Expansion of Integrated ANC/PMTCT Services

IntraHealth will continue to provide a comprehensive package of support for quality improvement, training,

supervision, and technical assistance in COP08 in a total of 150 new health centers and health posts.

IntraHealth will prioritize the expansion of PMTCT to the health-post and community level. IntraHealth will

expand the pilot home-based delivery of Nevirapine (NVP) while working to strengthen Mothers' Support

Groups at the community level to increase the overall quality, access, and use of ANC and PMTCT services

in Ethiopia. The breakdown of IntraHealth's FY08 funding by activity is as follows: $1,500,000 for MSG,

$1,700,000 for health center sites, and $1.8 million to expand the NVP home-delivery for a total of

$5,000,000.

IntraHealth currently supports 248 health centers as of the end of August 2007. IntraHealth will transfer the

supervision and support responsibilities in over 20 health centers in Gambella, Benishangul, and Somalia to

USG university partners in October 2007. In FY08, IntraHealth will pick up an estimated 200 new health

centers while transferring the current 248 sites to the Care and Support program under MSH. With FY08

funding, IntraHealth will maintain support to the 200 COP07 health centers until time to transition them to

MSH, while picking up 150 new sites in COP08. IntraHealth will assess the capacity of the 150 new health

centers and health posts in the areas of lab, staffing, equipment, etc. IntraHealth aims to train 320 new

health providers in PMTCT according to the new national PMTCT guidelines. IntraHealth will provide

additional refresher training in 2008 on the guidelines, covering such topics as the opt-out strategy, short-

course combined prophylaxis, and early infant diagnosis. In addition to providing training, IntraHealth aims

to improve the quality of the ANC and PMTCT services through the implementation of performance

standards, quality assurance tools, and sharing best practices, which include a family-centered approach.

IntraHealth will support the health facilities in initiating the integration of PMTCT services into existing MCH

services to ensure HIV+ women receive better referral linkages and increased access to a wide range of

health services, especially ART. Pregnant women will be routinely tested for HIV during ANC, L&D, and/or

postpartum, as appropriate. All HIV+ women should receive TB screening, FP counseling, clinical staging

and CD4 count when possible, treatment for STI and OI and IPT as needed. IntraHealth will prepare health

providers on how to better care for HIV+ pregnant women and their infants. Currently the health facilities

supported by IntraHealth are testing, on average, 62% of women attending ANC with a 5.5% HIV

prevalence rate. Of those testing positive, about 40% of mothers and 26% of infants receive NVP. There is

a significant cascade effect that IntraHealth will aim to address in the coming year.

A key strategy for providing better care and support to HIV-positive women will be the expansion of

Mothers' Support Groups (MSG). By the end of FY07, the MSG program under IntraHealth will expand to

reach a total of 64 ART health networks, and during FY08 another 50 networks will be added, for a total of

114 ART health networks offering MSG services. JHPIEGO will be supporting MSG programs in 35

hospitals in these networks. About 2,300 HIV+ women are expected to enroll in the MSG program

supported by IntraHealth during 2008. Given the chronic human-resource shortages health facilities are

grappling with every day, appropriately selected and trained Mother Mentors will continue to prove valuable

resources by serving as "expert patients." Mother Mentors and health providers will promote safe infant

feeding and be well informed on family planning methods in order to better counsel HIV+ mothers about

their options. The MSG program will continue to engage male partners of HIV+ mothers focusing on

behavioral issues related to testing and counseling, secondary prevention, and stigma reduction. The

activity will also be linked to IGA to improve women's access to financial resources and employment.

IntraHealth will provide on-site clinical mentoring, as well as routine supervision and site assessments, to

monitor progress. This partner will also be responsible for tracking the status of PMTCT supplies, including

test kits, infection-prevention materials, and drugs to make certain that PMTCT services are fully functional.

Part of the monitoring role will also involve strengthening the data surveillance system at the health-facility

level. IntraHealth will assist providers in collecting, reporting, and using data to evaluate the progress and

gaps in PMTCT services.

Over the past three years, IntraHealth trained 370 TBA, 732 HEW, and 560 community action facilitators on

social mobilization for PMTCT, referral of pregnant mothers for ANC/PMTCT, and male involvement. This

training is an integral part of a safe motherhood intervention aimed at averting new pediatric infections

through linking community and facility PMTCT endeavors. HEW and TBA are part of the community; they

share local customs, common values and norms, speak the local languages, and often have the trust and

respect of the community. These cadres can help mobilize the community to increase antenatal care-

seeking behavior, reduce stigma and discrimination, and increase male involvement. IntraHealth will

collaborate with EngenderHealth to incorporate Men As Partners activities into their program, which is

currently in communities around 270 health posts. IntraHealth-supported facilities are testing only around

15% of male partners during ANC visits and will aim to significantly increase this number in the coming

year.

Increasing the capacity of TBA and HEW to render household-level service delivery are vital to overcoming

the prevailing poor uptake of the PMTCT service. IntraHealth will work closely with the new FP/MCH

program to ensure coordination and collaboration of community outreach efforts. The PEPFAR partners will

convene monthly forums with healthcare providers, including HEW, to review the ANC/PMTCT intervention

being executed at the facility and community levels. The HEW and TBA will have their own mechanism to

track referred mothers with community referral cards.

In COP08, IntraHealth will expand the pilot of NVP home-delivery by training over 400 TBA and HEW to

educate and refer pregnant mothers for ANC/PMTCT and to administer NVP to the infant within 72 hours of

birth. This activity began in March 2007 in Tigray and Oromiya regions in six health centers and 30 health

posts. HEW take fixed doses of NVP from the health center or health post to the household to facilitate the

mother and baby receiving the medicine. Alternatively, HEW accompany pregnant HIV-positive women to

health centers/posts for delivery and follow-up visits to receive the NVP. The results from the first six

months of this activity will be available in early October 2007. Between April-June 2007, HEW made 895

household visits, referred 216 pregnant women to ANC services, and delivered NVP at the household level

to seven mothers and six infants. IntraHealth will work in collaboration with RHB, district health offices,

HAPCO, and others to monitor and build sustainability for this intervention. Supervision is an important

element of capacity building to ensure the proper application of the social mobilization and referral of

mothers for ANC/PMTCT services. IntraHealth will emphasize joint supportive supervision and regular

quarterly reviews in order to back up the duties of community actors. This activity will aim to refer and test

90,000 pregnant women, their partners, and HIV-exposed children. IntraHealth-supported facilities will

Activity Narrative: provide follow-up care and treatment for 3,500 HIV+ mothers and infants.

Linking Pediatric Clients to Treatment

This is a continuing activity from FY07.

The continuum of care during and after the postpartum period is an important time to keep a watchful eye

on the newborn's growth and development, ensuring the prevention, early detection and enrollment in

treatment of HIV. As the vulnerability of the child begins earlier than previously recognized, early detection

of HIV and initiation of ART and OI prophylaxis improves the chance for long-term survival in the youngest

children with HIV.

PEPFAR Ethiopia believes that prevention is only a half the battle, and that a full spectrum of HIV/AIDS

services is needed to effectively fight the pandemic. Prevention services must link to treatment and care

programs in order to keep families healthy, strong and together. Only 10% of pregnant women have access

to PMTCT services program in Ethiopia and only six percent deliver in a health institution. Children (under

15 years of age) born to HIV-positive mothers and children symptomatic with HIV infection are left without

access to testing or ART. Health extension workers and health providers at health centers and health posts

can play a central role, once they have received instruction/training to identify and diagnose infants who

have not been tested and/or are considered vulnerable.

In an effort to keep pace with the estimated 13% of new HIV infections occurring in children annually, at

least 15% of patients receiving treatment are expected to be children. During FY06, IntraHealth initiated a

comprehensive pediatric HIV/AIDS care and support (CPCS) activity. In the first six months of

implementation, the project covered 70 health centers and their respective three satellite health posts

reaching 210 health posts. IntraHealth and local partners trained 884 health providers at health centers and

health extension workers/community resource volunteers (HEW/CRV) to identify and refer children to

access testing and treatment. As a result, 1,378 children were identified and referred for testing from the

community and through provider initiated activity. Two hundred forty eight children tested positive among

whom, 157 were referred to hospitals for ART. Eighty-five HIV-positive children were referred back from

hospitals to health centers for chronic follow-up care. Pediatric HIV/AIDS referrals have improved from

almost null at the health-center level to over 1,000.

Building on the successful lessons and experience drawn from the pilot CPCS project, IntraHealth proposes

to scale up access of CPCS to communities around 50 health centers and the respective five satellite health

posts. IntraHealth will continue to strengthen the 90 existing sites from FY06 and the 40 additional sites and

respective five health posts that will be picked up under COP 07. As of the end of September 2009, this

partner would be supporting pediatric case follow-up in 180 health centers and 900 health posts in Addis

Ababa, Amhara, Oromiya, SNNPR, Dire Dawa, and Tigray.

Expansion will be carried out through five steps that will be well coordinated and will improve the quality of

services.

Step one - Orientation: IntraHealth will conduct decentralized orientation, baseline assessment and

resource mapping in the new sites. This step will only take one day and includes the participation of about

30 personnel from different levels of health structure.

Step two-- Training: The activity will provide a six day centralized training for health workers working in

pediatric units on integrated management of neonatal and childhood illnesses (IMNCI) and chronic

HIV/AIDS follow-up care using standard manuals. Other training will include decentralized one day training

for MCH entry unit health providers on case detection and referral, and a two days training for the

respective HEW/CRV on active case detection and referral, adherence to treatment and defaulter tracing.

Five days after the training, IntraHealth will undertake follow-up, which includes supportive supervision for

health managers at woreda level. Lastly, a two day refresher course for existing sites and respective health

posts will be conducted.

Step three-- Service implementation and reinforcement: Reinforcement of skills and knowledge learned will

be provided to each trained health worker post-training, to ensure that the quality of service delivery

conforms to established standards.

Step four-- Collaboration and harmonization of activities: At all steps of implementation, IntraHealth will

assure that its activities are harmonized with those of its partners to ensure the continuum of care.

IntraHealth will collaborate with partners by organizing and attending stakeholders meetings and working

together on complementary activities, as well as creating joint forums for discussion. Such advocacy will be

an important step to ensure the right of HIV-positive child for attending school without stigma and

discrimination and to benefit from inheritance.

Step five-- Monitoring and evaluation: IntraHealth will ensure the quality of reports and incorporate

additional indicators, to be consistent with the national HMIS and will harmonize the indicators of pediatric

follow-up with those of PMTCT to avoid duplications. This activity focuses on gather more strategic

information to inform PMTCT and ART efforts in Ethiopia. It also aims to shift tasks to HEW/CRV in order to

lessen the burden on clinic-based health providers and increase community outreach for pediatric case-

finding.

A practice of monthly meetings of referring units, particularly the health centers, the Woreda's and the

community (HEW/CRV) is well established in some areas, but needs strengthening in many places to

improve coordination between all levels of care. Strong work relationships are recognized between the

IntraHealth team and the personnel throughout the health structure. Effective information and data

exchange now exists between IntraHealth, government and PEPFAR Ethiopia partners. IntraHealth and its

collaborating partners jointly monitor progress and undertake supportive supervision visits with the

respective health managers, an outcome which is positively viewed by the officials of Ministry of Health.

IntraHealth will continue to collaborate with the US universities (Columbia, Washington and John Hopkins)

to link HIV exposed children 0-18 months for Dried Blood Spot analyses, and HIV positive children above 18

months to 14 years for CD4 counts and ART initiation. The activity will also continue to work with Save the

Children's PC3 Orphans and Vulnerable Children project (10396) to link clinically malnourished infants to

nutritional support and other community services. The ESHE project will also work to identify chronically ill,

Activity Narrative: malnourished, and/or HIV-exposed infants and children in order to refer them for testing and appropriate

treatment.

The targets for this activity will be counted by other PEPFAR clinical partners providing ART. IntraHealth will

590 health providers on identifying and providing pediatric ART. This program aims to help initiate ART for

2,000 infants and children.