Improving TB diagnosis and TB/HIV Monitoring and Evaluation

HIV-positive persons have to be properly screened for tuberculosis (TB) in order to receive directly

observed therapy, short course (DOTS) for active TB cases or to receive isoniazid for those free from TB.

However, diagnosis of TB in HIV-positive persons remains a challenge in Ethiopia, where both the diseases

are prevalent. In FY07, several activities focused on improvement of TB diagnostic facilities at the regional

level, including establishment of TB liquid-culture capacity, exploration of the feasibility of different

diagnostic methods (e.g., florescent microscopy, fine-needle aspiration, Microscopic Observation Drug

Susceptibility assay (MODS)), and improvement of chest x-ray services. In particular, the HIV/AIDS

Prevention and Control Office (HAPCO) used FY07 plus-up funds to assess the availability and functionality

of chest x-ray facilities in PEPFAR- supported hospitals. In addition, HAPCO purchased x-ray machines for

those hospitals that did not have them, as well as those who are serving a large number of TB/HIV cases. In

FY08, HAPCO will continue with that effort by purchasing x-ray machines for those hospitals with needs

identified in the original assessment which could not be assisted in FY07.

The activities will include: purchase and distribution of chest x-ray machines, in-service training of x-ray

technicians, and in-service training of physicians on how to read and interpret chest x-rays.

HAPCO will also continue its involvement in improving the TB/HIV data system which was initiated in

previous years. In FY07, the TB/HIV monitoring and evaluation system was established, and in FY08

HAPCO will concentrate efforts on supportive supervision and review meetings among hospital sites and

national and regional level HAPCO.

Support the National HIV Counseling and Testing Coordination

This continuing activity was initiated through FY07 plus-up funds to support the national effort to strengthen

the coordination of HIV Counseling and Testing (HCT) activities.

PEPFAR will channel funds to the Federal HIV/AIDS Prevention and Control Office (HAPCO) to support the

government's Millennium AIDS Campaign (MAC) that aims at counseling and testing nearly five million

clients by the end of September 2008 and beyond. The HCT target set for MAC Phase II was 1.8 million for

the period of February to September, 2007. A total of 504,564 (46.7%) people were tested through the end

of June. Major progress has been achieved in HCT site expansion; currently 968 sites are providing HCT

services in the country—654 government health centers and 105 hospitals (including 91 government

hospitals and 12 military hospitals), and 209 other health facilities, including private hospitals, clinics, and

nongovernmental organizations.

MAC has created demand for HCT services in all regions. However, the campaign faces many constraints

and problems: the human resource crisis; the campaign was generalized and not targeted specifically to

high-risk populations and routine and diagnostic testing; less attention was given to child testing; and HCT

was poorly linked to care and treatment service. Test kit supplies started out poor, but improved relatively

by June.

The objective of this activity is to strengthen HAPCO's coordination of the Millennium AIDS Campaign

(MAC) at the national level to increase uptake and improve the quality of HCT services. FY08 activities will

include:

1) Coordination of all HIV counseling and testing programs will be strengthened at the national and regional

level through collaboration of all stakeholders under the leadership of HAPCO.

2) HAPCO will conduct quarterly supervision of regional activities to review progress in the implementation

of the campaign.

2) Biannual review meetings will be conducted to identify strengths and gaps and provide direction.

3) HAPCO will provide support to regional health bureaus (RHB) and regional HAPCO to coordinate

regional implementation of the HCT program.

4) Strengthening of social mobilization activities to create demand for HIV testing

5) Strengthening of central-level data compilation and reporting

Some of the funds will be used to help sites to cover some operational costs, such as weekend activities in

areas with a high client load. Funds will also support social mobilization to create demand at the sites, and

to support regional-level data compilation and reporting.

ALERT National HIV/AIDS Training Centre

This is a continuing activity started in FY07 with plus-up funding.

One of the major challenges in the implementation of the national HIV/AIDS program in Ethiopia is the lack

of trained health workers who can provide the required services with acceptable quality. This has become

more and more critical as the program is being scaled up across the country and in numerous health

facilities. There is an urgent need to train health workers on a large scale and to follow this up with

continuing medical education (CME). This becomes more important when we consider the high attrition rate

of health workers from public health facilities, which leaves a vacuum in the delivery of services, severely

affecting scale-up and compromising quality.

The Ethiopian Federal Ministry of Health (MOH) has made a strong commitment to the process of

establishing a national center of excellence for CME, combining training, research, and health services.

Building the capacity of the Ethiopian health service is essential in order to address the multiple health

crises affecting the country. In particular, sustainable human resource development is an MOH priority.

Based on these facts, MOH plans to establish a national HIV/AIDS training center at ALERT Hospital, which

will provide training on HIV/AIDS to a wide range of health workers. This would build on ALERT's

comparative advantages of being an integrated hospital with longstanding community links, and a research

center and training division with solid managerial capacities and technical expertise in various medical

arenas.

ALERT is widely recognised as having an excellent reputation in research, training, and services, both in

the Ethiopian health sector and at international levels. The existing in-and out-patient hospital care with a

community outreach program, CME, and a research institute, among others, make it an ideal site for a high-

quality training center, which will be a national Center of Excellence for continuing medical and public health

education.

Currently, Ethiopia's short-term medical and public health training is conducted in a piecemeal fashion. No

single institution is responsible for delivery, so training is insufficiently coordinated, standardized and

certified. Necessary changes in terms of service expansion and improved quality have not been made.

There is high and urgent need for standardized, evidence-informed training packages for CME and a

massive scale-up of training programs in the regions, which makes establishing a national Center of

Excellence for CME at ALERT a priority.

The institute will serve as a quality control institution, so that effective and efficient training is guaranteed,

and will serve as a model for other national health trainings. It will be able to develop standards, models,

curricula, manuals, and guidelines for different training programs, based on in-depth needs assessment,

best practices and operational research. In addition, the experience of this national training center will be

replicated in three selected satellite regions.

The proposed national institute would standardise and strengthen evidence-informed training and provide

trainees with the opportunity to combine training with clinical practice.

In addition, the national training center will rollout training capacity to other regions. This will involve:

1) Providing technical assistance to establish accredited, satellite training-of-trainers (TOT) centers in the

regions, in collaboration with relevant regional, national, and international stakeholders, and support for

monitoring and evaluation of the satellite centers

2) Develop models for community care and area-appropriate HIV care, treatment, and support, based on

the experiences of satellite centers in different areas of the country

3) Provide training for the health professionals in the satellite TOT centers in the regions, using the models

developed

4) Monitoring the progress of the training services provided at the satellite sites

In order to upgrade the ALERT site for the purpose of providing all aspects of HIV/ AIDS training,

considerable financial, technical, and material assistance is required. Considerable capacity building needs

to take place in order for ALERT hospital to be ready to shoulder the task. Infrastructure, human resources,

and information technology equipment, among others, need to be significantly increased in order for ALERT

to provide practical and high-quality TOT. Meanwhile, the existing resources at ALERT alone are not

adequate to transform the training division into a national training center, and additional resources are

necessary.

PEPFAR Ethiopia, along with other partners like the World Bank and the Global Fund for AIDS, Malaria,

and Tuberculosis, supports the MOH in the effort to develop human capacity, as this helps to build

momentum and contributes significantly to meeting targets. Establishing a national HIV/AIDS training center

will also be vital to ensuring the sustainability of the HIV/AIDS program by creating an indigenous

institutional capacity to overcome a major constraint in its implementation. In FY07, PEPFAR Ethiopia has

supported this plan through the plus-up funds. In FY08, this support will continue to ensure the effective

realization of the National Training Center.

Support to the National TB/HIV Information/M&E System

According to the World Health Organization's (WHO) Global TB Control Report issued in 2006, Ethiopia

ranked seventh out of the top 22 High Tuberculosis (TB) Burden Countries in terms of total number of TB

cases notified in 2004 (123, 127 cases). The estimated incidence of all forms of TB and smear-positive,

pulmonary TB (PTB+) was 353 and 154/100,000 populations, respectively. The case-detection rate of PTB+

cases was 36%, nearly half the global target of 70%. The cure rate for PTB+ cases on directly observed

therapy, short course (DOTS) was 54% in 2004, falling short of the global target by 31%.

Information on prevalence of co-infection in Ethiopia is very limited and is based on very few hospital-based

surveys. The TB/HIV collaborative work was initiated in Ethiopia as a pilot project at 9 sites at the end of

2004. Based on the experience from these sites the collaborative work has scaled up to 61 hospitals in the

last year. The data generated from these TB/HIV implementing sites revealed 47.5% co-infection.

The TB/HIV reporting system is designed by the Ethiopian Ministry of Health (MOH) to follow the TB

reporting system and is handled separately from other diseases. The quarterly reporting of statistics on

patients diagnosed with TB/HIV is done at the district, zonal, regional, and central level. From those

numbers, epidemiological and operational indicators for monitoring of the program are calculated and

compiled. Quarterly reporting is done according to the Ethiopian fiscal year.

Proper monitoring and evaluation of the TB/HIV activities is critical not only for effective management of

individuals but also to keep track of trends of the co-epidemics and to facilitate subsequent planning. The

MOH in its revised third edition of the TB/Leprosy guidelines and the first edition of the TB/HIV

implementation guideline clearly indicated on how to record and report the TB/HIV data and the monitoring

and evaluation mechanisms of the TB/HIV activities. Although M and E activities are implemented to a

certain extent a number of challenges that require remedial action are observed in the last one year.

PEPFAR-assisted evaluation of the TB/HIV implementing sites was conducted a year ago and the following

drawbacks were observed: 1) poor data recoding and reporting as a result of poorly organized monitoring

and evaluation system; 2) shortage of human resources; 3) inadequate supervision; 4) lack of knowledge;

and 5) absence of an electronic data-management system.

This project aims to support the National TB Control program which is functioning as a lead in the TB/HIV

collaborative initiative at MOH and is chairing the TB/HIV Advisory Committee.

In 2007, activities will build on what has been started in previous years. The following activities are planned

to strengthen TB/HIV monitoring and evaluation:

1) Revision of the TB and HIV registers according to feedback received from implementing sites; revisions

will include any missing indicators; 2) Development of data systems at the national, regional, and district

levels to systematize the reporting and analysis of TB/HIV surveillance data. This includes training of MOH

and regional staff on data management, procurement of information technology equipment, recruiting staff

where needed, and other logistic support;3) Conduct regular supportive supervision to implementing sites;

4) Conduct review meetings (at regular intervals) which involve all stakeholders. This activity will link with

the national M&E and the data warehouse supported by CDC.

Stake Holders/ Sub partners

11 Regional Health Bureaus

HMIS in service training

The effectiveness of a health information system in providing information support for decision-makers

depends upon well-trained staff. Not only must the mechanics of data collection and reporting be mastered,

but high familiarity with case definition, disease classification, service standards, and information use are

equally important. Thus, for a health-information system to produce valid, reliable and useful information,

staff skills must be built and maintained through pre-service and in-service training, well-planned refresher

courses, and regular follow-up with supervision.

In-service trainings for health professionals, administrative staff (regional health bureaus (RHB) zonal health

bureaus (ZHB), WHO, etc.)) and dedicated HMIS personnel were initially planned in a decentralized and

cascading fashion. Regions and zones will be master trainers who train other trainers—these TOTs will train

district health-office (DHO) staff, who will, in turn, train health professionals at the facility level -with

technical support from Tulane University. Experience during the pilot phase of training has demonstrated

that the regions, zones and districts do not have the human resources or adequate technical skills to train

facility-based health professionals and hence extensive support and capacity building is required.

Decentralized training will be conducted for Federal staff and regional/zonal/district master trainers. These

in turn will train facility-based health professionals in the respective regions and facilities. The aim is to

improve effectiveness of the training by allowing more contact time between trainers and trainees and

facilitating discussions of problems and solutions relevant to their specific local context. It also decreases

the period the trainees stay out of work.

Training focuses on the registers and formats, health data management, basic statistics, use of information

for decision making. During the training, emphasis on how to ensure collaboration between HMIS staff,

program managers and decision-makers for performance monitoring is ensured. Training materials and

training sessions have been designed by bringing all groups together to make them understand each

others' needs. Training for regional/zonal/district staff as well as for hospitals/health centers and health

extension workers on data recording, reporting, analysis, interpretation, and use will last approximately two

weeks. However, there are differences in content and length of training courses according to the level of

health institutions.

Since the pilot phase has demonstrated that training alone does not ensure information usage, follow up for

application of the skills will be done by supervision and refresher courses. TA for the training will be

provided by Tulane University.

Involvement of Ethiopian Parliament in HIV/AIDS Prevention, Care and Treatment

This continuing activity primarily addresses prevention of HIV/AIDS and stigma reduction for people living

with HIV (PLWH), and will be linked closely with several outreach programs with interactive or interpersonal

peer group elements—strengthening the overall country program.

The House of Peoples' Representatives is the highest governing body in Ethiopia. The House has

legislative powers in all matters referred by the constitution to Federal jurisdiction. According to the

constitution, the House has 547 members who are accountable to the people who elect them. The 547

members are from both the ruling and opposition parties, and were elected in the May 2005 elections that

showed extensive involvement of the people in the political process. As such, involving popularly elected

members of Parliament (MPs) as peoples' representatives in HIV/AIDS prevention, care, and treatment can

have a major impact.

MPs can influence the Executive Body (Ministries) to address HIV/AIDS issues in their respective political

organizations, among their constituents, and in the parliamentary process of oversight to the Ministries.

They can also urge the Ministries to plan and implement programs by mainstreaming HIV/AIDS as part of

their organizational duties and responsibilities.

MPs are advocates for their respective constituencies, but they also address HIV prevention and promote

care and treatment (counseling and testing, PMTCT, ART, sexually transmitted infections (STI) services,

positive living, etc.) while conducting their representational duties in their localities. MPs also address

HIV/AIDS issues as they shape national legislation and Parliamentary activities. They mainstream HIV/AIDS

in all legislation, making it a regular agenda item in the Social Affairs Committee and at relevant caucuses

(e.g., Women's Caucus). They also use other opportunities at governmental or nongovernmental functions,

and with local district and ward administrations, to enhance their focus and attention to HIV/AIDS activities.

As the people's direct representatives, MPs are in a unique position to influence public opinion and confront

the stigma surrounding HIV/AIDS. Some individual members have their own initiatives and are highly

involved with PLWH associations. By virtue of the elevated positions of MPs, they can effectively mobilize,

motivate, and encourage the public to prevent new infections by promoting ART, PMTCT, voluntary

counseling and testing (VCT), and STI services, and increasing their uptake.

It is encouraging to note the increasing commitment in HIV/AIDS awareness, prevention, support, and

treatment on the part of current MPs. These include the Speaker of the House (the former Minister of Youth

and chair of the national HIV/AIDS Management Board), and the First Lady, who chairs the Social Affairs

Committee and Women's Coalition on HIV/AIDS. Both individuals are very active in HIV/AIDS matters.

While great progress has been made in the fight against HIV/AIDS, more effort is needed to ensure the

development, funding, and full implementation of strategies to combat it. Parliament needs current guidance

and sensitization in order to maximize its support to realize PEPFAR goals, especially focusing on

promotion of services like VCT, ART, and PMTCT. Armed with sufficient information, MPs can be role

models and campaign for uptake of HIV/AIDS services in their localities during their vacations. This is also

an important opportunity to strengthen the network model.

In FY07, the Federal HIV/AIDS Prevention and Control Office (HAPCO) has successfully provided training

and orientation for MPs on prevention, care and treatment, and planning processes, to ensure that they

have accurate and current knowledge about HIV/AIDS. HAPCO encouraged the MPs to pass such

information on in their localities during the vacation, and to urge district and ward leaders to include

HIV/AIDS in their development plans. Parliament is expected to continue working on HIV/AIDS when it

resumes work, and it is also expected that MPs will act as advocates for those infected and affected as well.

In FY08, HAPCO's activities with the Parliament will include:

1) Reviewing the achievements of FY07 and building on the lessons learned and successes achieved

2) Offering a training and orientation program to update MPs on prevention, care and treatment, and other

HIV/AIDS services

3) Adapting/developing an updated handbook for use in guidance and advocacy. The handbook will also

serve as reference material for the MPs.

4) Encouraging members of Parliament to continue HIV/AIDS campaigns and to promote prevention, care,

and treatment activities in their localities when Parliament is closed and during their representational duties

5) Supporting MPs' outreach activities to their respective constituencies . These include educating their

constituents on community support for infected and affected families and working to reduce stigma.

6) Encouraging MPs to play a leadership role in mobilizing the community to use HIV/AIDS services

7) Strengthening of HIV/AIDS activities of the Parliament in general, and the HIV/AIDS Committee, the

Social Affairs Committee, and relevant Caucuses in particular

8) Advocating for the legislation of rights-based, gender-sensitive, nondiscriminatory HIV/AIDS policies

In FY08, HAPCO will also sponsor the establishment of the Legislative AIDS Resource Center (LARC) in

the offices of the Ethiopian Parliament. This will assist and support MPs in their legislative activities on

HIV/AIDS and other health-related issues. The LARC will be created with the assistance of the National

AIDS Resource Center, and will provide a comprehensive source for HIV/AIDS and other health-related

information. The LARC will include access to valuable print, electronic, and audiovisual documentations on

both Parliamentary practices and procedures regarding HIV and AIDS of other countries. The Center will

have a library and audiovisual room exclusively for MPs and a computer center with access to the Internet

and e-mail facilities. LARC will also provide services for staff, committees, and Parliamentary parties. The

Information Center will be run jointly by the national AIDS Resource Center and the Library of the

Parliament.