDR-TB.
Counseling and Testing Support Service at Hospitals
In FY07, Johns Hopkins University - Bloomberg School of Public Health (JHU-BSPH) supported HIV
counseling and testing (HCT) services in 40 ART facilities (36 hospitals and four health centers) in
Operational Zone 2 (Addis Ababa, Benishangul-Gumuz, Gambella, and Southern Nations, Nationalities, and
Peoples Region (SNNPR)). This included: initial site assessment; training in collaboration with JHPIEGO;
refurbishing sites; standardizing data collection and reporting; and supervising HCT services. Site support
aimed to deliver improved quality HCT services for community and patients. So far in FY07, 19,088 people
have been counseled, tested, and received results.
In FY08, JHU-BSPH will support 48 sites (hospitals and emerging regions health centers) by training health
professionals and community counselors on standard voluntary counseling and testing (VCT) and provider-
initiated counseling and testing (PICT). This will be done in partnership with regional health bureaus (RHB).
JHU-BSPH will also provide site-level support for continued provision of integrated HCT activities as part of
ART/VCT/PMTCT/TB/STI activities, and the comprehensive care package will be available at all hospitals in
the four regions.
Major HCT interventions by JHU-BSPH will include:
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 JHU-BSPH experts
6) Support for minor renovation of physical space to ensure infrastructure which is consistent with the
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
JHU-BSPH technical assistance will continue to ensure that all relevant HCT protocols are followed
appropriately and consistently. To increase HCT uptake beyond site level, outreach programs will be
expanded to target high-risk populations and various other special populations, such as the disabled,
refugees, and those within other sectors (e.g., schools, universities, factories, and faith- and cultural-based
environments). JHU-BSPH will strengthen family-member screening, with particular focus being given to
couples counseling, pediatric screening, and improving partner notification. After-hours, weekend, and
holiday HCT service will be promoted, and national campaigns such as Millennium AIDS Campaign and
local initiatives to increase uptake of HCT will be supported.
JHU-BSPH will continue support for quality documentation and compliance with national reporting
requirements, including counseling-data management and data utilization at site and regional levels. JHU
will continue to support sites in the preparation and timely submission of reports to zonal, district, and RHB
and the Federal Ministry of Health (MOH). JHU-BSPH will further monitor administrative and technical
coordination mechanisms to build strong management systems at the facility level. Quality assurance
programs and burnout management sessions for HIV/AIDS care providers begun in FY07 will be expanded
and strengthened in collaboration with relevant partners.
JHU-BSPH will collaborate and harmonize HCT activities with partners implementing programs in the same
region. JHU works closely with the International Rescue Committee (IRC) and the United Nations' High
Commissioner for Refuges (UNCHR) to improve VCT services for refugees in Gambella and Benishangul-
Technical Support for ART Scale-up
In FY06 and FY07, Johns Hopkins University - Bloomberg School of Public Health (JHU-BSPH) led
Advanced Clinical Monitoring, initiated and sustained Private Hospital Involvement and supported ART
implementation in Operational Zone 3.
In FY07 to date, JHU-supported sites have initiated 2,290 persons on ART, support 23,755 persons
currently on ART, and have served 34,083 persons ever on ART. Training has been conducted for 533
healthcare workers, and JHU continues to lead with advanced ART workshops and CME telemedicine case
reviews. In addition, 506 infants (45% positive) have been tested with DNA PCR as part of the early infant
diagnosis (EID) program.
In FY08, JHU will continue to support FY07 ART facilities, expanding from 44 to 50 sites (hospitals and
emerging regions health centers) in collaboration with the regional health bureaus (RHB), according to
national guidelines. In FY08, JHU will continue all previous support provided to the ART hospitals and
health centers. Support will be divided among several programmatic activities: direct site-level support,
mentoring, human resources, infrastructure, training, quality care, expansion of ART to the private sector,
pediatric care, laboratory diagnostics, site-level management, community-level support, and monitoring and
evaluation of outcomes. To increase capacity, JHU will invest in personnel to support ART technical
assistance (TA) at sites and will augment support by sponsoring regional meetings, collaborative activities,
and by participating in the RHB ART coordinating and implementation teams. JHU will address region-
specific challenges to scaling up, while preparing new hospitals for free ART provision and maintaining
quality mentorship at established ART sites.
In FY07, as the lead for the post-exposure prophylaxis (PEP) program amongst university partners and
health network, JHU focused on national-level activities in policy development, as well as on regional-level
facility-based training to implement an effective PEP guidelines, targeting healthcare providers and victims
of sexual assault at ten pilot facilities. Specific activities included: ensuring availability of national guidelines
and protocols; ensuring the availability of ARVs for PEP; implementation of awareness programs to
increase uptake of the program by exposed individuals; and training of trainers (TOT) for health workers
and Ministry of Health (MOH) and RHB staff to ensure dissemination of activities to other regions and
Phase I of this activity addressed the need to increase safety and protection of healthcare workers and the
need for a comprehensive plan of care for victims of sexual assault. Phase II focused on development of
guidelines, policy, and an implementation model for providing comprehensive care to both target
populations. Continuing its activities in FY08, JHU will focus support on a PEP expansion plan in the 50
supported facilities within the four regions, and continue to provide guidance to other university partners.
FY08 activities will also include expansion of activities to the entire health network model in the two
emerging regions of Gambella and Benshangul Gumuz. JHU will further expand the comprehensive HIV
activities in the private sector —in particular TB)/HIV, PMTCT, VCT, linkages to ART clinics in private
hospitals, increased coverage of pediatric ART and DNA testing for EID at all JHU-supported ART sites.
JHU will continue to work with the Ethiopian Orthodox Church and International Orthodox Church Charities,
and expand activities to other faith-based organizations. Using guidelines and training materials, JHU will
work closely with the MOH and RHB to address malaria and HIV co-infection and to provide linkages to
insecticide-treated nets for all HIV patients in malaria endemic areas. JHU will expand peer network
advocacy for people living with HIV/AIDS (PLWH) and tracking systems to improve adherence, follow-up for
care, and community-level support for ART.
JHU will continue to provide expertise at all levels of ART provision, ranging from multidisciplinary team
mentoring and supportive supervision to creation of a cadre of local university mentors. These mentors will
provide clinical stewardship and develop additional expertise in data processing and management at ART
sites. Recognizing the majority of patients are lost between CT and the ART clinic, JHU will continue to
invest resources to improve networking and inter and intra-service linkages with CT, TB, antenatal clinics
(ANC), sexually transmitted infections, PMTCT services, and community-based care, based on the "Referral
Network Model for Ethiopia" project completed by JHU in FY06. JHU will support hospital and RHB activities
in transferring patients from hospital ART clinics to locally networked health centers. JHU will offer TA with
transfer readiness, patient identification, development of standard operating procedures for mentoring, and
case review for difficult cases. JHU will support developing a cadre of nurse specialist mentors to provide on
-site follow-up and mentoring for ART nurses, as well as to train counselors, lay counselors, and peer
educators on adherence. JHU plans to train or identify persons affiliated with PLWH associations in an effort
to promote ownership, communication, policy drafting, and overall sustainability of ART programs.
In FY08, JHU will manage high demand at urban centers by: increasing site-capacity through renovation in
coordination with the Regional Procurement Support Office and Crown Agents; training and innovative
methods to improve human resource retention; and by strengthening referral linkages between hospitals,
health centers, and community-based organizations to improve service delivery. JHU will support linking
treatment, care, and support services with PLWH associations. JHU will continue to strengthen provider-
initiated counseling and testing (PICT), referrals for TB/HIV and malaria/HIV.
In FY08, emphasis will be placed on increased pediatric care capacity at all sites. Collaborating with ICAP,
JHU will continue support to all sites in pediatric care, by training pediatricians and other health workers and
integrating pediatric ART into current ART activities. JHU will also focus on improved entry points for
children by supporting family focused care and family testing, PICT, and improved infant follow-up after
PMTCT. It will create linkages with OVC programs and orphanages. JHU will support the regionalization of
DNA PCR testing for early HIV diagnosis and will aim to have 100% of eligible infants placed on
cotrimoxazole preventive therapy. JHU will continue to expand the intensification of PMTCT to ART linkages
and to increase the number of pregnant women on ART at five pilot PMTCT and ART sites initiated in FY07.
In FY08, JHU will place PMTCT case managers and nurse assistants at sites to improve overall screening
for ART and to improve linkages to other programs (ART, pediatrics, TB/HIV).
JHU will work closely with the MOH, the Global Fund for AIDS, Malaria, and Tuberculosis, the Supply
Chain Management System/RPM+, and RHB to ensure drugs purchased to treat opportunistic infections
Activity Narrative: (OI) are distributed rationally, and to develop OI drug access for all HIV-positive patients, especially CTX for
TB patients, pregnant women, and HIV-exposed children. The availability of consistent and quality
laboratory services at all these sites is critical to ensure quality comprehensive HIV/AIDS services (please
see COP Activity 10433 for specifics).
JHU will expand MOH's basic ART Training activities within the hospitals, training inpatient healthcare
personnel, new graduates so that ART services expand accordingly. JHU will continue to supplement basic
training through HIV telemedicine, case review sessions, TheraSim, and work with other partners to expand
services to distant regions through satellite connections and possible portable videoconference capabilities.
In association with JPHIEGO, Standards Based Management and Recognition (SBMR) for all HIV activities
were introduced in FY07 and will be continued in FY08. These measures will assist measurement and
improvement of quality site services; performance on agreed indicators will be measured at facilities and
district and comparative reports produced. JHU will also continue to assess quality of reporting, recording,
and clinical services using Lot Quality Assurance Sampling techniques. These methods provide immediate
feedback to sites on areas requiring improvement and services management change.
Monitoring and evaluation (M&E) training for ART and laboratory technicians will continue to be provided as
part of the basic training package. JHU will work with the MOH to develop and distribute Information-
Education-Communication materials, reporting and recording formats, and all support for accurate
monitoring. M&E specialists will work closely with sites and RHB to analyze ART data and provide feedback
to clinicians. This will coordinate with the rollout of the health management information system and with
other PEPFAR partners.
Finally, JHU will continue to support the MOH in expanding free ART technical support to private sector
facilities in Addis Ababa. JHU will intensify its regional capacity building with greater emphasis on local
university and capacity. JHU will continue to build the capacity of Addis Ababa and Debub Universities in
knowledge-transfer, TA, supportive supervision, and mentoring to their respective RHB and catchments
Clinically Focused Record Systems
In FY07, Advanced Clinical Monitoring (ACM) achievements included: protocol submission and clearance;
initiation of cohort enrollment; ongoing support for the governing steering committee structure;
strengthening of clinic-based activities at seven participating university hospitals; development and
implementation of facility-based, project-management standard operating procedures (SOP) to initiate
cohort enrollment, collect data from the targeted sample of HIV+ patients put on ART at the seven
universities, and meet data-transfer and specimen-repository standards.
In FY08, continuation activities will include: ongoing support for cohort enrollment; maintenance of
implemented standardization measures for data collection and patient records management; monitoring of
data quality levels; data and specimen transfer to host institutions: ongoing facility staff training to use
national monitoring and evaluation (M&E) tools; monitoring electronic data management systems at site and
central levels; and Johns Hopkins University (JHU) will continue to support collaborative targeted
evaluations to meet project objectives, facilitate data and specimen requests from daughter protocols as per
steering committee approvals, and increase university hospital capacity to twin with local and international
Intensive monitoring and evaluation of approximately 3,000 patients on ART will provide critical information
on large-scale ART distribution without piloting on a small scale. This activity will improve case
management of treatment services at the university hospitals and will enhance the universities' capacity to
provide technical assistance (TA) and training to clinicians, residents, and medical students. Data generated
by this multisite project will inform and improve ART delivery in Ethiopia by providing important information
on ART-associated toxicities and early mortality. The multisite patient database and specimen repository
will facilitate operational research and scientific inquiry pertinent to HIV/AIDS, through in-depth monitoring
of: treatment; acceptance and adherence; assessment of indicators of adherence; clinical and virologic
efficacy of treatment protocols; assessment of monitoring protocols (CD4); evaluation of drug toxicity, drug-
interactions and viral resistance; and investigation of potential barriers to expanding ART access in
The project will train staff required for collection of additional data to answer programmatic issues and
perform patient follow-up. JHU will also support building the capacity of health providers and regional health
authorities to record, store, and share information to support providing appropriate services to individual HIV
patients and their families, across the continuum of care. These information systems will be flexible,
adaptable, and compatible with various existing healthcare information systems and will support program
M&E. JHU's team of healthcare informatics experts will provide expert technical input in developing a data
model for HIV care and will work with the CDC informatics group and national committee to develop an
infrastructure for installation of electronic health records to support the longitudinal care needed to combat
HIV over the long-term. When an electronic patient record system for HIV care or for overall hospital care is
developed, the JHU team will guide its implementation for the hospitals in its four regions. This activity will
include provision of the CDC medical record folders if supported.
This is approved country specific PHE activity. Reprogramming is taking place to reflect change of Prime
Partner and Agency. Prime Partner is changed from To Be Determined to the Ethiopian Public Health
Association (EPHA) and agecy is changed fro State Department/OGAC to HHS/CDC.There will be no
change in emphasis, coverage area or target population.
The narrative of this activity remains the same. The only change will be that it was initially proposed as a
potential multi country protocol, but now, it is approved and will be undertaken as a country specific Public
Health Evaluation (PHE).
PARTNER: Johns Hopkins University Bloomberg School of Public Health
Identifying Groups with Poor Access to ART - potential Multi Country Protocol
Time and Money Summary:
Expected timeframe: 1 year, Total projected budget: $ 100,000
Local Co-Investigators: In Ethiopia, this study would be carried out by Johns Hopkins University (JHU)
Technical Support For The Ethiopia HIV/AIDS ART Initiative (TSEHAI) as a supplement to the JHU/TSEHAI
Advanced Clinical Monitoring (ACM) of ART in Ethiopia project, which is governed by a Memorandum of
Understanding with 10 Ethiopian institutions.
Primary evaluation question:
What patient factors affect whether patients initially enroll in the national ART program at an early or late
clinical stage of disease?
This case-control study is designed to identify target groups with comparatively poor access to enrollment in
a country's national ART program. It takes advantage of the insight that hospitalizations for conditions
amenable to primary care can be used as indicators of poor access to primary care. The relationship of
access to demographic characteristics, risk behaviors, attitudes to HIV and pathways to care will be
Both WHO and the Institute of Medicine report evaluating PEPFAR have expressed great concern about
possible inequities in access to care for women, rural populations, the poor, and other vulnerable groups.
WHO said in April 2007 that in monitoring progress toward universal access to HIV/AIDS prevention,
treatment and care, "Higher priority must be given to promoting, monitoring and evaluating equity in access
to services. …special studies will be needed in order to help to understand uptake patterns, factors which
inhibit or facilitate access to services for men and women, and potential differences in clinical outcomes."
After these factors are identified, interventions targeting them can be developed.
Population of interest:
This study uses case-control methodology to compare the characteristics of three groups: (1) Cases:
Patients with "late" access to care, who are admitted to hospital wards with HIV disease without ever having
received outpatient HIV care. (2) Control group A: patients who enroll in ART "timely," become eligible due
to a CD4<200 without ever having developed WHO stage III or IV clinical disease, and (3) Control group B:
patients with "intermediate" access, who enroll in ART after developing WHO stage III or IV conditions but
without ever having been hospitalized for HIV disease. Cases will be sampled from hospital ward logs.
Controls will be identified from ART clinic registers. They will be matched by facility and month of case
admission matched to month of control ART enrollment. 900 participants per country will be selected: 180
cases, 360 from control group A and 360 from control group B.
The exposures shown in the table below will be abstracted from hospital and clinic records. Not all
exposures may be available for analysis in all countries or sites; they are available in Ethiopian nationally
standard ART clinic forms, and staff at ACM sites ensures that these data elements are captured. A subset
may be available in hospital charts. Conditional and ordinal logistic regression techniques will be used to
assess the association between each exposure and different levels of access to ART. To assess the direct
effect of demographic factors on access, it is necessary to control for the fact that different demographic
groups (e.g. men and women) may have been infected with HIV at different periods of the HIV epidemic in a
given country. Therefore multivariate regressions will be conducted including and excluding proxy variables
for length of infection: CD4 count and time since first positive HIV test.
Demographic: Gender, age, urban/rural residence, income/poverty status, level of education, religion,
employment, marital status, household composition
Behavior: Sex risk behavior, drug use behavior
Attitudes: Disclosure of HIV status, perceived stigma, depression, attitudes toward ART
Pathways to care: referral source, HIV support group member
Sample size calculation:
The sample size was based on the number of cases required to detect a 15% point difference between
cases and controls with rural residence (Power= 0.9, alpha=0.05, 1 case: 2 controls). Based on these
calculations, the total number of cases required was rounded up to 180. They would be matched at a ratio
of 1 case: 2 timely access controls: 2 intermediate access controls; therefore the number in each control
Activity Narrative: group was set at 360 and the total number of participants in Ethiopia at 900. The cases would be divided
evenly among participating facilities that serve both rural and urban patients. If the ACM sites are used for
this study in Ethiopia, there are 5 such sites; 36 cases, 72 timely access controls and 72 intermediate
access controls would be enrolled per site.
The study will be cleared by CDC and the ACM steering committee for publication in professional journals.
Ethiopian personnel - $ 24,400
Statistical support - $ 12,000
International travel - $ 7,000
Domestic travel - $ 2,250
Computers - $4,000
Supplies/Communications - $5,000
Total - $54,650
Total including indirect costs - $67,470
PARTNER: Johns Hopkins University Bloomberg School of Public Health
Title of Study:
Effectiveness of food by prescription programs for severely malnourished HIV+ patients
Time and Money Summary:
Expected timeframe: 1 year, Budget Year 1: $90,000
Dr. Solomon Gashu, Medical Director, St. Peter's Specialized Tuberculosis Hospital
Nutritional support is considered an essential part of a comprehensive HIV/AIDS package. Data indicate
that nutrient intake can improve ART absorption and is associated with medication adherence among ART
patients. Studies have shown that moderate to severe malnutrition (Body Mass Index, or BMI<17) at the
time of starting ART and severe anemia are independent predictors of mortality and likewise screening and
managing malnutrition among PLWH starting ART has survival benefits. USG partner Johns Hopkins
University (JHU) Technical Support For The Ethiopia HIV/AIDS ART Initiative has developed a plan to
introduce a food by prescription program (FBP) at the ART clinic at St. Peters' Specialized Tuberculosis
(TB) Hospital in Addis Ababa. Food by Prescription provides therapeutic and supplemental food to patients
on ART, pregnant or lactating HIV+ women, and HIV exposed children. A baseline nutritional assessment
of ART clients and then follow-up assessment after 6 months of nutritional support will be undertaken.
Change in body mass index, CD4 count, functional status, opportunistic infections and mortality, will be
compared to a historical cohort of patients that did not receive nutritional interventions.
This proposal will address the following questions:
1) What are the baseline nutritional indices for patients about to start ART?
2) How do these indices vary by TB/HIV co-infection?
3) Does an intensive six month FBP intervention for severely malnourished patients improve patient
outcomes as measured by decreased mortality and morbidity?
4) What is the cost-effectiveness and sustainability of the FBP program?
Achieving food security and appropriate nutritional support is difficult in environments such as Ethiopia that
have been long plagued by food insecurity. This problem is especially evident among patients who are co-
infected with HIV and tuberculosis. For example, registry data of ART patients at St. Peters Specialized TB
hospital indicate that 19% of patients weigh less than 40 kilograms (kg) at the start of ART and 3% of adults
weigh less than 30 kg. In an analysis of survival, underweight patients had an increased risk of dying in the
first year of follow-up after initiating ART.
The currently measured early mortality rate among the Ethiopia national program is close to 10%; however
rates are as high as 14% among TB/HIV infected patients. Follow-up data indicate that this mortality occurs
usually within the first three months; however, a second peak occurs between 8-12 months and is likely due
to immune reconstitution. We believe much of this early mortality may be associated with severe
malnutrition, anemia and co-infections with subclinical opportunistic infections. Once patients start ART,
many report poor adherence due to the lack of consistent food and subsequent gastro-intestinal distress
with the medications. Providing patients with food supplementation and therapeutic feeding during this
early phase of ART initiation is likely to reduce this early mortality rate and will hopefully lead to improved
medication adherence. This is important for the overall program to reduce the development of resistance
from poor adherence and to encourage more patients to accept ART even when severely debilitated. It will,
as well, lead to patients who more quickly return to a functional status and have improved quality of life.
1) Baseline nutritional assessment among pre-ART patients ready to start ART at St. Peters: A standard
nutritional questionnaire and nutritional screening tool (including BMI, mid-upper arm circumference and
diet review) will be developed and administered to all patients found eligible for ART, pregnant and lactating
HIV+ women and HIV+ and exposed children. Patients will be coded according to level of malnutrition with
severe malnutrition defined as BMI < 17. For children, standard z-scores will be used to assess
malnutrition. Any person with severe malnutrition will be offered the FBP intervention at the time of initiating
ART. A sample size of 200 is expected over the 12 month period of intervention; however all consecutive
patients who qualify will be enrolled into the study.
2) Food By Prescription Intervention: JHU will partner with the Ethiopian national FBP program with other
PEPFAR partners, UNICEF and other partners. This program will provide intensive therapeutic and
supplemental nutritional support, including ready to use therapeutic foods (RUTF) such as fortified flours
(e.g. First foods, Advantage or Foundation plus), prepared feeding (e.g. F75, F100), and biscuits and
PlumpyNut for children. Additionally, safe water will be secured for all patients in the program to avoid
diarrheal diseases. Counseling and education regarding local foods and nutrition will be conducted.
3) Evaluation of outcomes: After the patients have received 6 months of the food intervention and ART, and
evaluation of outcomes will be made. Comparison of change in weight, BMI, z-scores, CD4, and number of
opportunistic infections, loss to follow-up and death will be made between the patients receiving the FBP
support and a historical cohort at St. Peters with similar low weight who did not receive nutritional
intervention. Likewise, comparisons can be made with other ART programs that have not yet initiated the
FBP program. Factors associated with the outcomes of interest will be compared between the intervention
and comparison groups and independent risks measured using the chi-square and t-test analyses.
Multivariate analyses will be performed to identify independent risk factors while controlling for confounders,
such as TB/HIV co-infection or immune reconstitution inflammatory syndrome (IRIS).
4) Cost effectiveness: Costs for the FBP program will be compared to costs related to early mortality and
morbidity avoided with the intervention program.
Activity Narrative: Population of Interest:
The populations of interest are HIV+ clients, pregnant and lactating HIV+ women, HIV+ and exposed
children attending ART clinic who are severely malnourished and/or eligible for food by prescription
Information Dissemination Plan:
Stakeholders include the Ministry of Health (MOH), Addis Ababa Regional Health Bureau, local non-
governmental organizations and faith-based organizations working in these communities, health care
providers, PEPFAR and other entities involved in the support of health care delivery. In the planning phase
of the evaluation, stakeholders meetings will be organized to describe the goals of the evaluation.
Stakeholders will be involved in review of the assessment form and the indicators to measure malnutrition.
MOH personnel will be involved in the gathering of data and review of findings. Results will be
disseminated in a review meeting for the region and findings will be shared with PEPFAR and other
Budget Justification for Year One Budget:
Baseline & follow-up survey
Coordinator (responsible for developing assessment, training assistants, standardization)$10,000
Dietary and nutritional assessment survey assistants - $15,000
Materials - $1,500
Transportation (to and from evaluation site) - $1,500
Data collection, management and analysis - $15,000
Materials (includes educational and training materials) - $10,000
FBP program covered by other PEPFAR partners
On-site Training (on FBP) - $5,000
Office supplies and forms - $2,500
Transportation (Coordinator to travel to site weekly) - $6,750
Miscellaneous costs, telecommunications - $1,000
Review and stakeholders meetings- $10,000
Subtotal - $75,290
Indirect Costs - 18.8%
Total - $90,000
Site-Level Laboratory Support
In FY07, Johns Hopkins University 's Technical Support for the Ethiopia HIV/AIDS ART Initiative (JHU-
TSEHAI) supported comprehensive high-quality HIV/AIDS services at 44 public and private hospital
networks in Addis Ababa, SNNPR, Gambella, and Benishangul-Gumuz regions which built on previous
activities of FY06. JHU provided on-site and comprehensive HIV laboratory training, developed and
implemented standard operating procedures (SOP) for all HIV laboratory services, and internal quality
assurance (QA) training and recording formats. In FY08, JHU will expand the service to 50 sites (hospitals
and emerging region health centers).
In FY07, JHU expanded these activities by regionalizing national laboratory support to 39 laboratory-sample
transport networks, working closely with national, regional, and site levels to ensure the highest quality of
laboratory diagnostic services. For this, JHU worked with the Ethiopian Health and Nutrition Research
Institute (EHNRI) and regional labs to: deploy sample transport couriers; arrange SOP, registers, and
reports to document sample transport; and provide training for sample handlers. JHU supported
development and dissemination of SOP for all nationally purchased machines (CD4, hematology and
chemistry). In collaboration with EHNRI, CDC, and other laboratory partners, JHU also trained personnel at
national and regional levels. JHU regional lab-support staff also provided regular refresher and on-site
trainings for HIV serology-rapid testing, CD4, chemistry/ hematology, tuberculosis (TB) smear microscopy;
and opportunistic infection (OI) diagnosis. In collaboration with ICAP, JHU supported early infant diagnosis
(EID) services at Addis Ababa and Southern Nation, Nationalities and Peoples Region using dried-blood-
sample (DBS) referral to sites with DNA PCR testing facilities.
In FY08, JHU will continue to implement the strong laboratory support plan initiated in FY07 in collaboration
with EHNRI, CDC, the American Society of Clinical Pathologists, the Clinical and Laboratory Standards
Institute, the Association of Public Health Laboratories, and other laboratory partners. The plan will ensure
regional implementation of national laboratory training and develop on-site training and mentoring for lab
technicians. All training will require practical components and on-going follow-up to ensure adequate
technology transfer and capacity development. Trainings will cover: site and regional trainings on HIV
diagnosis (HIV serology testing, rapid testing); HIV disease monitoring (hematology, clinical chemistry, and
CD4); facility-level lab management; laboratory training on integrated diseases including diagnosis of
common OI. JHU, in collaboration with regional labs, will evaluate the quality of services delivered by lab
personnel after training in different disciplines.
JHU 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. JHU 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 patient samples; reporting of results; and
implementing and ensuring that standard guidelines and procedures are followed.
EHNRI will expand the pilot external quality control (QC) systems, and JHU will work directly with the
regional and hospital labs and with health center personnel to implement and monitor these programs.
QA/QC guidelines will be distributed to additional sites. JHU will continue to support the national QA
programs for blood safety, voluntary counseling and testing, PMTCT, TB prevention, and HIV and OI
surveillance by disseminating guidelines to the regional level and assuring uninterrupted links between
health center, hospital, regional, and national laboratories.
JHU will continue to improve OI diagnostics by introducing simple laboratory diagnostic techniques for OI
such as cryptococcosis, isospora, microsporidia, and cryptosporidiosis. JHU will support the regional
capacity building in different laboratory issues. JHU will provide supportive site supervision and mentoring to
all ART laboratories to improve quality of laboratory management, laboratory safety, lab set-up, specimen
management, test procedures, documentation, reporting, inventory, and stock management of laboratory
supplies at each facility in collaboration with the Supply Chain Management System (SCMS). JHU will
closely work with regional laboratory associates of SCMS and will support the national laboratory reporting
systems and conduct regular mentoring on standard record-keeping and timely and accurate reporting
(including QC forms, lab request forms, and registers) to facilitate monitoring of quality. JHU will work with
partners to ensure uninterrupted quality laboratory services at all 50 hospital networks through: continuous
and sufficient reagent supply; timely provision of preventive and troubleshooting maintenance; regional
capacity building to institutionalize laboratory equipment maintenance capability; develop laboratory
inventory systems at the hospital networks; and ensure availability of adequately trained laboratory
In FY08, JHU will continue to provide the comprehensive laboratory support previously outlined, and, as a
new activity, will renovate two regional labs to establish DNA PCR testing for scale-up of EID. JHU will work
to strengthen TB laboratories with concentrated acid-fast bacilli methods, and fluorescent microscopy
methods, treatment monitoring for adults and children. JHUS will continue supporting the establishment of
external quality control and quality assurance at regional and hospital levels
JHU will support the training rollout of HIV rapid testing and the QA program. JHU will work to improve
infection-prevention practice in labs and access to post-exposure prevention. JHU will support the
expansion of the laboratory information systems (LIS) by EHNRI at the pilot ART laboratory sites,
strengthen laboratory layout (process design flow), and laboratory technician training on laboratory
management in collaboration with regional laboratories. In collaboration with EHNRI, regional labs, and ART
laboratories, JHU will also expand on-site lab training on new HIV-testing algorithms and strengthen the
monitoring and site evaluation for implementation of the new algorithms.
The significant increase of budget was necessary to support upgrading two regional laboratories and
hospital laboratories in the three regions and health center laboratories in emerging regions and to support
integration of OI diagnosis.
Clinical Simulation Technology (TheraSim) to support training on ART
In FY07, this was a new activity which links to various HIV treatment services activities supported by
PEPFAR. The capacity for rapid ART scale-up is severely limited by the rapid turnover of trained and
experienced HIV clinicians. To reduce this attrition and improve the knowledge-base of urban and rural
clinicians, JHU will introduce a continuing medical education and clinical-decision support tool via TheraSim
HIV clinical care simulator. To date, in FY07, TheraSim has been deployed to 38 sites, trained nearly 200
persons, and has been used to evaluate training outcomes for a basic ART training conducted by Johns
Hopkins University - Bloomberg School of Public Health (JHU-BSPH).
In FY08, JHU-BSPH will continue to work with TheraSim to provide support to 50 ART clinical sites (hospital
and health centers) to ensure all new physician and nursing staff are oriented to the case-learning program
and receive support to complete the training. The program will also be extended to all medical residents
enrolled in Addis Ababa University and Hawassa's training programs. TheraSim, under the guidance of JHU
-BSPH, will develop three new modules to expand the case learning approach to nurses, and to incorporate
new cases dealing with pediatric HIV care, tuberculosis (TB)/HIV, and advanced cases that deal with
treatment failure and other complications, for clinicians who have completed the basic training program.
Along with increasing the number of sites, the depth of the clinical complexity of cases and extent of the
personnel involved in the training program, JHU-BSPH will design an evaluation system to assess basic
ART training through the JHU-BSPH HIV telemedicine program. The modules will be used pre- and post-
training to assess training activities. A validation study will be developed to compare patient outcomes from
the simulator versus actual patient-outcome data in the clinics. In addition, TheraSim will provide
opportunities for clinicians to submit Ethiopian-based cases to be incorporated into the training program.
Clinicians will be compensated for their efforts, and TheraSim will act as an incentive and possible retention
TheraSim was introduced because the success of the PEPFAR Ethiopia ART program depends on the
skills and stability of the ART team - doctor, nurse, pharmacist, and lab personnel. The stability of
healthcare workers in the Ethiopia HIV program has been challenged since trained clinicians often find
better-paying positions outside the public sector after graduating from medical school, and general
practitioners, who are expected to spend 2-4 years in public hospitals in isolated regions, often leave the
posts prior to completing their contracts. These clinicians report feeling cut off from learning, and they desire
increased clinical decision-making support, as consultations with more experienced clinicians are
impossible due to lack of communication technology. To improve the clinical skills of rural clinicians,
increase their capacity for appropriate decision-making, and address their desire for professional growth,
JHU-BSPH will continue its distance-learning program using TheraSim, a program for clinical-decision
support. For urban physicians, JHU-BSPH will continue to provide training centers and ART clinics with
access to the training programs via CDs or the Web. PEPFAR Ethiopia believes that improving information
transfer about HIV will reduce turnover of geographically isolated clinicians, as well as those from
overwhelmed urban clinics—thus improving HIV/AIDS care.
TheraSim, Inc. is a US-based company providing software and services internationally to measure and
improve the quality of clinical practice for HIV/AIDS and a variety of chronic and infectious diseases,
including malaria, tuberculosis (TB), hepatitis and diabetes. Capacity-building in Ethiopia faces several
challenges, including: a need for rapid scale-up of clinical capacity and expertise in treating patients with
HIV/AIDS; high cost and slow response of classroom-based learning; an ongoing need for clinically-based
mentoring following didactic training; and a general absence of empirical data after drug distribution.
TheraSim monitors and addresses gaps in clinical competence following existing classroom training and
helps improve patient outcomes in the ever-changing therapeutic environment. The TheraSim Clinical
Quality Assurance System has four key components: simulation-based assessment and intervention,
electronic medical records, decision support, and dashboard reports. The system is both Internet- and CD-
ROM-based, providing simulation of hypothetical patients in various stages of HIV/AIDS. The simulated
cases can be adapted for use by nurses, basic-level physicians (those who see few HIV/AIDS patients), and
expert-level clinicians. TheraSim uses guidelines approved by the World Health Organization (WHO) or
country-specific guidelines where they exist, and regionally-appropriate pharmacology and treatment
modalities with authentic "virtual" case studies for diagnosis and treatment of HIV/AIDS and co-morbidities.
It complements other methods, such as formal training, bedside teaching, and case discussions. Simulated
cases are used, for which diagnosis and treatment decisions must be made; the system then gives
feedback on these choices, referring to country and relevant international guidelines.
TheraSim can be adapted for training nurses and allied health professionals as needed. In the next phase
of support, TheraSim will advance existing capacity-building efforts efficiently by improving and measuring
the quality and outcome of clinical practice, including ART delivery for HIV/AIDS and the treatment of TB, in
compliance with published national treatment guidelines. TheraSim will seamlessly augment efforts begun
with CDC and other programs. For example, Washington University/I-TECH has developed training
curricula for ART, management of opportunistic infections (OI), and PMTCT with the support of international
partners and has organized numerous trainings. These training programs primarily reached health
professionals in the public sector. Various institutions have organized 2-5 day basic-training workshops on
HIV/AIDS management, one-day advanced courses for clinicians, and evening seminars on specific topics,
usually attended by clinicians from public and private sectors. However, no reliable and accessible system
exists to: assess individual health workers' skills; assess the overall effect of existing training activities;
provide ongoing mentoring and support; provide clinical support to reduce medical error; or to report clinical
skills and patient outcomes. TheraSim and JHU-BSPH will deploy TheraSim's field-tested Clinical
Performance Management computer-based decision support ("TheraSim CPM") system for rapid and
effective ongoing mentoring of healthcare workers throughout Ethiopia to support PEPFAR Ethiopia goals.
The system will continue to use regionally appropriate pharmacology and treatment modalities with
authentic case studies for diagnosis and treatment of HIV/AIDS and TB.
Site Level Data Support for Hospitals
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 Addis Ababa,
Benishangul-Gumuz, and Gambella regions, and the Southern Nations, Nationalities, and Peoples Region
In FY07, the International Johns Hopkins University-Bloomberg School of Public Health (JHU-BSPH)
supported 50 sites in Operational Zone 2 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,
JHU-BSPH has trained more than 90 health professionals and data clerks in monitoring and evaluation
(M&E) and assisted regional health bureaus (RHB) to organize experience-sharing workshops.
In FY08, JHU-BSPH 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. JHU 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
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. JHU-
BSPH will work to ensure availability of computers, computer peripherals, and storage equipment and an
uninterrupted supply of the national M&E tools at all the sites
3) Strengthen supportive supervision and mentorship. On-site supervision and mentorship will be provided
to enhance collection of accurate and complete data. JHU- BSPH 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, JHU- BSPH 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.
Title of Study: Public Health Evaluation of Training of Health Providers in Health PEPFAR funded health
centers in Ethiopia
Time and Money Summary:
The evaluation will be conducted from April 2008 to March 2009, pending clearance of the revised protocol,
and is expected to cost $150,000 for Year 2.
Local Co-Investigator: Marion McNabb, Mesrak Nadew, Yassir Abduljewad, Anne Pfitzer, Dr Anteneh
Worku, Petros Faltamo
The availability of trained and competent service providers in delivering quality HIV/AIDS services is of
utmost importance in the Ethiopian context. Ethiopia's single point HIV prevalence is 2.1%, which translates
into a target of 350,000 eligible for ART in order to obtain the universal access for ART by 2010. The
Ministry of Health's 2005-06 publication "Health and Health Related Indicators" reported that there is one
physician for every 35,493 people and one nurse for every 4,207 people in Ethiopia. The numbers are
significantly below the WHO international standards for physicians with the standards set at one physician
for 10,000 people and near to the nurse ratio of one nurse for every 5,000 people making access to regular
healthcare services by skilled
There have been multiple reports of high attrition of health care providers in Ethiopia. The resources and
efforts put into PEPFAR training have been enormous. It is important to provide measurable information and
assess training effectiveness periodically. In the context of the Ethiopian scale up of ART services, health
centers were recently added as service provision sites. COP08 will be an opportune time to review the
effectiveness of training programs at this health facility-level to refine strategies for the future.
Status of study/progress to date
In FY07, JHPIEGO was funded to conduct an evaluation that will provide feedback to PEPFAR Ethiopia
regarding the effectiveness and cost of investments to train health care workers at facilities. The evaluation
included descriptive review of training processes and methodologies utilized by PEPFAR implementing
partners employing a quasi-experimental data collection methods to assess the performance of trained and
untrained providers(either on the job or in a simulation) on specific knowledge and skills included in the in-
service training they received. Additionally, the evaluation measured the attrition rates and reasons for
The main evaluation questions were:
1) What proportion of health care workers who have attended training funded under PEPFAR are still in the
post they were in at the time of training?
2)Where are the providers that left the facilities?
3)How effectively are health care workers performing on specific skills for which they were trained?
4)What was the average training cost per trainee, by category of knowledge and skills of the training event?
What is the anticipated cost for re-training providers?
5)How are the PEPFAR trainers being used within the program and how many training events have they
6)What is the perceived risk of HIV infection in providers trained versus providers not trained in providing
JHPIEGO reviewed PEPFAR Ethiopia's Training Information Management Information System (TIMS) for
data on providers trained in HIV/AIDS services to identify the population of health care workers trained by
PEPFAR in all areas of prevention, care and treatment at hospitals. Accordingly, data were collected from
selected but representative cohort hospitals in Ethiopia. Due to funding limitations in COP 07 the sample
only included hospitals.
The skills of trained providers were evaluated by comparing skills that providers are expected to have post-
training versus skills that are displayed at the time of assessment using standardized case study
assessment tools which were developed using competencies agreed upon in Ethiopia and all PEPFAR
Ethiopia Training Partners reviewed and approved the tools.
Surveys were distributed to PEPFAR Ethiopia's university partners to determine the costs of training. The
protocol was finalized and submitted for the CDC Institutional Review Board approval.
Planned FY08 Activities:
In COP08, JHPIEGO proposes another Training Evaluation with a similar study design and the same
objectives, but with a protocol targeting staff at health centers. The evaluation will assess similar elements
as the hospital version collected: including trainers, cost, and competency of providers and attrition rates of
providers at the health center level. The selection of health centers will be confined to those networked to
hospitals. JHPIEGO will work closely and collaborate with implementing partners that have trained staff at
health center level in refining the protocol and evaluation tools, including US agencies and
international/local partners. The evaluation of training effectiveness will provide useful information across all
PEPFAR funded training programs; working closely with PEPFAR partners on the evaluation will bring
greater impact. The availability of trained and competent service providers in delivering quality HIV/AIDS
services is of utmost importance in the Ethiopian context. Ethiopia's single point HIV prevalence is 2.1%
which translates into a target of 350,000 eligible for ART in order to obtain the universal access for ART by
2010. In 2005/06 the Ministry of Health document "Health and Health Related Indicators" that there is one
healthcare services by skilled providers limited for a significant proportion of Ethiopians.
Information Dissemination Plan:
The findings can be used by HAPCO and the Human Resource Department of Ministry of Health, Regional
Health Bureaus, and PEPFAR partners that invest in in-service training for capacity building. The study will
also inform retention strategies with a specific focus on the needs of health centers
Activity Narrative: Budget Justification for FY08 monies:
Given experience to date and the breadth of the proposed FY08 scope of work, the study is budgeted at
$150,000 in COP08. The funding will be used for protocol development, recruitment of data collectors,
training of data collectors, data collection and supervision, data cleaning, entry and analysis, dissemination,
salaries of staff, other direct costs and Johns Hopkins University financial and administration costs.
This is a continuing activity in COP 08 originally planned with JHPIEGO-E as Prime Partner. It was
erroneously entered in the databasewith JHU -Bloomberg as prime partner. The activity is to conduct a
targeted evaluation on the effectiveness of Training for staff at Health Centers under PEPFAR -E. The
findings of the evaluation will provide useful information across all PEPFAR funded training programs ,
partners and stakeholders to identify the retention and attrition status of trained health care providers.
JHPIEGO-E is a prime partner which has a strong potential in conducting targeted evaluation. CDC-E will
provide guidance and follow up of the targeted evaluation.