Support for Integrated ANC/PMTCT Services

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care-and-support activity in Ethiopia at the primary healthcare-unit level and

at health centers and satellite health posts. CSP provides coverage nationwide. This program will support

the GOE to provide HIV/AIDS prevention, care, and treatment services at health centers and at the

community and household levels through technical assistance, training in strengthening of systems and

services, and expansion of best practice HIV prevention interventions. The lead partner is Management

Sciences for Health (MSH).

This is a continuing activity begun in FY06 and previously conducted by IntraHealth International.

IntraHealth has coordinated the introduction of PMTCT services in over 250 health centers and trained a

substantial number of health professionals. While IntraHealth will continue to introduce and integrate

PMTCT into antenatal care (ANC) services in new sites in 2008, MSH/CSP will systematically transfer the

responsibility for maintaining quality PMTCT services at their current sites to the CSP. The GOE and

PEPFAR remain committed to implementing HIV prevention, care, and treatment services that include

moving PMTCT services into an integrated comprehensive HIV/AIDS treatment and care program. Without

adequate investment in operational readiness, however, the quality of PMTCT services will be

compromised. This activity addresses PMTCT services at health centers by increasing their operational

capacity including integration into ART services and the health network. MSH/CSP will support PMTCT

services in 240 sites under FY07 and 150 additional sites in FY08 with the activities below.

1) Supportive Supervision, Mentoring, and Training of Health Workers: Human resources will be

strengthened through training in multiple program areas and supportive supervision in conjunction with GOE

personnel. The activity will facilitate training on PMTCT using current PMTCT Guidelines that include

multiple drug therapy. Updates and refresher training will be carried out for health workers previously

trained on the single drug therapy regimen using Nevirapine and on PMTCT/ART integration. In close

collaboration with regional health bureaus (RHB) and district health offices, standard operating procedures

(SOP) and care protocols will be implemented with other relevant stakeholders and partners. To strengthen

the provision of PMTCT services in the ART health networks, mentoring of health workers and monitoring of

PMTCT clients with experienced hospital and private-sector clinicians will be organized. This will help build

provider capacity to manage clients and improve client care. The mentoring activity will be jointly carried out

by the ART mentors, who will be trained to mentor health workers providing the comprehensive continuum

of HIV/AIDS care and treatment.

2) Strengthening the Referral System and Community Outreach: This component will be linked with multiple

services in health centers and health posts to support the integration of PMTCT, ANC, TB, reproductive

health (RH), and ART services. The existing community outreach activities begun under IntraHealth will be

supplemented with new CSP outreach activities, including the introduction of community-oriented outreach

workers (COOW). MSH/CSP will identify, train, deploy, and support 6,350 COOW over the next three years.

The COOW will ultimately work with health extension workers (HEW), community groups, local leaders, and

government health institutions to strengthen support to communities and households impacted by

HIV/AIDS. CSP will support the training and capacity-building of the COOW in: basic HIV and symptom

management for adults and children (e.g., integrated management of adult and adolescent illness(IMAI) and

integrated management of childhood illness(IMCI)); appropriate and timely referrals to health centers for

ART therapy for clinically eligible pregnant women; and pediatrics HIV case detection and referral. The

program will reinforce provider-initiated counseling and testing (PICT) on an opt-out basis for ANC clients;

cotrimoxazole prophylaxis for HIV-exposed infants; and systematic tracking, follow-up and support of

mother-infant pairs emphasizing clear links with well-child services and the existing and expanded network

of community services coordinated through the health posts and COOW.

HIV-exposed infants will be traced through mothers who access PMTCT and identification of infants at

routine immunizations and community-based health and nutrition services (e.g., growth monitoring). The

COOW will provide oversight for the Mothers' Support Groups (MSG). MSG provide educational, emotional,

and psychosocial support to women living with HIV and their families during and after pregnancy. In addition

to empowering the women, the MSG provide links to other services. The COOW will also focus their

activities on families affected by HIV/AIDS and ensure increased partner involvement in HIV/AIDS treatment

care and support activities.

By the end of COP08, CSP will be supporting an integrated package of HIV/AIDS services including

PMTCT in 390 health facilities and the communities around them. The program will support all links in the

PMTCT/ART and care-network continuum, from client and household to community and health center, with

a focus on the delivery of PMTCT/ART services at the health center and community level.

This is a continuing FY07 activity that is linked to other Care and Support Program activities under HTXS

(10604), HVCT (10399), HVTB (10400), HBHC (10647), and HVOP (10403). These activities will

complement other community outreach efforts involving Health Extension Workers and Community-Based

Reproductive Health Agents, such as those used in the PMTCT programs of IntraHealth and the new

FP/MNCH program.

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities, in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care and support activity in Ethiopia at Primary Healthcare Units, health

centers and satellite health stations, and provides coverage in . This project will support the GOE to provide

HIV/AIDS prevention, care, and treatment services at health centers and at the community and household

levels through provision of technical assistance, training in strengthening of systems and services, and

expansion of best-practice HIV-prevention interventions.

Given the low urbanization rates, a significant proportion of HIV/AIDS cases remain in rural areas. Antenatal

care (ANC) surveillance in many peri-urban health centers indicates a high HIV/AIDS case burden where

limited services are available. Furthermore, Demographic and Health Survey (DHS) reveals limited reach of

mass media , including radios. In response, this activity prioritizes the deployment of case managers and

outreach volunteers to the peri-urban fringe and rural areas in/around ART health networks to conduct face-

to-face community outreach, and supports GOE efforts to deploy health extension workers (HEW) to these

areas. The activity has several components.

The first component uses non-medical case managers in health centers to support consistent HIV

prevention, abstinence, be faithful, and consistent and correct condom use (ABC) communications for

people living with HIV and most-at-risk groups. These brief counseling periods, anticipated after a closer

relationship is formed with case managers, represent efforts to integrate and mainstream brief motivational

interventions alongside clinical integrated management of adult illness (IMAI) among the clinical care team.

The second component of this activity includes providing technical assistance to zonal and district health

offices to support the HIV-prevention activities of HEW. Technical assistance will encompass engagement

by Management Sciences for Health (MSH) and its partners to ensure adequate in-service training, referrals

for most-at-risk populations, and counseling in the community and at a health post level of the ART health

network. This new cadre of health worker is placed at the community level to serve several villages in peri-

urban fringe and rural areas. In total, 30,000 HEW will be deployed by 2010. The HEW is the first point of

contact at the community level for the formal healthcare system. The HEW reports to public health officers

at the health center and is responsible for a full range of primary and preventive services at the community

level. They function as a significant and new link in the referral system and will be able to move vulnerable

and underserved populations into the formal health system through community counseling and mobilization.

HEW will function as the lead position at the health post and the community level to provide social

mobilization activities in HIV prevention.

The third component of this activity includes, in partnership with local authorities, identifying, training and

deploying outreach volunteers to support and facilitate the role of the HEW. Through this activity, outreach

volunteers will provide technical support to the Regional HIV/AIDS Prevention and Control (HAPCO)

activities through community conversations and outreach counseling at the household level. In addition,

outreach volunteers will support case managers in tracking and counseling those who drop from

appointments for clinical care. Outreach volunteers, as local individuals, will use culturally appropriate

approaches in discussing HIV/AIDS, primary ABC and secondary prevention. This will include identifying

misconceptions, stigma reduction, highlighting the gender and HIV burden for young women in Ethiopia,

and negative social and cultural norms.

This activity will strongly support regional government prevention efforts through social mobilization. The

HIV Care and Support Project's coverage is anchored in predominantly peri-urban settings reaching out

from health centers to health posts through outreach volunteers in coordination with HEW and other

community agents for social mobilization activities. Case managers will refer HIV-positive clients to lay

counselors for prevention for positive counseling. Outreach volunteers, in coordination with HEW, will be

responsive to local needs, distinctive social and cultural patterns. They will coordinate and assist in the

implementation of HIV-prevention efforts of local governments by supporting the provision of accurate

information about correct and consistent condom use and supporting access to condoms for those most-at-

risk of transmitting or becoming affected with HIV (funded under HVOP). Outreach volunteers will play an

active role in broader community and family-based counseling , including the distribution of GOE and

PEPFAR Ethiopia information education and communication (IEC) materials. Both case managers and

outreach volunteers will support the provision of counseling interventions with abstinence and fidelity

messaging, and improve client knowledge and understanding of discordance.

The Care and Support Program will collaborate with existing prevention partners so as to complement

ongoing PEPFAR Ethiopia and GOE activities. This activity will consolidate the delivery of prevention

messages to clients of ANC, voluntary counseling and testing (VCT), family planning (FP), TB and sexually

transmitted infections (STI) services, and PLWH and ART clients to capture programming synergies and

cost efficiencies. Case managers and outreach volunteers will use interpersonal approaches to behavior

change on topics , including VCT, substance abuse, abstinence, faithfulness, correct and consistent use of

condoms, STI referral, targeted condom promotion and distribution, and other risk-reduction education.

This activity will reinforce the HIV-prevention community efforts of such as partners as the Ethiopian

Orthodox Church (10512), PACT's Muslim Faith-based HIV-prevention program (10520), FHI's work in

Amhara with MARPS (10594), and the new transport corridor program (10593). This activity will strongly

support regional government prevention efforts through social mobilization. The Care and Support

Program's coverage is anchored in predominantly peri-urban settings reaching out from health centers to

health posts through outreach volunteers in coordination with HEW, Peace Corps, and other community

agents for social mobilization activities. Community members will be reached through these volunteers, who

are already members of and accepted within the community, as well as through HEW. The use of HEW and

outreach volunteers also helps to ensure that relevant messages appropriate for the audience are

disseminated. Training and building of local capacity will be achieved through the collaboration with regional

and district health bureaus and the participation of HEW and outreach volunteers in this activity.

Activity Narrative: This is a continuing FY07 activity that is linked to other Care and Support Program activities under HTXS (1

Care and Support Program

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health-network care and support activity in Ethiopia at Primary Healthcare Unit, health

center and satellite health post, and provides coverage nationwide. This project will support the GOE to

provide HIV/AIDS prevention, care, and treatment services at health centers and at the community and

household levels through provision of technical assistance, training in strengthening of systems and

services, and expansion of best-practice HIV-prevention interventions.

This is a continuing activity for Other Prevention and Condoms under the broader CSP project that builds on

PEPFAR Ethiopia's support of Ministry of Health (MOH)/Health Extension Workers (HEW). Recent

antenatal clinic (ANC) and Ethiopian Demographic and Health Survey (EDHS) indicate greater

concentrations of HIV infection in urban and peri-urban areas. Given the low urbanization rates, a significant

proportion of HIV/AIDS cases remain in rural areas. In response, this activity prioritizes the deployment of

case managers and outreach volunteers to the peri-urban fringe and rural areas in/around ART health

networks, and supports GOE efforts to deploy health extension workers (HEW) to these areas. The activity

has several components.

1) The first component uses non-medical case managers in health centers to support consistent ABC

communications with people living with HIV/AIDS (PLWH) or most-at-risk groups. These brief counseling

periods, anticipated after a closer relationship is formed with case managers, represent efforts to integrate

and mainstream brief motivational interventions alongside clinical Integrated Management of Adult Illnesses

(IMAI) training among the clinical care team.

2) The second component of this activity is technical assistance to zonal and district health offices to

support HIV-prevention activities of HEW. Technical assistance will encompass engagement by

Management Sciences for Health (MSH) and its partners to ensure adequate in-service training, referral

support for most-at-risk populations (MARPs), and counseling at community and at health-post levels. This

new cadre of community health workers is to serve several villages in peri-urban fringe and rural areas. An

anticipated 30,000 HEW will be deployed by 2010. The HEW is the first point of contact at community level

with the formal healthcare system. The HEW reports to public health officers at the health center and is

responsible for a full range of primary and preventive services. They function as a significant and new link in

the referral system, and using community counseling and mobilization, they will be able to move vulnerable

and underserved populations into the formal health system. During FY08, HEW will function as the lead

position at health-post and community levels to provide social mobilization activities.

3) The third component of this activity includes, in partnership with local authorities, identification, training,

and deployment of outreach volunteers to support and facilitate the role of HEW. Through this activity,

outreach volunteers will provide technical support to the regional HIV/AIDS Prevention and Control

(HAPCO) activities in communities through community conversations and outreach counseling at the

household level. In addition, outreach volunteers will support case managers in tracking and counseling

those who miss clinical appointments. Outreach volunteers, as local individuals, will grasp culturally

appropriate manners in discussing HIV/AIDS primary ABC and secondary prevention. This will include

mitigating misconceptions, stigma reduction, highlighting the gender and HIV burden for young women, and

negative social and cultural norms.

The USG anticipates that this activity will strongly support regional government prevention efforts through

social mobilization. CSP coverage is anchored in predominantly peri-urban settings reaching from health

centers to health posts through outreach volunteers in coordination with HEW and other community agents

for social mobilization. Case managers will refer HIV-positive clients for prevention-for-positives counseling.

Community-outreach-oriented workers (COOW), in coordination with HEW, will be responsive to local

needs and distinctive social and cultural patterns. They will coordinate and assist implementation of local

government HIV-prevention efforts, education on correct, consistent condom use, and access to condoms

where needed.

Outreach volunteers will play an active role in broader community and family-based counseling, including

distribution of GOE and PEPFAR Ethiopia information-education-communication/behavior-change

communication (IEC/BCC) materials. Both case managers and outreach volunteers will support provision of

counseling interventions with AB messaging that improve client knowledge and understanding of

discordance.

CSP will collaborate with existing prevention partners to avoid duplication of ongoing PEPFAR Ethiopia and

GOE activities. This activity will consolidate the delivery of prevention messages to clients of PMTCT,

voluntary counseling and testing (VCT), family planning, tuberculosis, and sexually transmitted infection

(STI) services, as well as to PLWH and ART clients, to capture programming synergies and cost

efficiencies. Case managers and outreach volunteers will use interpersonal approaches to behavior change

on topics including: VCT; substance abuse; abstinence; faithfulness; correct, consistent condom use; STI

referral; targeted condom promotion and distribution; and other risk-reduction education.

The target populations of MARPs will be reached through expansion of available facilities. In addition, social

mobilization activities conducted by the HEW will allow for greater reach within the community. The target

includes commercial sex workers, mobile people with disposable income, and people engaged in

transactional sex.

Local organization capacity will be built through the training of health facility staff and the support of health

centers for improvement of health systems, data collection, and patient service. The Performance Based

Management approach will be the key strategy to work with partners and stakeholders, including regional

health bureaus, zonal health offices, and district health offices. This is believed to strengthen the capacity of

the institutions in taking over responsibilities in due course.

HIV Care and Support Program

The Care and Support Program (CSP) is a three year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care and support activity in Ethiopia at the primary healthcare level,

including health centers and satellite health posts, and provides coverage nationwide. This program will

support the GOE to provide HIV/AIDS prevention, care, and treatment services at health centers and at the

community and household levels through provision of technical assistance, training in strengthening of

systems and services, and expansion of best practice HIV prevention interventions.

This is a continuing activity from FY05 and FY06 implemented by the Family Health International IMPACT

project and launched in FY07 by Management Sciences for Health (MSH) as part of the CSP. The palliative

care activity within the CSP is focused on health centers. Hospital-centered delivery of care and support

services is near capacity. Johns Hopkins University recently conducted an assessment that indicates that

hospital providers on average spend only seven minutes with each ART patient. GOE has accelerated

decentralization of care and treatment to health centers. To complement this strategy, PEPFAR Ethiopia will

expand the delivery of palliative services throughout the health network. The MSH CSP will continue to work

in health centers and health posts—the facilities that deliver most preventive and curative services

throughout Ethiopia. As part of the ART health network, CSP will link with ART hospitals for referrals and

work with clients and their families in the community.

During FY08, this activity will continue to support a massive scale-up of care and support services that

began in FY06 following the MOH decentralization of HIV/AIDS care at health centers. Activities include

implementation of enhanced palliative care services in 393 selected health centers nationwide. Health

centers that are geographically and functionally linked to ART health networks will be included in this

category.

At these health centers, CSP will provide technical assistance to support asymptomatic and symptomatic

care in several areas. CSP will expand the reach of care services on multiple levels through developing and

updating semi-annual HIV/AIDS prevention, care, and service plans jointly with district health offices, health

center administrators and clinical care teams; and by implementing personalized and family-focused care

plans.

The program will strengthen health centers and management systems by improving clinical care services-

based on Integrated Management of Adult and Adolescent Illnesses and treating opportunistic infections;

establishing, standardizing and/or strengthening chronic care clinics and clinical care teams including terms

of reference for health providers, supportive supervision and cross-training opportunities; working closely

with Tulane University and other PEPFAR partners to achieve effective patient tracking and identification,

and data measures to ensure that PLWH receiving palliative care services at different levels will be reported

only once; and delivering clinic-based elements of the preventive care package including long lasting

insecticide-treated nets in malaria endemic areas, cotrimoxazole preventive therapy, prevention for

positives, screening for active TB among HIV-positive clients, and nutrition counseling in collaboration with

the Global Fund for AIDS, Malaria, and Tuberculosis and World Bank.

CSP will increase the scope of palliative care by educating on safe water and personal hygiene and linking

to community-based safe water initiatives and integrating nutrition assessment and monitoring in the health-

center-based HIV care settings, and referring severely malnourished PLWH to food-by-prescription and

later to Title II food or livelihood support initiatives. (Food-by-prescription will be initiated at least 25 health

centers providing ART services).

Laboratory services will be improved, including complete blood count, acid fast bacilli microscopy, stool for

ova and parasites, malaria smear, pregnancy test and serology for HIV and syphilis; and routine quality

assurance and control of laboratory practices with CDC support. CSP will also implement standardized

paper records management including procurement in coordination with the US universities and regional

health bureaus (RHB).

Ensuring quality of palliative care services at health center and community levels will be a critical element of

the program. The program will build on the catchment area and regional meetings pioneered by Family

Health International (FHI), to update the skill and knowledge of managerial and technical staff. This activity

will also strengthen pediatric palliative services by increasing detection of pediatric HIV cases through family

-centered, PMTCT,OVC, TB/HIV, adult palliative care and home-based care programs and improved

pediatric diagnosis. In addition to provision of elements mentioned under the adult preventive care package,

pediatric clients will receive regular nutrition and growth monitoring, safe infant feeding, therapeutic and

supplementary feeding through facility-level food by prescription in selected health centers, and referral to

community-based World Food Program (WFP) food and nutrition outlets. Moreover, infants and children will

benefit from existing non-PEPFAR child survival interventions. While rapidly expanding palliative care

services, this activity will ensure provision of quality services through use of standard guidelines. This

mechanism will continue to provide technical assistance to RHB, zonal, and district health offices to deploy

case managers in 393 health centers providing enhanced palliative care. Support includes the cost of the

case managers' training, deployment, supportive supervision, and salary.

The activity continues to support major elements of the health network model including case managers-

based at health centers. These key staff will continue to collaborate with health extension workers (HEW),

community health agents, and traditional birth attendants to support and link patients with community-based

services. These include the promotion of adherence, referral to reproductive health/family planning and

child survival services, delivery of elements of the preventive care package, and referrals to spiritual

counseling. These efforts will continue to promote effective referrals within health centers, to and from

hospitals for specialized care, and to and from community and faith-based organizations. A data tracking

system supporting case management will link hospitals, health centers and community services through

Tulane University strategic information support.

To create additional linkages between the health network, communities and families, PEPFAR Ethiopia will

continue to provide technical assistance to selected ward-level HIV/AIDS desks and health posts to deploy,

at a minimum, five volunteer outreach workers supporting HEW in their community outreach activities. The

Activity Narrative: outreach workers will collaborate closely with existing community health promotion volunteers and

reproductive health agents. In addition, CSP will work closely with FHI's community-level responses to

palliative and preventive care activities to further strengthen local ownership and capacity development of

indigenous partners. Finally, CSP will work closely with PEPFAR Ethiopia university partners and the World

Health Organization (WHO) to provide clinical mentoring at health centers.

The greater expansion of ART services through 240 health clinics throughout Ethiopia will allow for greater

access to care and services for PLWH, including most-at-risk populations. Program linkages through

palliative care and other activities will reach 500 health centers. The program will rely on HEW at health

posts to provide information, referrals, and counseling. The community-based HEW are key to identifying,

referring, and counseling most-at-risk populations. For example, HEW form the bridge between health

facilities and prisons, to assure that counseling and appropriate care are provided to incarcerated

populations. HEW and community outreach oriented workers provide out-of-facility counseling and care to

discordant couples. As community members, they know, develop relationships with, and can refer street

youth and persons who engage in transactional sex. They also are adept at identifying and referring mobile

populations - transport workers, traders -- to health facilities and/or support groups. In certain areas and/or

during times of drought, HEW work at gathering points such as for internally displaced persons (e.g., food

distributions) to provide messages, counseling, and referrals. Expansion of facilities for service provision will

allow the activity to reach a greater population and thus provide testing, treatment, care, and prevention

messages to the larger population and enable more people to access treatment. All HIV-positive clients on

pre-ART and ART service are potential targets of the services.

Local organization capacity will be built through the training of health facility staff and the support of health

centers for improvement of health systems, data collection and patient service. There will be close

collaboration with HAPCO/MOH, WHO, USG and PEPFAR university partners in standardizing and

updating HBHC related training materials and modules.

The implementation of performance-based contracting strategy under CSP, a novel approach in Ethiopia, is

believed to strengthen the capacity of partner organizations and, in particular, government stakeholders,

including RHB, zonal health departments and district health offices. The managerial capacity of these

groups is the key to the success of the program.

Care and Support Program

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care-and-support activity at primary healthcare units, health centers, and

satellite health stations in Ethiopia and provides coverage nationwide. This project will support the GOE to

provide HIV/AIDS prevention, care, and treatment services at health centers and at the community and

household levels by providing technical assistance, training in strengthening of systems and services, and

expansion of best practice HIV-prevention interventions.

This is a continuing activity from FY05 and FY06; it was previously implemented by Family Health

International (FHI) and launched in FY07 by Management Sciences for Health (MSH) as part of the CSP.

As of March 2007, FHI established 198 TB/HIV sites in the four major regions. FHI trained 40 health

workers in the management of dual TB/HIV infection. A total of 5,266 HIV-positive clients received treatment

for active TB in the 196 facilities. This figure is believed to be a gross underestimate as the National TB

monitoring and evaluation (M&E) system is currently functioning poorly.

According to the World Health Organization's (WHO) 2007 Global TB Control Report, the national estimate

of adult TB cases infected with HIV is 11%. Health-center and community-outreach activities are major

venues for case detection, diagnosis, care, and treatment in Ethiopia, where TB/HIV services are highly

decentralized. The government policy of decentralization demands that all health centers serve as providers

of TB diagnosis and treatment. This activity will continue to strengthen health centers and health posts—the

facilities that deliver most preventive and curative health services throughout Ethiopia. As part of the ART

health network, CSP-TB/HIV will link with network hospitals for referrals and work with clients and their

families in the community. It is anticipated that health centers will continue receiving TB referrals from

hospitals. Complex TB cases will be referred to hospitals. By September 2009, CSP-TB/HIV will be

established in 500 health centers linked to the 131 ART hospitals. Many of these sites overlap with existing

additional HIV counseling and testing (HCT) services, including the preventive-care package and ARV.

During FY06 and FY07, much experience was gained from health-center based TB/HIV activities. HCT has

been decreasing the HIV burden in tuberculosis patients. Cotrimoxazole preventive therapy (CPT) was

provided by FHI and the Global Fund to Fight AIDS, Malaria, and Tuberculosis (Global Fund) for TB

patients who are co-infected with HIV, and the patient referral system was improved. Gaps still exist:

integration between HCT and TB services requires continued support. Important lessons learned include:

(1) the need to strengthen patient referral systems; (2) the need for a case manager for HIV-positive

patients, to ensure that services required by individual patients were accessed, recorded, and monitored;

and (3) the need to facilitate the referral of patients "up the line" for ARV treatment centers in hospitals—as

well as referral of patients for follow-up services at health-center and community levels.

In FY08, CSP-TB/HIV will continue to coordinate with regional health bureaus (RHB) and USG partners

(including WHO) to provide regionally distributed trainings on providing TB/HIV services, including:

opportunistic infection (OI) counseling; bi-directional referral systems between TB, voluntary counseling and

testing (VCT), OI, family planning (FP), and sexually transmitted infections (STI) services through a case

manager; data management; and customer service, performance standards, and ethics. These trainings will

use using nationally accepted curricula and will be offered to public health providers, including VCT

counselors and laboratory technicians. TB/HIV interventions are a key component of the preventive-care

package. Health centers provide TB diagnosis and treatment through the Directly Observed Therapy - short

course (DOTS) strategy and VCT services.

In FY08, PEPFAR-supported TB clinics will conduct the following: (1) all TB patients will be offered provider-

initiated counseling and testing (PICT), using an opt-out strategy; (2) co-infected patients will receive

ongoing counseling along with their TB drugs; (3) after the intensive phase of TB treatment, patients will be

referred formally to the ART treatment center for ARV evaluation; (4) co-infected patients will be provided

with preventive-care services at the health-center and community levels; and (5) VCT clients will receive TB

screening and formal referral to the TB clinic for diagnosis and treatment if necessary. The issue of

provision of isoniazid prophylactic therapy (IPT) at health-center levels needs further consultation. Its

feasibility can be assessed in a selected number of health facilities to guide future policy decisions.

In FY08, CSP-TB/HIV will support 500 health centers to diagnose and treat 36, 000 TB patients, 94% of

whom will receive HIV counseling and testing services. Of the 220,000 HIV-positive clients expected to

receive palliative care services at health centers, 100% will receive routine, symptomatic TB screening.

Screening is based on sign/symptom review and acid fast bacilli (AFB) smear microscopy for patients with a

history of productive cough of more than two weeks. Patients with signs and symptoms suggestive of active

TB will undergo proper diagnostic workup. TB patients who test positive for HIV will be immediately linked to

pre-ART and ART services, as appropriate.

The results of TB screening among HIV-positive clients receiving palliative care will be recorded in the pre-

ART and ART registers at health centers. The results of HIV screening among active TB patients will also

be captured in the quarterly TB reports. Program performance will be monitored every quarter, under

leadership of the district health office and RHB. Supportive supervision will be provided by the RHB staff

and experts from implementing partners. National and regional TB/HIV review meetings will be held on

regular basis. Increasing case detection by providers at health centers and within the community

(specifically family-oriented case detection) is critical. Social mobilization activities will be supported through

outreach workers who will establish relationships at health posts with health extension workers (HEW).

They will provide community groups and households with HCT referral, adherence support, and TB/HIV

information-education-communication/behavior-change communication (IEC/BCC) messages. CSP-TB/HIV

interventions will have outreach workers and HEW who will screen people living with HIV/AIDS (PLWH) for

TB based on symptoms and refer suspected cases to health centers for diagnosis. They will also counsel

TB/HIV patients to adhere to TB treatments, and confirm that TB/HIV patients receive HCT and CPT.

The CSP-TB/HIV approach conforms to the PEPFAR Ethiopia five-year strategy of building up the public

health sector and of promoting a set of internationally accepted TB/HIV interventions in the ART health

network.

Activity Narrative: The activity is linked to PSP/Abt program, WHO, and US university TB/HIV activities, as well as with other

activities within the CSP project to extend service delivery of counseling, testing, diagnosis, and treatments

to underserved community members. The activity also links with the Ethiopian Ministry of Health, RHB, and

PEPFAR Ethiopia.

The target populations of most-at-risk populations will be reached through expansion of available facilities.

In addition, social mobilization activities conducted by the HEW will allow for greater reach within the

community.

Local organization capacity will be built through the training of health facility staff and the support of health

centers for improvement of health systems, data collection, and patient services.

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities ,in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health-network care-and-support activity in Ethiopia and provides coverage nationwide.

This program will support the GOE to provide HIV/AIDS prevention, care, and treatment services at health

centers and at the community and household levels through provision of technical assistance, training in

strengthening of systems and services, and expansion of best practice HIV prevention interventions. The

program is implemented by Management Sciences for Health (MSH) and several partners.

PEPFAR Ethiopia supports the scaling up of counseling and testing (CT) services to enable Ethiopia to

reach its targets for prevention, care, and treatment. PEPFAR Ethiopia currently assists voluntary

counseling and testing (VCT) centers based in hospitals, health centers, workplaces, and stand-alone sites.

The CSP provides rapid expansion of health services among three progressively more comprehensive tiers.

The first tier (500 health centers) offers basic services, including tuberculosis (TB)/HIV and VCT. The

second (393 health centers) offers TB/HIV, VCT and palliative care services. The third tier (240 health

centers) offers ART, as well as the above services.

Rapid expansion of HIV/AIDS care and treatment services has prompted a significant increase in VCT

nationwide through PEPFAR-funded activities, such as Family Health International's (FHI) IMPACT project,

Save the Children Federation/US (Save/US) project along the Addis Ababa- Djibouti High-Risk Corridor and

hospitals supported by US university partners. This support has encompassed assessment of existing

services and implementation with respective regional health bureaus (RHB). The number of VCT centers

continues to increase, and the Ministry of Health (MOH) plans to have at least one VCT center per health

center and per hospital. The national counseling and testing guidelines are being revised to include provider

-initiated counseling and testing (PICT), engagement of non-medical counselors, and other important

issues.

PEPFAR Ethiopia will support health centers to implement the new GOE guidelines and maintain support to

existing health-center VCT services and scale up CT services through PICT and involvement of non-

medical counselors. Moreover, case managers will link all VCT services supported by this program to a

specific, functioning, referral system, to ensure that HIV-positive clients are linked to care and treatment

services.

In FY07, PEPFAR Ethiopia provided technical assistance to 500 health centers nationwide through the

previous mechanism. The technical assistance included: support for HIV VCT by medical and non-medical

counselors and PICT services; quality assurance of counselor performance, including in-service

performance improvement; screening for active TB among VCT/PICT clients; outreach services to target

most-at-risk populations (MARPs) in surrounding areas; quality HIV tests, including implementation of

simpler techniques (e.g., finger-pricking instead of venous puncture) to collect samples (once approved by

national authorities); and routine quality assurance and quality control of laboratory services mechanisms.

This activity will also build local capacity and continue to improve upon CT services in a sustainable manner

through training-of-trainers (TOT) programs on HIV testing and counseling for regional-, zonal-, and district-

level master trainers. Technical assistance for Human-resource capacity building will include the training of

five counselors per health center, followed by refresher training and site-level cross-training to facilitate

knowledge transfer and sustainability. CSP will also help to ensure the consistent availability of HCT

services at the health centers by advocating availability of full-time medical or non-medical counselors.

Data collection and maintenance will be enhanced by: ensuring the availability of standard registration

books and client intake forms; supporting site-level data analysis, use, and timely reporting to public health

authorities; strengthening regular supportive supervision by regions, zones, and districts; and conducting

regional and national review meetings to discuss best practices, strengths, weaknesses, challenges and the

way forward to establish sustainable VCT services.

CSP will partner with PEPFAR commodity logistics programs implemented by Rational Pharmaceutical

Management Plus (RPM+—ID 10534) and Partnership for Supply Chain Management (PfSCM—ID 10532)

to support facilities, districts, zones, and regions to ensure a consistent supply of HIV test kits, as well as to

support regular quality control of HIV tests in partnership with national, regional, and sub-regional

laboratories. This activity will also work to improve the quality of HIV/AIDS counseling services through

integration of standard self-reflection and peer-supervision tools in all health centers supported by this

mechanism.

The strengthening and expansion of CT service delivery through a greater number of health centers will

enable the program to extend its reach into the community. The TOT will assist in the creation of a larger

cadre of qualified health facility workers and continue to increase the capacity of the program as a whole.

This activity will also support the linkage of VCT services with HIV/AIDS prevention, care, and treatment

services with strong emphasis on "prevention for positives" counseling and strong linkages with community-

based HIV/AIDS services through case managers, health extension workers (HEW), and outreach workers.

Youth and adults will be reached by this activity through the increase of quality services available in a

greater range of communities through a variety of healthcare facilities. A greater percentage of the

community will have access to care and support because health-center-level services will be available at a

more localized level. The program will rely on HEW at health centers to provide information, referrals, and

counseling. The community-based HEW are key to identifying, referring, and counseling MARPs. For

example, HEW form the bridge between health facilities and prisons, to assure that counseling and

appropriate care are provided to incarcerated populations. HEW and community-outreach-oriented workers

provide out-of-facility counseling and care to discordant couples. As community members, they know,

develop relationships with, and can refer street youth and persons who engage in transactional sex. They

also are adept at identifying and referring mobile populations (e.g., transport workers, traders) to health

facilities and/or support groups. In certain areas and/or during times of drought, HEW work at gathering

points, such as those for internally displaced persons (e.g. food distributions), to provide prevention

messages, counseling, and referrals.

The activity will build significant local organizational capacity through the training of health facility staff and

Activity Narrative: the support of health centers for improvement of health systems, data collection, and patient service.

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care and support activity at primary healthcare unit level, health center and

satellite health post, in Ethiopia and provides coverage nationwide. This project will support the GOE to

provide HIV/AIDS prevention, care, and treatment services at health centers and at the community and

household levels through provision of technical assistance, training in strengthening of systems and

services, and expansion of best practice HIV-prevention interventions.

This is a continuing activity from FY07 previously conducted by FHI. It continues the expansion of ART

decentralization to health centers. FHI coordinated the assessment of 120 health centers for ART- site

readiness and trained 402 health professionals in seven regions, in close collaboration with World Health

Organization (WHO). This activity is linked to care and support, ARV Services, and technical support for

ART scale-up, allowing PEPFAR Ethiopia to meet ART targets and to ensure quality of care through fully

functional HIV service networks. The fund increase from FY07 funding is attributable to the gross

underestimate for the activity in FY07, and the further decentralization of ART services to 120 additional

health centers in FY08. Experience from FHI ART decentralization service support revealed that

coordination of services at facility level, organizing regional and catchment meetings, capacity building,

refurbishing facilities to provide the minimum clinical services, and coordinating clinical mentoring and

supportive supervision cost much more than originally planned.

The GOE recently rapidly expanded access to ART at health centers. A site-readiness assessment was

carried out by the USG at 120 health centers. Human resources consisted, on average, of one health

officer, one lab technician, and a few nurses at each site. Health-center ART readiness is hampered by

basic infrastructure inadequacies in human resources, and by limited administrative capacity of district

health offices and regional health bureaus (RHB).

The GOE remains committed to implementing HIV care and treatment services, including ART, at health

centers. Without adequate investment in operational readiness, the quality of ART care for patients will be

compromised. This activity increases operational capacity to manage ART services, including integration

into the health network. ART services will be supported with the following activities: operational site

readiness; commodities; health management information system (HMIS); refurbishing of facilities and

provision of equipment; network implementation; and support to nurse-centered ART service delivery at the

health-center level.

Operational site readiness will increase through human resource development. Human resources will be

strengthened through training in multiple program areas and supportive supervision in conjunction with GOE

personnel. The activity will facilitate training on HIV disease management and ART services, including

adherence counseling, nutrition, case management, laboratory and pharmacy services. In close

collaboration with RHB and district health offices, standard operating procedures will be implemented with

other relevant stakeholders and partners. To strengthen clinical management in the ART health network,

mentoring and monitoring of ART patients with experience will be organized based on the national clinical

mentoring guidelines. This will help to build provider capacity to manage patients and improve patient care.

The activity will complement the focused activities of USG partners in supply chain and pharmacy

management, collaborating with RPM Plus and the Supply Chain Management System (SCMS) to ensure

that their interventions achieve maximum impact at site level. The project will work with relevant PEPFAR

Ethiopia partners and key stakeholders such as the HIV/AIDS Prevention and Control Office (HAPCO),

implementer of the Global Fund to Fight AIDS, Tuberculosis (TB) and Malaria grants, complementing their

efforts to strengthen laboratory services at 240 ART sites.

Site-level ART patient monitoring will be enhanced through collaboration with Tulane University's health-

center-level HMIS activities supporting an ART patient-tracking system. Tulane will train data clerks in this

paper-based system. Community networks supporting adherence, follow-up, and new patient intake will be

strengthened. This activity will also support community-based organizations to strengthen monitoring for

ART adherence and follow-up. This will facilitate multi-agency referral channels for clinical and non-clinical

services to reinforce the existing continuum of care and treatment.

Infrastructure and equipment need to be available and adequately maintained. This activity will assess and

prioritize renovation needs at health centers in collaboration with Crown Agents, to ensure a synchronized

scale-up of ART service capacity in high client flow sites. There will a needs assessment to look at what

basic medical equipment is required to support delivery of a minimum ART service package. In addition,

procurement coordination with district health offices and USG partners will leverage Global Fund resources.

Network implementation will be a patient-centered approach. This activity will be linked with multiple

services in health centers and hospitals to support integrated ART services. Furthermore, this will be

integrated with the CSP activities, linking households and community members to the health networks

through outreach efforts by USG and GOE supported community outreach workers, community-based

organizations, private providers and case managers.

This activity will support ART services at 240 health centers. By the end of FY08, through linked activities

within palliative care, services will be extended to support 500 health centers and community-based care.

The CSP provides rapid expansion of health services among three progressively more comprehensive tiers.

The first tier, 500 health centers, offers basic services including TB/HIV and voluntary counseling and

testing (VCT). The second, with 393 health centers, offers TB/HIV, VCT and palliative care services. The

third tier, at 240 health centers, offers ART as well as the above services (see the Annex- for more details).

This activity will support all links in the ART and care network continuum, from patient and household to

community, health center and hospital, with a focus on the delivery of ART services at the health center and

community level. This activity will facilitate patient receipt of critical lab results. By leveraging previous

PEPFAR investments at the hospital level, laboratory linkages to hospitals will be maximized to ensure that

patients who present with complicated diagnoses will receive further laboratory services, with specialized

equipment at hospitals functioning optimally through effective health network implementation.

This activity also provides support to nurse-centered ART service delivery at health-center level through I-

TECH, University of Washington and Hadassah University, Jerusalem. FHI's ART site readiness

Activity Narrative: assessment showed that highly capable nurses are present in larger numbers at the health centers

assessed, though more personnel of all types are needed. The MOH is supporting the initiation of nurse-

centered HIV/AIDS services, featuring task-shifting, particularly in the area of ART services. The Hadassah

University AIDS Center (HAC), supported ART service delivery at the hospital level for the last two years in

collaboration with I-TECH, has implemented training of trainer (TOT) courses in integrated HIV/AIDS patient

care. Forty Ethiopian physicians, nurses and laboratory staff have been trained in Israel. To support the

decentralization of ART services, MSH will collaborate with the HAC, WHO, and the four US universities

supported by PEPFAR Ethiopia. MSH will support Hadassah in identifying nurses to be trainers supporting

nurse-initiated ART, and will coordinate with these personnel to support follow-up activities in Ethiopia. MSH

may also collaborate with Hadassah in designing and implementing the evaluation of the nurse-centered

ART model, focusing on programmatic factors that may affect ART effectiveness.

The CSP will collaborate with existing treatment partners so as not to duplicate ongoing PEPFAR Ethiopia

and Government of Ethiopia activities. This activity will expand on the delivery of treatment services, access

to care and human resource development.

The expansion of ART services through 240 health clinics throughout Ethiopia will allow for greater access

to care and services for PLWH. Project linkages through other program activities will enable a reach into

500 health centers. Expansion of facilities for service provision will allow the activity to provide testing,

treatment, care, and prevention messages to the larger population.

The emphasis on in-service training, task-shifting, and a greater retention strategy is integral to this activity.

These areas will be addressed through provision of training for healthcare workers and the strengthening of

systems and infrastructure at the health-center level.

HIV Care and Support Project

The HIV Care and Support Project (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health-network care-and-support activity in Ethiopia at the primary healthcare-unit level and

at health centers and satellite health posts; it provides coverage nationwide. This program will support the

GOE to provide HIV/AIDS prevention, care, and treatment services at health centers and at the community

and household levels through technical assistance, training in strengthening of systems and services, and

expansion of best practice HIV-prevention interventions.

The CSP laboratory component will involve site-level laboratory support in 240 health centers. The program

complements other PEPFAR Ethiopia efforts to strengthen laboratory capacity nationally by working through

the Ethiopian Health and Nutrition Research Institute (EHNRI). The focus of PEPFAR Ethiopia activities has

been to strengthen central and regional laboratories and install an external quality assurance (EQA)

program. There are encouraging results in some regions in institutionalizing EQA, and efforts should be

strengthened to expand the program at health-center level. The proposed CSP laboratory component at the

240 health centers in which CSP is also providing comprehensive HIV/AIDS services, including ART, is

designed to complement and strengthen the national EQA work with respective regional reference

laboratories (RRL) and EHNRI.

The facility-level, comprehensive, laboratory-support activities have been conducted in collaboration with

EHNRI, RRL, CDC, and US universities. They include:

1) Organizing training for lab staff at health-center level on laboratory diagnosis of integrated diseases

(including common opportunistic infection (OI) diagnosis using centrally developed and standardized

training modules)

2) Making standard operational procedures (SOP) available at individual labs and providing the necessary

mentorship and supportive supervision to ensure staff abide by the SOP

3) Working with EHNRI, RRL, the Partnership for Supply Chain Management (PFSCM) and Rational

Pharmaceutical Management Plus (RPM+) to have an uninterrupted supply of laboratory commodities,

including rapid test kits, reagents and equipment

4) Working with EHNRI, RRL and relevant partners to have a functional recording and reporting system,

including establishing/strengthening a tracking system for samples and results

5) Facilitating the collection of samples for transport through RRL/EHNRI funding for tests at higher level;

and ensuring that results of samples sent to higher level are received on time.

Management Science for Health/Community Support Program is also expected to be engaged in improving

laboratory layout, work flow, gap identification, and system strengthening.

MSH/CSP will facilitate the renovation of health center laboratories to expand the uptake and improve

quality of the services. As stated above, MSH/CSP will also support integration of OI diagnosis, including

improvement of TB microscopy.

The CSP laboratory component is part of CSP's overall health-systems-strengthening component. The CSP

implementing partner, MSH, will recruit and hire a lab strengthening advisor with intimate knowledge and

experience within the Ethiopian health system and with an advanced degree in laboratory services. The

advisor's primary responsibility will be to coordinate and supervise all laboratory-strengthening activities at

the health centers. Working together with the PEPFAR Ethiopia and EHNRI staff, this advisor will take

existing laboratory standards for regional labs and adapt them to meet the situation of the health-center labs

(if these standards already exist, CSP will use those). The laboratory standards will be incorporated into

CSP's standards-based-management performance-quality-improvement tool for health centers, called the

Fully Functional Service Delivery Point (FFSDP) tool. The FFSDP contains nine standards in various

functions critical for high-quality health-center services, with appropriate criteria for each. The new health-

center lab standards will be incorporated into the FFSDP as one of the critical standards.

During FY08, MSH/CSP will train regional health bureau (RHB) and district health office (DHO) staff in the

application of this tool to the health centers selected to provide ART. In collaboration with RHB and DHO

staff, CSP will undertake an FFSDP baseline evaluation which will identify any laboratory deficiencies for

the health center. CSP will then collaborate with those staff to develop an intervention plan to address the

deficiencies. The FFSDP will be applied twice more over a 12-month period to assist the health center to

improve standards compliance and to assist the RHB/WHB personnel to monitor progress.

CSP will use performance-based contracting to provide technical assistance and support to assist the

laboratories to meet the standards. CSP pans to use a competitive process to outsource laboratory training

and support to a local organization with the capacity to train lab staff, help install the EQA programs,

develop preventive maintenance and replacement programs for lab equipment, and assist with the supply of

reagents and other supplies locally. Once in place, the contract with this local organization will support the

health centers to achieve 80% or greater of the lab standards. That will be the performance standard

included in the contract. CSP will award another set of performance-based contracts to the RHB and DHO

to improve health-center adherence to the standards. Through the contracts, the RHB and DHO will have

the responsibility and the resources to improve health-center operating conditions, including staff shortages,

renovations, equipment, or other structural issues.

In addition, CSP will establish standards for handling of laboratory specimens in the facilities in which it

works, and safe transport to RRL for tests not available in the health centers, such as CD4 counts and viral

load. Specimen transport is currently the responsibility of the university PEPFAR partners. CSP plans to

work closely with these PEPFAR partners to ensure health centers adhere to the appropriate standards for

specimen preparation and transfer—this will also be incorporated into the lab standards.

Through application of the FFSEP standards at the health-center level, coupled with performance-based

contracting with both private and public local organizations and collaboration with other PEPFAR partners

(such as EHNRI, PfSCM, and the universities), CSP expects to show and measure significant improvement

in health-center laboratory capabilities over time. This high-quality laboratory support to the health centers is

essential to the provision of high-quality, comprehensive HIV/AIDS services, including ART, throughout the

health network.

Activity Narrative: HIV Care and Support Project

The Care and Support Program (CSP) is a three-year effort to focus on HIV/AIDS at health centers and

communities in partnership with PEPFAR Ethiopia partners and the Government of Ethiopia (GOE). CSP is

PEPFAR's lead health network care-and-support activity in Ethiopia and provides coverage nationwide. This

program will support the GOE to provide HIV/AIDS prevention, care, and treatment services at health

centers and at the community and household levels through technical assistance, training in strengthening

of systems and services, and expansion of best-practice HIV-prevention interventions. The program is

implemented by Management Sciences for Health (MSH) and several partners.

This is a continuing activity from FY07. This strategic information activity will strengthen implementation of

the national Health Management Information System (HMIS) and the use of data at the site level for

programmatic improvement.

In FY07, MSH/CSP will conduct an assessment to determine the status of data use at health centers and

district health offices. The assessment will help to clarify the existing situation in relation to data use and

identify constraints as well as best practices. The assessment will look at human resource issues in terms

of: availability and skill levels, organizational policies and structures, and existing infrastructure for data

management. The findings will aid MSH/CSP to design an effective and focused intervention to improve the

data management skills of health center and district health office staff. The program will begin

implementation in FY07 and will serve 267 health centers that are providing voluntary counseling and

testing (VCT), PMTCT and tuberculosis (TB)/HIV services.

This activity will focus primarily on health centers that are undertaking HIV/AIDS interventions including

VCT, ART, and PMTCT. It will work within existing systems, such as the national monitoring and evaluation

framework, and link with other health facilities in the network model with the aim of enhancing information-

sharing for program improvement. District health bureaus will also be supported to build their capacity in

data management.

In FY08, MSH/CSP will provide training to appropriate health-center staff on data entry, data cleaning, and

data analysis techniques of HMIS and the national HIV/AIDS Monitoring and Evaluation system. Hands-on

training will be provided on basic computer packages for capturing and analyzing patient data. Where

computers are not available or feasible, effective use of manual systems will be promoted. This activity will

include training on report writing and data presentation techniques to ensure staff are able to successfully

communicate accurate and practical status reports that reveal both problems and success stories.

Information should be used for decision-making at the point of source. To that effect, staff will be trained on

how data are used to improve program and service delivery, and how to measure progress of programs.

Sites will receive technical assistance to conduct routine data quality assessments to ensure the validity and

reliability of data coming from the facilities. Data use at the point of origin will foster data quality,as it will be

easier for staff to identify errors and make appropriate corrections.

Health facility staff will be trained to use the national HIV/AIDS monitoring and evaluation framework, and

the associated data capturing and reporting formats. Once the new HMIS starts full operation, this activity

will coordinate with the HMIS reform to facilitate adoption of the new tools. Facility staff will also be trained

to develop their own monitoring and evaluation plans, which will promote effective communication and

utilization of information within and outside of the health centers. Regular data review meetings at different

levels will be promoted and supported, including training in dynamic and participative methodologies for

presenting and analyzing information for decision-making.

Computers, printers, and related information-communication technology equipment will be supplied to the

facilities, as appropriate, for local conditions based on assessment findings on existing gaps. Protective

measures such as voltage regulators, surge protectors, grounded electrical lines, and antivirus software, will

be included in all cases.

The program will enable staff at health facility and regional/zonal/district health office levels to properly use

and manage data. Sites will be further enabled to appropriately tabulate and visualize their data so that they

will be capable of making sense of the data they generate and be able, in the long run, to make evidence-

informed decisions supporting all facets of the HIV/AIDS program. This strategy fits with the GOE plan to

improve monitoring and evaluation (M&E) and HMIS in Ethiopia. It will also be instrumental in the

implementation of the performance-based contracting scheme of MSH at health centers and regional/district

health offices.

This activity will build on best practices modeled from the national HMIS support activity (10413). In

addition, it will collaborate with and expand on the site level data support by US universities (ID 10427, ID

10433, ID 10437, ID 10440) and the Global Fund for AIDS, Malaria, and Tuberculosis. This activity is in line

with the National HMIS rollout plan led by MOH.

Local organization capacity building will be improved through training of staff, provision of needed material

inputs such as computers, and support for activities such as supportive supervision and catchment area

meetings. Strategic Information will be supported in the same ways. The program will target 300 health

centers and 100 district health offices with two individuals being drawn from each organization to participate

in the trainings.