PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
PMTCT Services at Hospital and Health Center Level by Region - Johns Hopkins University
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
This is a continuing activity from FY08. In FY08 JHU has supported PMTCT program at 34 health facilities
in Addis Ababa, Benshangul- Gumuz, Gambella and the Southern Nations, Nationalities, and Peoples
Regions (SNNPR). JHU TSEHAI expanded and enhanced interventions to prevent Mother-to-child
transmission and to link HIV-positive pregnant women and their families to comprehensive HIV care and
treatment services. The SAPR indicates that the partner has achieved all its PMTCT targets for the two
quarters. The partner has adopted innovative mechanisms like outreach ANC/PMTCT service delivery and
assignment of case managers to facilitate effective PMTCT service provision at facility level. It has also
played significant role in supporting FHAPCO to strengthen the national Program leadership. JHU TSEHAI
is still working to build PMTCT coordination capacity through secondment of a PMTCT advisor to the FHD
at the Ministry of Health. Furthermore, JHU has actively participated in the rolling out of the revised national
PMTCT Guidelines.
In FY08, JHU experienced high staff turn over at facility level and interruption in the supply of test kits. The
weak M&E system for PMTCT and PMTCT registers not capturing some important indicators on PMTCT
program has also affected the partner's performance. Very low ANC attendance rate, loss to follow up of
mothers and infants, low male involvement in PMTCT program and need for renovation of labor and
delivery at most PMTCT sites are some of the challenges that the partner faced in the last fiscal year.
In FY 09, JHU will work to address the above challenges and will also build on FY 08 activities and continue
strengthening the PMTCT program at 45 health facilities in Addis Ababa, SNNPR, Benshangul Gumuz and
Gambella regions. In FY 09 JHU will scale up the PMTCT program in addition to the FY 08 planned
activities by including the following:
1)Support the transitioning of the national PMTCT program from Federal HAPCO to the Family Health
Department (FHD) of the Federal MOH through active participation in the national PMTCT TWG and also
support integration of PMTCT with MCH services
2)Support regional health bureaus and PMTCT TWG to build PMTCT program management capacity at a
regional level and ensure sustainability. JHU will second a PMTCT advisor to SNNPR Regional Health
Bureau to assist in the scale-up, integration, coordination, quality assurance and oversight of PMTCT
program.
3)Promote the use of PMTCT TC Support tools at all PMTCT sites.
4)Expand outreach PMTCT services focusing on higher prevalence areas to reach large number of women
not coming to health facilities for ANC or delivery
5)Support strategies and program plans to coordinate Prevention With Positives (PWP) with PMTCT
6)Expand Mothers' Support Group (MSG) to additional 10 sites
7)Assist to strengthen the PMTCT M&E system: JHU will assist the national and regional PMTCT program
to improve data collection and reporting on key PMTCT indicators
COP08 ACTIVITY NARRATIVE
This is a continuing activity from FY07. In FY07, Johns Hopkins University/ Technical Support for the
Ethiopia HIV/AIDS ART Initiative (JHU TSEHAI) supported PMTCT services in 30 hospital networks in
Addis Ababa, Benshangul- Gumuz, Gambella and the Southern Nations, Nationalities, and Peoples
Regions (SNNPR). JHU TSEHAI expanded and enhanced interventions to prevent prenatal and
postpartum transmission, and to link HIV-positive pregnant women and their families to comprehensive HIV
care and treatment services. In FY08, JHU will extend these services to a total of 42 health facilities,
working to dramatically reduce the number of infants born with HIV, in collaboration with the Federal
Ministry of Health (MOH) and regional health bureaus (RHB) of target areas.
Accordingly, JHU will provide PMTCT services at five hospitals in Addis Ababa, two hospitals and 11 health
centers in Benshangul-Gumuz, one hospital and six health centers in Gambella, and 17 hospitals in
SNNPR. JHU uses antenatal care (ANC), maternal/neonatal/child health (MNCH), and PMTCT programs as
entry points to HIV care and treatment for women, children, and families. The Government of Ethiopia has
recently issued revised national PMTCT guidelines, and JHU, in collaboration with JHPIEGO, will support
the rollout of the new PMTCT guidelines in these regions. Major areas of emphasis include: integration of
PMTCT with MNCH services and HIV prevention, care, and treatment programs; provider-initiated, routine,
opt-out HIV testing and counseling at ANC and labor and delivery; implementation of more potent and
complex PMTCT regimens; prompt clinical and immunologic staging of HIV-positive pregnant women and
rapid initiation of ART for eligible patients; enhancing the quality of infant-feeding initiatives; strengthening
systems for PMTCT service delivery; and supporting human resources by providing high-quality training and
clinical mentoring.
JHU will work to support PMTCT programming at the national, regional, and site levels. At the national level,
as a member of the National Technical Working Group on PMTCT, JHU will contribute to the development
of training materials, clinical support tools, guidelines, formats, and standards. JHU will continue to provide
technical input and guidance to the MOH and RHB, supporting initiatives to expand PMTCT beyond single-
dose nevirapine (SD-NVP) where appropriate, enhancing PMTCT-plus training, and supporting links
between PMTCT programs, HIV care and treatment programs, and pediatric services. At the facility level,
the JHU-supported package of PMTCT Plus/family-focused care includes:
1) Support for linkages between healthcare facilities and community-based implementing partners, including
PLWH organizations, to promote uptake of antenatal and PMTCT services and to support follow up of
infants enrolled in early infant diagnosis (EID) programs
2) Enhanced linkages between ANC, MNCH, PMTCT, family planning (FP), STI, and HIV care and
treatment clinics at the facility level
3) Promotion of partner testing and a family-centered model of care, using PMTCT as an entry point to HIV
services for mothers, children, and families
4) Routine, opt-out HIV testing and counseling at ANC, labor and delivery according to national guidelines
5) Active case-finding within families and households using a simple, validated tool—the Family Enrollment
Form
Activity Narrative: 6) Adherence and psychosocial support and enhanced follow-up and outreach services for pregnant women
testing positive for HIV to encourage retention in care. In collaboration with JHPIEGO, implementation of
peer-educator programs and Mothers' Support Groups (MSG) at selected sites, to maximize adherence to
care and treatment among pregnant HIV-positive women, and to strengthen their links to psychosocial
support and community resources.
7) Provision of a basic care package for all HIV-positive pregnant women, including patient education, TB
screening, prophylactic cotrimoxazole (CTX) when indicated, nutritional support (see below), insecticide-
treated bed nets, condoms, and safe water in coordination with the Global Fund to Fight AIDS, Malaria, and
Tuberculosis (Global Fund) and other partners
8) Routine assessment of all HIV-positive pregnant women for ART eligibility using clinical staging and CD4
testing, and provision of prophylaxis and treatment as appropriate, including ART when indicated
9) Nutritional education, micronutrient (MVI) supplementation, and "therapeutic feeding" for pregnant and
breastfeeding women in the six-month postpartum period
10) Enhanced postnatal follow-up of HIV-positive mothers and HIV-exposed infants
11) Promotion of infant-feeding initiatives and healthy infant-feeding practices by facilitating on-site trainings
and mentoring of MNCH staff (including traditional birth attendants) on safe infant-feeding practices in the
context of HIV, developing infant-feeding support tools, and establishing infant-feeding MSG
12) Linkages of all infants born to HIV-positive women to the HIV-Exposed Infant Clinic to ensure EID by
DNA PCR using dried-blood spot (DBS) testing. Enhanced laboratory capacity for infant diagnosis at
selected facilities and strengthened linkages with regional labs at remaining facilities (see the laboratory
narrative). Initiation and expansion of the clinical and health-management information systems (HMIS)
needed to implement EID services
13) Ensuring that HIV-exposed infants are enrolled in care and receive prophylactic CTX, immunizations,
nutritional support, careful clinical and immunologic monitoring, monitoring of growth and development, and
ongoing assessment of eligibility for ART
14) Determination of infection status at 18 months of age for HIV-exposed infants not found to be HIV-
positive via EID
15) Facilitate availability of supplies for PMTCT services
16) Support for site-level staff to implement national performance standards and the JHPIEGO-supported
Standard-based Management Program
17) Provision of PMTCT-Plus training to multidisciplinary teams at the facility level
18) Provision of ongoing clinical mentoring and supportive supervision in partnership with RHB
19) Ongoing development and distribution of provider job aids and patient-education materials
20) Routine monitoring of PMTCT-plus programs, reporting of progress against targets, and ongoing
assessment of linkages within facilities (from PMTCT to ART clinics, for example) and uptake of services by
family members
21) Support for the availability and correct usage of PMTCT registers and forms, HIV-exposed infant
registers and follow up cards, timely and complete transmission of monthly reports to regional and central
levels, and appropriate use of collected data
22) Minor renovation, refurbishing, and repair (as needed) of ANC, labor and delivery rooms, and maternity
wards at JHU-supported sites
23) Radio and TV outreach campaigns and use of information-education-communication/behavior-change
communication (IEC/BCC) materials in local languages to enhance public awareness and use of ANC,
MNCH, PMTCT and HIV care & treatment services
In FY07, JHU-TSEHAI also implemented an initial pilot program to support infant-feeding practices in the
postpartum period. In FY08, this activity will continue as before, but will incorporate the following expanded
activities: (1) Expansion to SNNPR by linking with Intrahealth/JHPIEGO to introduce MSG at hospital level
for ongoing feeding support; (2) Supporting institutions to become baby friendly hospitals that promote
exclusive breastfeeding; (3) Training counselors and nurses in this activity; and (4) Training HIV-positive
mothers and family members in optimal feeding at all hospital sites.
JHU, in collaboration with Addis Ababa University, had followed more than 1,000 HIV-positive women and
their infants who were in a clinical trial for PMTCT. Review of feeding practices showed that although good
infant-feeding counseling was provided by trained healthcare staff, less than 50% of those who chose to
breastfeed were exclusively breastfeeding beyond three months. Appropriate ongoing counseling by
healthcare providers, mother-to-mother support groups, and involvement of family members would provide
a vehicle to promote and support optimal breastfeeding practices for mothers who are breastfeeding. The
proposed FY08 continuation activities include: (1)Assessment and improved current breastfeeding
counseling practices; (2) Targeting pregnant women in the antenatal period to counsel on infant-feeding ;
(3) Collaborating with partners on revising and updating current infant-feeding guidelines and manuals; (4)
Assessing and supporting factors that promote optimal breastfeeding such as maintaining breast health and
appropriate breastfeeding (positioning, attachment, etc.), developing IEC materials on exclusive
breastfeeding, ensuring maternal health and nutrition status, and family support; and (5) Training MSG to
ensure ongoing support for optimal infant-feeding and support for exclusive breastfeeding. JHU proposes
to train 150 counselors and nurses and 300 mothers and family members on optimal feeding options.
Additional narrative to COP08 narrative: This activity will provide support for outreach ANC/PMTCT
services. It will train health care workers to provide ANC and PMTCT services to the hard-to reach rural
communities. Trained nurses based at a hospital and health center and Health extension workers will be
involved to provide outreach PMTCT services. Community level PMTCT activities will be linked to the near-
by Hospital or Health center PMTCT programs through referral linkages and establishment of catchments
area networks. Experiences elsewhere and in Ethiopia (JHU and IntraHealth) have shown that outreach
PMTCT services can effectively be utilized to improve the uptake of PMTCT services. JHU will be involved
in the expanding outreach PMTCT services in Addis Ababa, Gambella, Benishangul and SNNPR regions.
New/Continuing Activity: Continuing Activity
Continuing Activity: 16631
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
16631 5641.08 HHS/Centers for Johns Hopkins 7485 3787.08 Support for $1,100,000
Disease Control & University program
Prevention Bloomberg School implementation
of Public Health
through US-
based
universities in
the FDRE
10632 5641.07 HHS/Centers for Johns Hopkins 5484 3787.07 FMOH $482,760
Disease Control & University
Prevention Bloomberg School
5641 5641.06 HHS/National Johns Hopkins 3787 3787.06 $100,000
Institutes of Health University
Bloomberg School
Emphasis Areas
Gender
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* Malaria (PMI)
* Safe Motherhood
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $20,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
APRIL 2009 REPROGRAMMING
Strengthening STI Services for MARPs
As a result of the Prevention Portfolio Review, we have determined this activity to have 20% AB component
from the previous 100% OP activity.
Expand access to PLHA and other MARPs to comprehensive STI care and treatment services at 76 sites in
Addis Ababa, SNNPR, Benishangul and Gambella regions.
Prevention of sexually transmitted infections (STI) among most-at-risk populations (MARPs) and people
living with HIV (PLWH) is a critical activity in preventing new HIV infections and slowing the pace of the
epidemic. During FY07&08, Johns Hopkins University Bloomberg School of Public Health (JHU-BSPH)
supported STI activities to Addis Ababa, Benishangul-Gumuz, Gambella, and Southern Nations,
Nationalities, and Peoples (SNNPR) regions. The support included: training healthcare providers on
syndromic management of STI, and providing technical assistance to implement the syndromic approach at
hospital level. Development of a work plan and an assessment tool to identify the sources of STI treatment
and prevention activities at the hospital level; Coordination with Regional Health Bureaus (RHB) to help
facilitate and coordinate linkages between STI and HIV/AIDS services, and strengthen external referral
linkages between hospitals, health centers, and community service organizations (CSO), faith-based
organizations (FBO) and PLWH support groups and associations. A recent study by CDC/EPHA in
selected urban and rural areas identified a number of barriers that limit the utilization of STI services in the
country, operating at individual, community, health facility, and policy/program levels. These include: at
facility level space problems, shortage of basic functioning diagnostic equipment, failure to implement
syndromic management guidelines, lack of BCC/IEC materials, poor recordkeeping, lack of confidentiality.
At provider level lack of training; health workers lack basic patient counseling and education skills; health
workers are judgmental to patients with STDs. At patient level urban patients buy STI drugs to treat their
disease without consulting health care; government facilities seen as the last resort; fear of stigma,
judgmental clinic staff, breach of confidentiality, long waiting times seen as barriers to attending clinics.
One of the major gaps identified by the ‘Know your epidemic Know your Ethiopian Episynthesis' is lack of
data on STIs with only few cases being reported from health facilities throughout the country. Therefore,
the major focus in FY09 shall include support for sites for STI syndromic data documentation and reporting
and support STI surveillance program within the health-delivery structure in the specified Regions FY09
activities at the hospital/facility level will include: 1) Continuation of support on STI services of 76 sites
supported by JHU-BSPH (including hospitals and emerging region health centers) 2) Provision of on-site
technical assistance to improve STI diagnosis and treatment following national syndromic management
guidelines 3) Training, supportive supervision, and mentorship of 300 providers (including physicians, health
officers, and nurses) on STI prevention, diagnosis, and treatment, with a focus on the linkages between STI
and HIV infection, as per national guidelines. 4) Have core T.O.T trained at the regional and Zonal health
offices 5) Development of linkages with the Global Fund for AIDS, Malaria, and Tuberculosis and other
PEPFAR funded partners to ensure adequate supplies of STI drugs at all facilities 5) Development of
linkages to HIV counseling and testing (HCT) services, promoting a provider-initiated, opt-out approach for
all STI patients, and linkages to care and treatment services for those who are HIV-infected 6) STI
education focused on risk reduction, screening, and treatment for patients enrolled in HIV/AIDS care and
treatment at the hospitals 7) Provision of condoms, and education on how to use them, to patients enrolled
in care and treatment, with a special focus on MARPs 8) Integration of STI services into antenatal and
PMTCT services. This will ensure that all pregnant women are educated on and/or treated for STI, and
receive education on STI prevention during pregnancy (according to national STI management and
antenatal care guidelines) 9) Development of linkages to community-based organizations that promote risk
reduction and HIV/STI prevention and early/complete treatment in communities surrounding ART sites
supported by Columbia 10) More Strengthening of STI data recording and reporting system at all
levels .Support for sites for STI syndromic data documentation and reporting 11) In FY08, Johns Hopkins
University Bloomberg School of Public Health (JHU) was provided with supplemental funding to mainstream
and strengthen IEC and BCC programs with its existing care and treatment activities to conduct outreach
activities and promote services with in and outside the health facility areas in four regions of the country
(Addis Ababa, SNNPR, Gambella and Benishangul regions). In FY09, JHU will strengthen and continue this
activity by expanding sexual prevention outreach activity using the ABC strategy in universities in the region
(Hawassa University). The target populations are university students. The activity will be implemented in
collaboration with JHSPH Behavioral Sciences Department. In FY09, JHU will facilitate and coordinate
linkages between STI and HIV/AIDS services. One of the major gaps identified by the know your epidemic
know your response of Ethiopian Episynthesis is lack of data on STIs with only few cases being reported
from health facilities throughout the country. Therefore, the major focus in FY 09 will be to include support to
sites for STI syndromic data documentation and reporting and support STI surveillance program within the
health-delivery structure. Others include having core T.O.T trained at the regional and zonal health offices
and providing on-site training.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.02:
Confidential STI Clinics for MARPs
As a result of the Prevention Portfolio Review, we have determined this activity to have 10% AB component
Establish new user-friendly confidential STI clinics including outreach for commercial sex workers and their
clients in urban areas. Partnering with local NGOs such as Family Guidance Association of Ethiopia
(FGAE).
In FY09 the following major activities will be undertaken to realize the project objectives: 1) Identification of
clinic sites and implementing partners and renovation and construction of the model clinics 2) Development
of training curricula, procurement of audio-visual educational equipment, training of clinic health and support
staff 3) Procurement and provision of condoms 4) Provision of STI medicines 5) Design of referral linkages
6) Promotion of clinics emphasizing their low cost/free services, confidentiality, and quality of service
(including hospitality) FY 2008 ACTIVITY NARRATIVE This is a continuation activity. The main objectives
of this activity are to establish comprehensive most-at-risk population (MARP)-friendly sexually transmitted
infections (STI) services and to link confidential clinics with other services like mobile counseling and
testing, ART, PMTCT, the Wegen Talkline, and ABC comprehensive prevention messages. In FY07, three
confidential STI clinics were to be renovated/constructed in Addis Ababa, Bahir Dar, and Nazareth to
provide comprehensive STI services. In FY08, four more clinics will be renovated /constructed to provide
comprehensive STI services, including reproductive health and post-exposure prophylaxis services for rape
survivors. Evidence suggests that STI are spreading widely in Ethiopia, particularly among MARPs, which
include commercial sex workers and their clients, long-distance truck drivers, low-income women,
substance abusers, street people, migrant workers, bar owners, and urban men with money, among others.
MARPs have the highest partner rates and are therefore critical targets for comprehensive STI prevention
and control. They are often socially marginalized, discriminated against and the last reached by traditional
health services. In recent years, increasing poverty in Ethiopia has lead to large-scale unemployment and
homelessness, which coupled with widespread commercial sex work, has increased STI prevalence. HIV
has spread between Ethiopian cities following the main trading routes. The sixth report on "AIDS in
Ethiopia" indicates that the 2005 HIV prevalence was 3.5% (urban 10.5%, rural 1.9%), and indicated the
national prevalence had stabilized. However prevalence remains high in MARPs and in rural Amhara. The
2005 STI regional report indicated 13,768 and 14,322 cases of urethral and vaginal discharge respectively;
and 5,582 cases of genital ulcer. The 2005 antenatal care survey indicated a general 2.7% syphilis
prevalence and a 4.9% prevalence of syphilis among HIV-positive clients, with higher incidence in rural
areas. Rates were higher in all settings than they were in 2003. Although it is widely acknowledged that STI
are rampant across the country, the number of cases seen at formal health service points is low. The
treatment-seeking behavior of STI patients, especially of MARPs with STI, remains poorly understood. They
tend to seek treatment from alternative sources, such as drug vendors, traditional healers, and open
marketplaces. Services provided there are inferior in terms of provider knowledge, availability of other
services like condom supply and voluntary counseling and testing (VCT), provision of
promotional/educational materials, etc. Among commercial sex workers, there is lack of knowledge of early
STI symptoms and thus lack of early care and treatment seeking; most commercial sex workers also lack
the skills to negotiate safer sex with their clients. Most MARPs do not seek STI treatment until it interferes
with their routine life, mainly due to stigma and lack of accessible affordable health services. There is also a
lack of staff trained in managing such marginalized populations. Therefore, confidential clinics, particularly
for MARPs, are essential to reach them. Strategies for this intervention will include: 1) Rapid assessment
to decide sites and services for the confidential MARPs clinics 2) Integration of MARPs clinics with partners'
clinics 3) STI diagnosis and treatment, including drug provision, condom promotion and provision,
establishment of peer-support groups, STI education and counseling, and referral linkages to VCT, ART
and PMTCT 4) Clients will receive messages and educational materials through linking clinics with AIDS
Resource Centers 5) Communications skill training will be provided to clinic staff to improve service delivery
and to make user-friendly The following major activities will be undertaken to realize the project objectives:
1) Communication/consultation with other PEPFAR partners on implementation of the clinic service 2)
Identification of clinic sites and implementing partners and renovation and construction of the model clinics
3) Development of training curricula, procurement of audio-visual educational equipment, training of clinic
health and support staff 4) Procurement and provision of condoms 5) Provision of STI medicines 6) Design
of referral linkages 7) Promotion of clinics emphasizing their low cost/free services, confidentiality, and
quality of service (including hospitality)
ACTIVITY MODIFIED IN THE FOLLOWING WAYS:
epidemic.
During FY07&08, Johns Hopkins University Bloomberg School of Public Health (JHU-BSPH) supported STI
activities to Addis Ababa, Benishangul-Gumuz, Gambella, and Southern Nations, Nationalities, and Peoples
(SNNPR) regions. The support included: training healthcare providers on syndromic management of STI,
and providing technical assistance to implement the syndromic approach at hospital level. Development of a
work plan and an assessment tool to identify the sources of STI treatment and prevention activities at the
hospital level; Coordination with Regional Health Bureaus (RHB) to help facilitate and coordinate linkages
between STI and HIV/AIDS services, and strengthen external referral linkages between hospitals, health
centers, and community service organizations (CSO), faith-based organizations (FBO) and PLWH support
groups and associations.
A recent study by CDC/EPHAin selected urban and rural areas identified a number of barriers that limit the
utilization of STI services in the country, operating at individual, community, health facility, and
policy/program levels. These include: at faclility level space problems, shortage of basic functioning
diagnostic equipment, failure to mplement syndromic management guidelines, lack of BCC/IEC materials,
poor recordkeeping, lack of confidentiality. At provider level lack of training; health workers lack basic
patient counseling and education skills; health workers are judgmental to patients with STDs. At patient
level urban patients buy STI drugs to treat their disease without consulting health care; government facilities
seen as the last resort; fear of stigma, judgmental clinic staff, breach of confidentiality, long waiting times
seen as barriers to attending clinics.
and support STI surveillance program within the health-delivery structure in the specified Regions
FY09 activities at the hospital/facility level will include:
1) Continuation of support on STI services of 76 sites supported by JHU-BSPH (including hospitals and
emerging region health centers)
2) Provision of on-site technical assistance to improve STI diagnosis and treatment following national
syndromic management guidelines
3) Training, supportive supervision, and mentorship of 300 providers (including physicians, health officers,
and nurses) on STI prevention, diagnosis, and treatment, with a focus on the linkages between STI and HIV
infection, as per national guidelines.
4) Have core T.O.T trained at the regional and Zonal health offices
5) Development of linkages with the Global Fund for AIDS, Malaria, and Tuberculosis and other PEPFAR
funded partners to ensure adequate supplies of STI drugs at all facilities
5) Development of linkages to HIV counseling and testing (HCT) services, promoting a provider-initiated,
opt-out approach for all STI patients, and linkages to care and treatment services for those who are HIV-
infected
6) STI education focused on risk reduction, screening, and treatment for patients enrolled in HIV/AIDS care
and treatment at the hospitals
7) Provision of condoms, and education on how to use them, to patients enrolled in care and treatment, with
a special focus on MARPs
8) Integration of STI services into antenatal and PMTCT services. This will ensure that all pregnant women
are educated on and/or treated for STI, and receive education on STI prevention during pregnancy
(according to national STI management and antenatal care guidelines)
9) Development of linkages to community-based organizations that promote risk reduction and HIV/STI
prevention and early/complete treatment in communities surrounding ART sites supported by Columbia
10) More Strengthening of STI data recording and reporting system at all levels .Support for sites for STI
syndromic data documentation and reporting
11) In FY08, Johns Hopkins University Bloomberg School of Public Health (JHU) was provided with
supplemental funding to mainstream and strengthen IEC and BCC programs with its existing care and
treatment activities to conduct outreach activities and promote services with in and outside the health facility
areas in four regions of the country (Addis Ababa, SNNPR, Gambela and Benishangul regions). In FY09,
JHU will strengthen and continue this activity by expanding sexual prevention outreach activity using the
ABC strategy in universities in the region (Hawassa University). The target populations are university
students. The activity will be implemented in collaboration with JHSPH Behavioral Sciences Department
In FY09, JHU will facilitate and coordinate linkages between STI and HIV/AIDS services. One of the major
gaps identified by the know your epidemic know your response of Ethiopian Episynthesis is lack of data on
STIs with only few cases being reported from health facilities throughout the country. Therefore, the major
focus in FY 09 will be to include support to sites for STI syndromic data documentation and reporting and
support STI surveillance program within the health-delivery structure. Others include having core T.O.T
trained at the regional and zonal health offices and providing on-site training.
Continuing Activity: 16632
16632 10635.08 HHS/Centers for Johns Hopkins 7485 3787.08 Support for $550,000
10635 10635.07 HHS/Centers for Johns Hopkins 5484 3787.07 FMOH $100,000
* Addressing male norms and behaviors
* Reducing violence and coercion
Table 3.3.03:
Support for Program Implementation
ACTIVITY UNCHANGED FROM FY2008
COP 08 ACTIVITY NARRATIVE:
In FY06, Johns Hopkins University - Bloomberg School of Public Health (JHU-BSPH) introduced a basic
care and support approach to 20 ART facilities and then in FY07 expanded this activity to 44 sites in
Operational Zone 2 (Addis Ababa, Benishangul-Gumuz, Gambella, and SNNP). Initial work included: a
baseline assessment of the palliative care and support activities at sites; development of site-level training
materials for palliative care and the prevention care package in cooperation with the national leadership;
development of national pain management guidelines and training materials; and supervision of palliative
care activities.
Training and supervision focused on identifying pain and discomfort among HIV patients, ensuring
cotrimoxazole (CTX) prophylaxis (pCTX)for all eligible patients, conducting tuberculosis (TB) screening for
HIV-positive patients, and targeting elements of the preventive care package (e.g., multivitamins, nutrition
assessments, condoms, and links to programs that distribute insecticide-treated bed nets (ITN) to HIV
positive patients. In FY07, this project has provided care and support services to 22 244 people, and has
distributed 22 000 condoms, 1.2 million CTX tablets, 33 000 bottles of cotrimoxazole and 630 000
multivitamins to ART sites. Four programs have linked ART clinics with the regional ITN distribution,
reserving 1 200 nets for HIV-positive persons of all ages.
As the lead for nutritional programs among university partners, JHU-BSPH has collaborated with the
HIV/AIDS Prevention and Control Office (HAPCO) and Food and Nutrition Technical Assistance (FANTA) to
facilitate the introduction of "food by prescription" programs at hospital level. To this end, National Guideline
on Nutritional and HIV/AIDS is being revised and Guide to Clinical Nutrition Care for Children 6 Months-14
Years Old and Adults Living with HIV training manual is being finalized. In the training manual section on
safe water system, hygiene and sanitation have been added to reflect the PEPFAR Ethiopia effort to
strengthen this service to PLWH and their families. The task force has standardized the national initial site
visits have been conducted at St. Peter's Hospital by JHU with FANTA.
In FY08, JHU plan to expand the services to total of 50 but to date it is only possible to support palliative
care and support activities at 45 sites providing HIV/AIDS care and treatment (hospital and emerging
regional health centers), via a multidisciplinary, family-focused approach to providing the preventive care
package for both adults and children. This approach will continue to incorporate best practices for health
maintenance and the prevention of opportunistic infections for people living with HIV (PLWH), slowing
disease progression and reducing morbidity and mortality.
In FY09, JHU will try to expand the services to 50 facilities that provide the preventive care package,
complementing the Global Fund for AIDS, Tuberculosis, and Malaria (Global Fund), the Federal Ministry of
Health, and other PEPFAR Ethiopia funded activities when possible. JHU will continue to focus on providing
the basic care package for adults, which includes: pCTX; micronutrient and nutrition supplements and
counseling; ITN (through linkage with the Global Fund malaria control program); water disinfectant and
ensuring personal and environmental hygiene for PLWH at community and hospital level; condoms and
education for prevention among positives; and TB screening and pain management for all patients. The
basic care package for children includes: pCTX to prevent serious illnesses like Pneumocystis carinii
pneumonia, TB, and malaria; prevention and treatment of diarrhea; nutrition and micronutrient supplement;
and links to national childhood immunization programs.
JHU will continue to work closely with other university partners to ensure complementary of activities with,
for example, the implementation of national pain management guidelines and implementation of the
Palliative Care Training curriculum.
JHU support to facilities will be continued or expanded as follows:
1) Strengthen the internal and external linkages required at facility level to identify HIV-positive individuals
and provide them with access to care. Internal linkages include referrals to the HIV/AIDS/ART clinic from
antenatal clinics, TB clinics, under-5 clinics, inpatient wards, out-patient departments, and voluntary
counseling and testing. External linkages include referrals to and from community-based resources
providing counseling, adherence support, home-based care, and financial/livelihood and nutritional support
2) Provide on-site implementation assistance, including staff support, implementation of referral systems
and forms, and support for monthly HIV/AIDS team meetings to enhance linkages
3) Provide training on palliative care and the preventive care package to multidisciplinary teams
4) Provide clinical mentoring and supervision to multidisciplinary teams related to the care of PLWH,
including those who do not qualify for, or choose not to be, on treatment, in partnership with regional health
bureaus in the respective regions
5) Continue to develop and distribute provider job aids and patient education materials related to palliative
care and positive living
6) Identify and sensitize community-based groups to palliative care, to the importance of adherence to both
care and treatment for PLWH, and to the palliative care services available at the facility level
7) Improve nutrition assessment at health facilities
8) Promote interventions (pharmacologic and non-pharmacologic) to ease distressing pain or symptoms
9) Continue patient management after hospital discharge, if pain or symptoms are chronic
10) Link patients with community resources after discharge
11) Continue to provide safe water interventions like point of use water treatment by disinfectant and
general personal and environmental hygiene for people living with the virus and families.
JHU will: ensure that all supported sites have reliable stocks of CTX tablets; provide emergency supplies
when needed for quality and continuity of care; promote TB screening; and provide and promote INH
prophylaxis for HIV positive adults and children. Supportive supervision and the institution of standard
operating procedures and national guidelines will improve the use of CTX and INH prophylaxis. Attention
Activity Narrative: will be given to the issue of HIV/malaria co-infection, and the routine provision of ITN in HIV/AIDS and
PMTCT programs in collaboration with Global Fund. Health education and behavior-change communication
for HIV-positive individuals will be provided by facility and lay staff, complementing Global Fund and other
USG-funded activities. Health education, counseling, and support will encourage positive living to forestall
disease progression and promote prevention among positives to prevent further HIV transmission.
In FY09, JHU will continue to support and expand nutritional activities to:
1) Assist in development of guidelines for nutrition assessment.
2) Improve dietary and nutrition assessment at the point of care and evaluate the effectiveness of the
assessment technique.
3) Improve nutrition counseling by assessing current practices and implementing identified best practices for
nutrition counseling.
4) Assess and address micronutrient supplement needs and examine and address therapeutic and
supplemental feeding needs.
5) Integrate therapeutic "food-by-prescription" with ART and PMTCT programs.
6) Support implementation of "food-by-prescription" in at least 20 hospitals, based on criteria agreed upon
by PEPFAR Ethiopia.
7) Evaluate therapeutic and supplementary feeding programs with adaptation of WHO criteria for eligibility
and exit criteria for programs.
8) Support dietary assessment and supplementation of micronutrients to pregnant and lactating women and
children.
9) Assess and recommend effective ways to improve dietary intake in patients with weight loss due to
appetite loss and inadequate intake.
10) Integrate infant feeding counseling and maternal nutrition in PMTCT programs.
11) Assess effect of ART in chronically malnourished populations.
12) Develop capacity and skill of hospital staff in nutritional assessment.
13) Examine the use of lay counselors (i.e., PLWH) to assist with nutritional counseling so that clinic staff is
not overburdened.
14) Share information regarding nutritional assessment guidelines and experiences gained through pilot
implementation programs with the other university partners.
Continuing Activity: 16633
16633 5618.08 HHS/Centers for Johns Hopkins 7485 3787.08 Support for $469,836
10497 5618.07 HHS/Centers for Johns Hopkins 5484 3787.07 FMOH $421,000
5618 5618.06 HHS/National Johns Hopkins 3787 3787.06 $675,000
Table 3.3.08:
April 2009 Reprogramming:
Expansion of HIV/AIDS Pre service Education Problem Statement Ethiopia's goals for expanding access to
HIV/AIDS prevention, care, and treatment services consistently face common and recurring challenges,
particularly when dealing with human resources. These include absolute shortages in terms of numbers, an
inadequate knowledge and skills base which require extensive and expensive in-service training, and poor
distribution and low motivation of those healthcare workers in the system. The crisis in human resources for
health is most severe in emerging regions, where vacancy and attrition rates are nearly double the national
average.
In FY06 and FY07, JPIEGO (PEPFAR partner) worked with seven health professional schools of three
major universities (Addis Ababa University, Gondar University, and Jimma University) to integrate and
strengthen the teaching of HIV/AIDS in pre-service education. Efforts included: consensus-building
workshops with stakeholders; an in-depth needs assessment; faculty updates in HIV/AIDS content areas,
effective teaching skills, infection prevention, etc.; and the development of educational standards specific to
this program and linked with the Higher Education Relevance and Quality Agency (HERQA) standards.
Also, the PEPFAR partner worked with instructors to develop relevant teaching materials for HIV/AIDS and
supported individual departments and schools in introducing these into relevant sections of the curriculum.
The PEPFAR partner also procured teaching equipment, including computers, LCD projectors, screens,
TVs and VCRs, printers, overhead projectors, clinical models, teaching charts, DVDs, videos, etc. for
distribution to each school. As of July 2007, 87 faculty attended training workshops (with many attending a
series involving both HIV/AIDS updates and effective teaching skills), and 349 students received pre-
placement training prior to graduation. The effective teaching skills component, in particular, has led
faculties to re-think and re-design how they deploy students to clinical practice sites (e.g., Jimma), and to
adopt the use of clinical preceptors as a way of maximizing mentoring of students in clinical areas.
In FY08, the PEPFAR partner consolidated its efforts in the three universities and expand to new cadres
within the university. These cadres included laboratory technicians, pharmacists and others. The partner
worked with PEPFAR partners—Strengthening Pharmaceutical Systems (SPS) and a CDC laboratory
partner. The partners worked to update faculty knowledge and skills and revise curricula, and provided
effective teaching-skills training and teaching equipment. The partner also applied the Standards Based
Education Management and Recognition (SBEM-R) approach for strengthening the quality of the pre-
service education. In addition, the partner applied the lessons learned in university settings to regional
health college for diploma-level nursing education. With the assumption that nurses recruited from and
trained in the regions of Gambella and Benishangul are more likely to stay in the regions for a longer
proportion of their career, the PEPFAR partner strengthened the nursing schools in Gambella and
Benishangul and prepared them to accept larger intakes of students. The focus was on HIV/AIDS content,
but the strengthening will include equipping classrooms and clinical skills labs, ensuring good scheduling of
clinical attachments/internships so that students learn by doing, upgrading faculty skills, etc, and testing
whether the SBEM-R methodology can be effectively applied in such a setting. Core groups of
faculty/tutors will also receive training in effective teaching skills and HIV/AIDS content support, working
with PEPFAR partners to carry out the latter as appropriate. Educational development centers will be
established in large universities and in all participating schools. The partner established a core team of
"Educational Mentors for Health" to build capacity for internal development of instructors and to overcome
the problem of teacher turnover. The PEPFAR partner continued to support the development of printed
materials, tools (question banks, learning resource packages for faculty, clinical attachment logbooks for
students, etc.) and support for other resources, such as teaching supplies/equipment, models, and other
supplies for clinical skills labs, as the curriculum development evolves. The partner shared other resources
that are available to school faculties and leadership, such as the virtual/distance leadership course
established by the Leadership and Management Support project, which is funded by the US Agency for
International Development.
In FY 09 these activities were reprogrammed from JHPIEGO to John Hopkins University (JHU) to
implement the following activities.
• Ensure that one Academic Development and Resource Center (also known as educational development
centers) is established and strengthened at each of the two universities in the cities of Awassa and Addis
Ababa
• Ensure that two skills laboratory are strengthened
• Ensure that competency-based education is promoted and strengthened at the universities in the cities of
Awassa and Addis Ababa.
• Educational quality is improved based on the increment in achievement of performance standards through
standards-based educational management and recognition
• 50 instructors will be trained on effective teaching skills
• 50 instructors will be trained on Instructional Design (ID)
• 50 instructors will be trained on student's performance assessment teaching and student performance
assessment will be improved.
• In collaboration with the Ministry of Education, Ministry of Health, the Higher Education Relevance and
Quality Agency, and professional associations, accreditation and licensure processes will be developed and
implemented
• Pre-service HIV/AIDS education strengthening support is expanded to other health science disciplines and
universities
• Practical training sites and their linkages with teaching institutions are strengthened; through training of
preceptors and strengthening the support to practical sites.
Table 3.3.09:
Clinically Focused Record Systems
This is a continuing activity from FY 08.
This activity has been delayed from starting enrolling patients due to slow process of obtaining ethical
clearance from all concerned parties. Now, clearance has been obtained from Centers for Disease Control
and Prevention (CDC) and Johns Hopkins University (JHU). As of October 2008, the protocol had been
finally presented to the Science and Technology Commission of Ethiopia and is expected to get the required
clearance soon. Patient enrollment will start as soon as this process is finalized. Furthermore, coordination
among the different partners involved was a challenge, but, now things are going forward with better
coordination.
In FY 07, Advanced Clinical Monitoring (ACM) achievements included protocol submission and clearance,
initiation of cohort enrollment, ongoing support for the governing steering committee structure,
strengthening of clinic based activities at seven participating university hospitals, development and
implementation of facility based project management standard operating procedures to initiate cohort
enrollment and collect data from the targeted sample of HIV positive patients put on ART at the seven
universities and meet data transfer and specimen repository standards.
In FY 08, continuation activities include ongoing support for cohort enrollment, maintenance of implemented
standardization measures for data collection and patient records management, monitoring data quality
levels, data and specimen transfer to host institution, ongoing facility staff training to use national M&E
tools, monitoring electronic data management system at site and central levels and JHU will continue to
support collaborative targeted evaluations to meet project objectives, facilitate data and specimen requests
from daughter protocols as per steering committee approvals and increase university hospital capacity to
twin with local and international institutions.
Intensive monitoring and evaluation of approximately 3 000 patients on ART will provide critical information
on large scale ART distribution without piloting on a small scale. This activity will improve case management
of treatment services at the university hospitals and will enhance the universities' capacity to provide
technical assistance and training to clinicians, residents, and medical students. Data generated by this multi
-site project will inform and improve ART delivery in Ethiopia by providing important information on ART
associated toxicities and early mortality. The multi-site patient database and specimen repository will
facilitate operational research and scientific inquiry pertinent to HIV/AIDS, through in-depth monitoring of
treatment, acceptance and adherence, assessment of indicators of adherence, clinical and virologic efficacy
of treatment protocols, assessment of monitoring protocols (CD4), evaluation of drug toxicity, drug-
interactions and viral resistance, investigation of potential barriers to expanding ART access in Ethiopia.
The project will train staff required for collection of additional data to answer programmatic issues and
perform patient follow-up. JHU will also support capacity building of health providers and regional health
authorities to record, store and share information to support provision of appropriate services to individual
HIV patients and their families, across the continuum of care. These information systems will be flexible,
adaptable, and compatible with various existing health care information systems and will support program
monitoring and evaluation. JHU team of healthcare informatics experts will provide expert technical input in
developing a data model for HIV care and will work with the CDC informatics group and national committee
to develop an infrastructure for installation of electronic health records to support the longitudinal care
needed to combat HIV over the long-term. When an electronic patient record system for HIV care or for
overall hospital care is developed, the JHU team will guide its implementation for the hospitals in its four
regions. This activity will include provision of the CDC medical record folders if supported
Continuing Activity: 16637
16637 5685.08 HHS/Centers for Johns Hopkins 7485 3787.08 Support for $1,170,000
10598 5685.07 HHS/Centers for Johns Hopkins 5484 3787.07 FMOH $850,000
5685 5685.06 HHS/National Johns Hopkins 3787 3787.06 $700,000
Technical Support for ART Scale-up
This is a continuation of activity from FY08.
Johns Hopkins University - Bloomberg School of Public Health (JHU-BSPH) supported ART
implementation in Operational Zone 3 which includes Addis Ababa City Administration (region), Southern
Nations Nationalities and Peoples (SNNPR) region, Beni-shangul Gumuz region and Gambella region. By
the end of June, 2008, JHU was providing support for comprehensive HIV care and treatment services to 48
ART sites in the four regions. These ART sites included public and private hospitals in Addis Ababa City
Administration, public hospitals in the SNNPR, and public hospitals and health centers in the emerging
regions of Beni-shangul Gumuz region and Gambella region.
As of June 30, 2008, 31 917 persons were receiving ART, and 46 938 persons had been initiated on ART at
JHU supported ART sites in the four regions. These achievements exceed the targets set for COP07
(ending on September 30, 2008), three months before the end of the reporting period. Furthermore, training
has been provided to different cadres of ART providing healthcare workers, and JHU continues to lead with
advanced ART workshops and CME telemedicine case reviews.
In COP09, the care and treatment activities to HIV patients in these regions will continue through delivery of
the care and treatment services to those patients enrolled to care and initiated on ART, and also by
enrolling and initiating new patients. JHU will continue to support the ART facilities in its Operational Zone,
which includes public and private hospitals in Addis Ababa and SNNPR regions, and hospitals and health
centers in the emerging regions of Beni-shangul Gumuz region and Gambella region. Support will be
divided among several programmatic activities: direct site-level support, mentoring, human resources,
infrastructure, training, quality care, expansion of ART to the private sector, pediatric care, laboratory
diagnostics, site-level management, community-level support, and monitoring and evaluation of outcomes.
To increase capacity, JHU will invest in personnel to support ART technical assistance (TA) at sites and will
augment support by sponsoring regional meetings, collaborative activities, and by participating in the RHB
ART coordinating and implementation teams. JHU will address region specific challenges to scaling up,
while maintaining quality mentorship at established ART sites.
Establishing effective referral linkages between facilities (hospitals and health centers) and between
facilities and community services has been a challenge due to insufficient coordination among partners,
poor referral system and poorly developed community support services (particularly in remote sites).
Retention of patients to care and treatment services is an issue with high rate of ART patient mortality and a
significant proportion of patients being lost to follow-up.
In the preceding years, as the lead for the post-exposure prophylaxis (PEP) program amongst university
partners and health network, JHU focused on national-level activities in policy development, as well as on
regional-level facility-based training to implement an effective PEP guidelines, targeting healthcare
providers and victims of sexual assault at ten pilot facilities. Specific activities included: ensuring availability
of national guidelines and protocols; ensuring the availability of ARVs for PEP; implementation of
awareness programs to increase uptake of the program by exposed individuals; and training of trainers
(TOT) for health workers and Ministry of Health (MOH) and RHB staff to ensure decentralization of
activities to other regions and partners.
Phase I of this activity addressed the need to increase safety and protection of healthcare workers and the
need for a comprehensive plan of care for victims of sexual assault. Phase II focused on development of
guidelines, policy, and an implementation model for providing comprehensive care to both target
populations. These activities continued with a PEP expansion plan in the supported facilities within the four
regions, and continued to provide guidance to other university partners.
The ART technical support also included expansion of activities to the entire health network model in the
two emerging regions of Gambella and Benshangul Gumuz. JHU will further expand the comprehensive
HIV activities in the private sector —in particular TB/HIV, PMTCT, VCT, linkages to ART clinics in private
hospitals, increased coverage of pediatric ART and DNA testing for EID at all JHU-supported ART sites.
JHU will continue to work with the Ethiopian Orthodox Church and International Orthodox Church Charities,
and expand activities to other faith-based organizations. Using guidelines and training materials, JHU will
work closely with the MOH and RHB to address malaria and HIV co-infection and to provide linkages to
insecticide-treated nets for all HIV patients in malaria endemic areas. JHU will expand peer network
advocacy for people living with HIV/AIDS (PLWH) and tracking systems to improve adherence, follow-up for
care, and community-level support for ART.
JHU will continue to provide expertise at all levels of ART provision, ranging from multidisciplinary team
mentoring and supportive supervision to creation of a cadre of local university mentors. These mentors will
provide clinical stewardship and develop additional expertise in data processing and management at ART
sites. Recognizing the majority of patients are lost between CT and the ART clinic, JHU will continue to
invest resources to improve networking and inter and intra-service linkages with CT, TB, antenatal clinics
(ANC), sexually transmitted infections, PMTCT services, and community-based care, based on the "Referral
Network Model for Ethiopia" project completed by JHU in FY06. JHU will support hospital and RHB activities
in transferring patients from hospital ART clinics to locally networked health centers. JHU will offer TA with
transfer readiness, patient identification, development of standard operating procedures for mentoring, and
case review for difficult cases. JHU will support developing a cadre of nurse specialist mentors to provide on
-site follow-up and mentoring for ART nurses, as well as to train counselors, lay counselors, and peer
educators on adherence. JHU plans to train or identify persons affiliated with PLWH associations in an effort
to promote ownership, communication, policy drafting, and overall sustainability of ART programs. Through
these activities, it will work to improve quality of service delivery, improve patient out-come and retention of
Activity Narrative: patients to care and treatment services.
JHU will manage high demand at urban centers by: increasing site-capacity through renovation in
coordination with the Regional Procurement Support Office (RPSO) and Crown Agents; training and
innovative methods to improve human resource retention; and by strengthening referral linkages between
hospitals, health centers, and community-based organizations to improve service delivery. It will work with
partners working at health centers and community level to ensure transfer of stable patients from
congested, high-load ART sites to health centers closer to patients' residences and community services.
JHU will support linking treatment, care, and support services with PLWH associations. JHU will continue to
strengthen provider initiated counseling and testing (PICT), referrals for TB/HIV and malaria/HIV.
JHU will continue to expand the intensification of PMTCT to ART linkages and to increase the number of
pregnant women on ART. JHU will place PMTCT case managers and nurse assistants at sites to improve
overall screening for ART and to improve linkages to other programs (ART, pediatrics, TB/HIV).
JHU will work closely with the MOH, the Global Fund for AIDS, Malaria, and Tuberculosis, the Supply Chain
Management System/RPM+, and RHB to ensure drugs purchased to treat opportunistic infections (OI) are
distributed rationally, and to develop OI drug access for all HIV-positive patients, especially CTX for TB
patients, pregnant women, and HIV-exposed children.
JHU will expand MOH's basic ART Training activities within the hospitals, training inpatient healthcare
personnel, and new graduates so that ART services expand accordingly. JHU will continue to supplement
basic training through HIV telemedicine, case review sessions, TheraSim, and work with other partners to
expand services to distant regions through satellite connections and possible portable videoconference
capabilities.
In association with JPHIEGO, Standards Based Management and Recognition (SBMR) for all HIV activities
were introduced in FY07 and will be continued. These measures will assist measurement and improvement
of quality site services; performance on agreed indicators will be measured at facilities and district and
comparative reports produced. JHU will also continue to assess quality of reporting, recording, and clinical
services using Lot Quality Assurance Sampling techniques. These methods provide immediate feedback to
sites on areas requiring improvement and services management change.
Monitoring and evaluation (M&E) training for ART and laboratory technicians will continue to be provided as
part of the basic training package. JHU will work with the MOH to develop and distribute Information-
Education-Communication materials, reporting and recording formats, and all support for accurate
monitoring. M&E specialists will work closely with sites and RHB to analyze ART data and provide feedback
to clinicians. This will coordinate with the rollout of the health management information system and with
other PEPFAR partners.
Finally, JHU will continue to support the MOH in expanding free ART technical support to private sector
facilities in Addis Ababa. JHU will intensify its regional capacity building with greater emphasis on local
university and indigenous capacity. JHU will continue to build the capacity of Addis Ababa and Debub
Universities in knowledge-transfer, TA, supportive supervision, and mentoring to their respective RHB and
catchments health networks.
Continuing Activity: 16636
16636 10430.08 HHS/Centers for Johns Hopkins 7485 3787.08 Support for $7,000,000
Palliative Care and Nutrition Support at Hospitals
ACTIVITY IS REPLACED ENTIRELY AS FOLLOWS:
In FY07 and FY08, the Johns Hopkins University Bloomberg School of Public Health (JHU-BSPH) is
working in pediatric care and support as part of the care and support activities, previously Palliative care. In
FY07 and FY08, JHU-BSPH supported basic pediatric care and support services at 30 facilities. These
included: an initial assessment of site-level palliative care activities, training of the multidisciplinary team,
site-level clinical mentoring, enhancement of data collection and reporting, minor renovations, and
supportive supervision pediatric care and support services. Other services included training and supervision
focused on identifying and managing symptoms, pain, and discomfort among HIV-positive children, and on
providing cotrimoxazole prophylaxis (pCTX), tuberculosis (TB) screening, and key elements of the
preventive-care package, such as multivitamins and nutritional assessments. This program was introduced
to the hospitals in Operational Zone 2 (Addis Ababa, Benishangul-Gumuz, Gambella, and SNNP).
JHU-BSPH supported all facilities in an effort to ensure facility-based care for HIV-exposed children aimed
at extending and optimizing quality of life for HIV-infected children and their families throughout the
continuum of illness. Clinical care will include
1) Supporting sites to perform early infant diagnosis, preventing and treating opportunistic infections (OI),
excluding TB, and other HIV/AIDS-related complications including malaria and diarrhea
2) Providing access to commodities such as pharmaceuticals, insecticide treated nets, safe water
interventions and related laboratory services
3) Providing pain and symptom relief
4) Providing nutritional assessment and support including the distribution of food.
In FY09, JHU-BSPH will strengthen pediatric care and support in existing sites and expand activities to all
sites providing adult HIV care and treatment via a multidisciplinary, family-focused approach to providing the
preventive care package for children. This approach will incorporate best practices for health maintenance
and the prevention of OI for children with HIV, slowing disease progression and reducing morbidity and
mortality. JHU-BSPH will continue to participate in the revision of the developed national pediatric guideline
and standard operating procedures for pediatric HIV care as appropriate. In the face of having a national
guideline which adopts WHO recommendations for early diagnosis and initiation of treatment, JHU-BSPH
will work to improve access to early infant HIV diagnostics using dried-blood spot DNA PCR testing and
networking to avail the service to hospitals and health centers.
JHU-BSPH will continue to provide the preventive care package, complementing the Global Fund for AIDS,
Tuberculosis, and Malaria (Global Fund), the Federal Ministry of Health (MOH), and other USG-funded
activities when possible. JHU-BSPH will focus on provisions of the preventive care package for children.
The package for children includes: appropriate prophylaxis and ITN to prevent serious illnesses like
pneumocystis carinii pneumonia, TB, and malaria; symptom management; prevention and treatment of
diarrhea; nutrition and micronutrient supplements; and linkage to national childhood immunization
programs. JHU-BSPH will also ensure that all HIV-positive children receive careful and consistent clinical,
developmental, and immunologic monitoring to promptly identify those eligible for ART. Orphaned and other
vulnerable children (OVC) enrolled in care and treatment will be prioritized for palliative care services and
linked to community-based OVC care programs in order to receive a continuum of care.
JHU-BSPH support to facilities will be continued or expanded as follows. JHU-BSPH will:
1) Strengthen the internal and external linkages required at facility level to identify HIV-positive children and
provide them with access to care. Internal linkages include referrals to the HIV/AIDS/ART clinic from
antenatal clinics, TB clinics, under-5 clinics, inpatient wards, out-patient departments, as well as voluntary
providing counseling, adherence support, and financial/livelihood and nutritional support
and forms, and support for monthly pediatric team HIV/AIDS team meetings to enhance linkages
3) Provide training on pediatric care and support and the pediatric preventive care package to
multidisciplinary teams
4) Provide clinical mentoring and supervision to multidisciplinary teams for care of infected children,
including those who do not qualify for or choose not to be on treatment, in partnership with regional health
5) Continue to develop and distribute pediatric provider job aids and patient education materials related to
pediatric care and support
care and treatment services available at the facility level
7) Improve nutrition assessment of children at health facilities
9) Continue patient management after hospital discharge if pain or symptoms are chronic
10) Link families with community resources after discharge
general personal and environmental hygiene for people living with the virus and families
JHU-BSPH activities will promote prophylaxis (pCTX) and treatment for opportunistic infections in
accordance with national guidelines. Appropriate use of pCTX is an essential element of care for HIV-
positive children, and for HIV-exposed infants, and will be an important component of JHU-BSPH
implementation activities, especially at those sites not yet providing ART. JHU-BSPH will ensure that all
supported sites have reliable stocks of CTX syrup, and will provide emergency supplies when at a time of
absolutely necessary to ensure quality and continuity of care. Similarly, TB screening and isoniazid
prophylaxis (IPT) will be promoted and provided for HIV-positive children. (See TB/HIV narrative).
Supportive supervision and the institution of standard operating procedures (SOP) will improve the use of
CTX and IPT.
Activity Narrative: Those sites with "therapeutic feeding-by prescription" will target HIV-exposed or infected infants who are no
longer breastfeeding along with HIV positive pregnant or breastfeeding women and malnourished patients.
JHU-BSPH continues to be a leader for hospital-level nutrition programs and will continue to provide
guidance for other partners. The family of children graduating from therapeutic program will be linked to
food security program as appropriate.
Table 3.3.10:
This is a continuing activity from FY05, FY06, FY07, and FY 08 which has previously been included within
treatment/ARV services. Johns Hopkins University (JHU) has supported the implementation of pediatric
ART in the two major regions of Addis Ababa and Oromiya, as well as the emerging regions of Benishangul
and Gambella.
In FY08, JHU actively participated in the national pediatric care and treatment activities to update and
enhance national policies, protocols, and guidelines on pediatric HIV. JHU supported full-spectrum pediatric
HIV prevention, care, and treatment services at 30 health facilities including hospitals and health centers
and is currently on track in meeting targets for COP08. In FY08 to date, JHU-supported sites have initiated
2069 children on ART, and 1585 children are currently on ART. JHU has effectively supported the
decentralization of ART services to health centers in Benishangul and Gambella regions by training staff
from health centers, establishing catchment area meetings, providing ongoing clinical mentoring, and
developing standard operating procedures (SOP) to facilitate appropriate "down referral". This enables
health centers to follow stable patients or initiate ART services in some cases and refer complex cases to
hospitals (up-referral).
In FY09, JHU will continue to support pediatric care and treatment services in the existing sites and expand
the services to private facilities.
At the national level, JHU will continue to support the Ethiopian Federal Ministry of Health's (MOH) National
Pediatric HIV/AIDS Care and Treatment Program, by continuing and expanding the following activities:
1) Assist the Government of Ethiopia (GOE) to update national policies and guidelines on pediatric HIV
2) Expand the national pediatric care and treatment training curriculum and continue widespread distribution
of pediatric support materials
3) Assist with the integration of pediatric monitoring and evaluation into existing care and treatment tracking
systems
4) Provide technical input into the development/revision and implementation of forms, registers, and
charting tools for pediatric care and treatment
5) Support radio and TV campaigns and the use of Information, Education and Communication and
Behavior Change Communication (IEC/BCC) materials in local languages to enhance public awareness of
pediatric HIV care & treatment services
JHU will continue to provide technical support in the areas of family-centered HIV care and treatment, and
will work with the National ART Program to strengthen the growing Ethiopian PMTCT program and linkage
to pediatric care and treatment services. JHU will contribute its experience with treatment of HIV-exposed
and infected infants and children and assist with the expansion of national pediatric treatment guidelines
At the regional level, JHU will work with Regional Health Bureaus (RHB) in its operational zone and other
partners to build their capacity to effectively design, implement, and evaluate Pediatric HIV/AIDS programs.
. JHU will work with RHB to evaluate the clinical, infrastructural, management and informatics needs of
facilities, develop implementation strategies to enable each facility to meet required national standards, and
to provide assistance to support the implementation of national treatment guidelines.
In FY09, emphasis will be placed on increased pediatric ART service uptake at all sites. JHU will focus on
improved entry points for children by supporting
1) Family-focused care and family testing
2) PIHCT at under-5 clinic, pediatric inpatient, TB clinic and EPI clinic
3) Linkages with PMTCT service and improved infant follow-up
4) Linkages with orphans and other vulnerable children (OVC) programs and orphanages
5) Advocacy to create better awareness among health professionals and the community to improve the
attitude towards pediatric care and treatment
6) Expansion of the service to private sector
FY09 activities will also include expansion of activities to the entire health network model in the two
emerging regions of Gambella and Benshangul Gumuz. JHU will further expand the comprehensive
pediatric HIV care and treatment activities in the private sector in particular, linkages to ART clinics in
private hospitals, increased coverage of pediatric ART and DNA testing for early infant diagnosis (EID) at all
JHU-supported ART sites.
In FY09, JHU will continue to provide expertise at all levels of ART provision, ranging from multidisciplinary
team mentoring and supportive supervision to creation of a cadre of local university mentors. These
mentors will provide clinical stewardship and develop additional expertise in data processing and
management at ART sites. On-site assistance will be provided to develop medical records, referral linkages,
patient follow-up and adherence support defaulter tracing mechanisms. Moreover, more frequent site-level
clinical mentoring and supportive supervision will be carried out at all hospitals and health centers providing
pediatric care and treatment service in JHU supported regions.
Collaborating with I-CAP and other partners, JHU will continue support to all sites in pediatric care, by
training pediatricians and other health workers and integrating pediatric ART into current ART activities.
Assessing and improving the quality of service for pediatric care and treatment through standardized
approach in all operating sites will be one of the core activities in FY09.
JHU will emphasize strengthening the internal and external linkages including internal referrals to HIV care
clinics from various points of care and externally through referrals to and from community-based resources
to identify HIV-infected children and provide care and treatment services. Under the ART health network,
JHU will work to establish and strengthen links between hospital services, different levels of facilities and
community based services, nongovernmental and faith-based organizations, and communities with other
partners working at these levels. Orphans and other vulnerable children (OVC) enrolled in care and
Activity Narrative: treatment will be prioritized for treatment services and linked to community based OVC care programs for
continued care.
JHU will support pediatric ART training, according to national guidelines and curriculum. Additional training,
including training on early infant diagnosis (EID), will be provided to all new sites initiating ART in FY09 and
to sites already providing ART services to fill the gaps created by high staff turnover. This will be
supplemented by refresher trainings, focusing on an integrated multidisciplinary team approach to care and
treatment. JHU will expand MOH's basic ART Training activities within the hospitals, training inpatient
healthcare personnel, new graduates so that pediatric ART services expand accordingly. JHU will continue
to supplement basic training through HIV telemedicine, pediatric case review sessions, TheraSim, and work
with other partners to expand services to distant regions through satellite connections and possible portable
videoconference capabilities.
distributed rationally, and to develop OI drug access for all HIV-exposed and infected children. The
availability of consistent and quality laboratory services including early infant diagnosis at all these sites is
critical to ensure quality comprehensive pediatric care and treatment services.
Table 3.3.11:
TB/HIV Linkage Support at Hospital Level
In FY 08, JHU has been expanding TB/HIV collaborative activities from 34 to 46 health facilities including
health centers in emerging regions and private hospitals to providing HIV counseling and testing of TB
patients in TB clinic, 3180 new HIV positive patients were screened for TB and 444 health care workers
were trained in TB/HIV. More over, JHU has participated in the national MDR-TB management working
group and have supported the development of proposal for second line anti TB treatment to the green light
committee and the MDR-TB management implementation guideline.
In FY09, Johns Hopkins University - Bloomberg School of Public Health (JHU-BSPH) will strengthen its
support to MOH in the TB/HIV program implementation in line with Ethiopian Federal Ministry of Health
(MOH) and the Office of the Global AIDS Coordinator (OGAC) priorities.
TB infection control will be given more emphasis in all HIV care and treatment clinics and wards. Due
emphasis will be given at all facilities in improving early detection of infectious TB cases and timely initiation
of treatment and follow up till completion in order to render them non infectious. Ventilation and lighting will
be considered during renovations and refurbishment of patient examination and counseling rooms, wards,
and patient waiting areas. TB infection control measures will be incorporated as part of the hospitals'
comprehensive infection control plan. Due attention will be given to prevent the spread of TB to other
patients and health care workers at all HIV-related clinics through health education, cough triage in the
outpatient clinics, and isolation of admitted infectious TB patients in the wards.
MDR-TB: As an active member of the national MDR-TB technical working group, JHU-BSPH will participate
in the development and revision of MDR-TB management guidelines, protocols, and tools. JHU-BSPH will
also support MOH's MDR-TB management initiative through both the pilot program at St. Peter's Hospital
and the expansion plan to the regional referral hospitals.
TB/HIV Monitoring and Evaluation (M&E): Intensive training, supportive supervision, and mentorship will be
provided to JHU-BSPH-supported facilities to strengthen the TB/HIV information system to generate good
quality data. JHU-BSPH will also assist national and regional TB/HIV review meetings and joint supportive
supervisions. A standard operating procedure (SOP) will be introduced at the facilities to generate timely
reporting and good quality TB/HIV data to the national level. The TB/HIV national surveillance sites will
given due attention in strengthening their TB/HIV information system to be able to report on the core TB/HIV
activity indicators to the national level in a sustainable manner.
Pediatric TB/HIV: In FY09, more emphasis will be given during the TB/HIV trainings and site level
mentorship in building the capacity and knowledge of health care workers in pediatric TB diagnosis and
TB/HIV co-management. Pediatric TB and Intermediate Presumptive Treatment (IPT) eligibility screening
tools will be used to evaluate HIV-exposed and infected children. All eligible TB/HIV co-infected children will
be linked to HIV-related care and treatment services through intra-facility and inter-facility referrals. The
revised TB/HIV reporting format, which includes age break down, enables reporting of pediatric TB/HIV
activities separately and will be used for TB/HIV activity reporting at all sites.
An integrated TB/HIV program is an essential component of the comprehensive HIV care preventive
package. With this program, JHUBSPH aims to strengthen the linkages between TB and HIV services in
hospitals of operational zone 2, which encompasses Addis Ababa, Benishangul-Gumuz, Gambella, and
Southern Nations, Nationalities, and Peoples Region (SNNPR).
Moreover, Tuberculosis infection control is a major concern in resource-limited settings. With the high
volume of TB patients seen in many health facilities in Ethiopia and the limited availability of infection control
practices, there is a concern for nosocomial TB transmission, including transmission to healthcare workers.
JHU will closely work with CDC-Ethiopia to establish a system for monitoring and evaluation of TB among
facility staff at the United States President's Emergency Plan for AIDS Relief (PEPFAR)-supported HIV care
& treatment sites. As a first step, CDC-DTBE-IRPB will collaborate with CDC-Ethiopia and JHU to conduct a
baseline assessment of nosocomial transmission of TB to healthcare workers at selected healthcare
facilities. Data will be gathered through interviews with hospital staff and administration to determine the
burden of TB among healthcare workers and to attempt to calculate rates of TB disease among workers.
This will help to determine the infection control needs for the country, as well as help to determine the
efficacy of planned interventions. This activity will be complementary with the infection control activities of
WHO, and technical assistance will be provided by CDC Atlanta to assist in the implementation of this
activity.
Support will be provided to St. Peter's TB Hospital in serving as a training and demonstration site, and plans
are underway to review the TB curriculum, conduct a review of multi-drug-resistant (MDR) TB cases,
establish culture activity at St. Peter's laboratory, and implement infection control measures in the inpatient
setting. On-site trainings are planned to be provided to the staff working at the hospital.
In FY09, JHU-BSPH will continue with all previous activities, supporting 50 sites in Operational Zone 2
(hospitals and emerging region health centers), and will focus on expanding activities to improve monitoring
and evaluation (M&E) and improved use of the current and revised TB/HIV recording system. Widespread
on-site training for TB/HIV activities will address the human resource attrition in the field. Improved TB
diagnostics (e.g., chest x-ray (CTX), concentrated acid-fast bacilli (AFB) staining methods, fluorescent
microscopy, fine-needle aspirations, culture and sensitivity, and—eventually—molecular diagnostics) will
improve site-level capacity to diagnose active TB. JHU-BSPH will support the phased implementation of
World Health Organization (WHO) guidelines on smear-negative disease and extra-pulmonary TB and will
assess TB relapse and failure rates as a proxy for resistance (MDR-TB).
JHU will further expand TB/HIV collaborative activities to those private-sector hospitals providing free
Activity Narrative: Antiretroviral Therapy (ART) and PPM-directly observed therapy services, in addition to expansion of IPT
and cotrimoxazole preventive therapy (CPT) to co-infected pediatric patients. In FY08, JHU-BSPH will work
with Columbia University and the MOH to assess training needs and curricula related to family-focused
TB/HIV activities, including provider-initiated counseling and testing (PICT) guidelines for children. With the
International Center for AIDS Care and Treatment Programs - Columbia University (ICAP-CU) as the lead
TB-implementing partner among university partners, current didactic materials will be modified to reflect
current needs.
In FY09, JHU-BSPH will continue to implement previous interventions, such as:
1)Expansion of PICT for TB patients
2)Referral of HIV/TB patients for HIV-related care including CTX and ART
3)TB screening in HIV care and treatment settings with improved documentation of these activities at the
HIV clinic
4)IPT for HIV-positive patients in whom active disease has been safely ruled out, and
5)Support at site level for improved ability to rule out active TB by providing CXR capacity in rural areas and
in network/referral hospitals.
These activities, implemented in FY08, will continue to be closely coordinated with the national TB and HIV
control programs and regional health bureaus (RHB) in the operational zone covered by JHU-BSPH. JHU-
BSPH will continue to work closely with the RHB in strengthening the TB/HIV working groups and review
meetings at regional level, along with providing strategies for: joint supportive supervision for TB/HIV
activities; M&E of TB/HIV activities; programs to improve prevention, diagnosis, and treatment advocacy for
MDR-TB; and human resources training and retention. JHU site-support teams will continue to provide
monthly supportive supervision and clinical mentoring in the field of TB/HIV, and teams will work closely
with the RHB to solve implementation road blocks.
In FY06, FY07, and FY08, JHU-BSPH initiated and continued its support to strengthen TB diagnostics
among HIV-positive patients through improvement of smear microscopy services, quality assurance of
laboratory networks, and support for regional referral. JHU-BSPH laboratory personnel assisted in the
review of new smear microscopy guidelines, trained on concentrated AFB methods, and disseminated this
information to JHU-supported TB/HIV sites. JHU-BSPH will continue to support improved smear microscopy
but will expand this laboratory support to labs providing culture and sensitivity testing at regional and federal
levels, in collaboration with the Plus-Up fund activities. The goal will be to increase ease of referral and
improve information feedback to patients and efforts to assess the situation of MDR-TB.
Continuing Activity: 16634
16634 5754.08 HHS/Centers for Johns Hopkins 7485 3787.08 Support for $316,800
10429 5754.07 HHS/Centers for Johns Hopkins 5484 3787.07 FMOH $264,000
5754 5754.06 HHS/National Johns Hopkins 3787 3787.06 $150,000
Construction/Renovation
* TB
Table 3.3.12:
Creating Demand for Counseling and Testing through Promotional Activities
COP 08 NARRATIVE:
This continuing activity links to activities AB (ID10386, 10590, 10592 and 10605), Other Prevention (ID
10387 and 10388), Treatment (ID 10606 and 10623), Other Policy (ID 10422, 10423 and 10428) and all
HCT activities.
In view of expanding HIV counseling and testing (HCT) service availability, it is important that public
demand and utilization continue to increase. Since its inception, the Johns Hopkins University/Center for
Communication Programs AIDS Resource Center (CCP\ARC) has not only empowered people to access
voluntary counseling and testing (VCT), but also targeted service providers to provide quality VCT services.
JHU CCP/ARC produced print and multimedia materials encouraging use of VCT and distributed VCT
communication materials to service providers. CCP/ARC also conducted three national VCT Day promotion
campaigns in collaboration with partners. CCP/ARC played a major role in establishing the annual National
HCT Day on the eve of the Ethiopian New Year. As more people and organizations observe HCT Day, use
of services and efforts to improve quality will increase.
In FY08 JHU-CCP designed a communication strategy with participation of 30 prominent organizations
working on HCT in Ethiopia. In consultation with partners selected the theme of the year to focus on youth
between the ages of 18-24. The information was distributed to the regions.
On the VCT day (Sept 10 2008) a mass rally was organized involving 2,000 (two thousand) young people
from the various sub-cities. A huge billboard was unveiled at Public Square in Addis Ababa. Similarly the
regions have conducted events mostly related to community mobilization. Different educational materials
were produced and distributed.
In FY09, CCP/ARC plans to continue promotion via two approaches:
1) Implementation of HCT Day 2009 with local and international partners, in both Addis Ababa and in all of
the regions
2) Development of a long term HIV counseling and testing BCC campaign aimed at increasing quality and
uptake of services
3) Creation of synergy between its HCT promotion activities and those of the Millennium AIDS Campaign
through shared messaging, images, sponsorship, or events
4) Closely work with HAPCO to harmonize with the Ethiopian government's HIV/AIDS social mobilization
strategy
CCP/ARC will continue to support HAPCO and partners for HCT Day 2009 by producing campaign
materials (posters, flyers, radio/TV spots, and newspaper ads), creating web pages, organizing and
coordinating media coverage, and facilitating and providing information through its Wegen Talkline and
Warmline for service providers. CCP/ARC will support HCT Day activities at both the national and regional
levels.
In addition to the HCT Day communication strategy JHU CCP/ARC will support FHAPCO to development of
National HCT communication strategy for the longer-term campaign, which will likely target different
audiences than HCT Day activities (including youth and residents in rural areas) will serve as an important
entry point in HIV prevention and early access to treatment, care and support.
CCP/ARC will promote both VCT and provider-initiated counseling and testing to create demand and
reduce stigma against people living with HIV/AIDS.
The campaign will use traditional and modern channels to develop region-specific promotion messages,
support annual HIV-testing campaigns, lead development of an HCT communications strategy; and support
development of national HIV counseling and testing themes and logos. This campaign will complement
other CCP/ARC activities, including the Betengna Radio Diaries program and other prevention activities
carried out through CCP/ARC's website, as well as materials distribution and outreach at the regional
ARCs. These new mass media and community mobilization activities will be complemented by training
journalists and other partners in HCT reporting and communication. This expanded HCT campaign will be
supported through the addition of key staff.
Continuing Activity: 16635
16635 10545.08 HHS/Centers for Johns Hopkins 7485 3787.08 Support for $496,800
10545 10545.07 HHS/Centers for Johns Hopkins 5484 3787.07 FMOH $0
Table 3.3.14:
Site-level Laboratory Support
John Hopkins University (JHU) in addition to the activities in FY08 will support the facilities to attain
minimum standards set by EHNRI. JHU will technically assist for the process improvement including
accreditation of regional laboratories. JHU will address integrated laboratory system and will also provide
support for establishment of regional laboratory in Gambela and Benshangul, TB culture and viral load
facilities in regional laboratories and will work to develop capacity of regional laboratories for sustainability.
In FY08, John Hopkins University (JHU) has provided comprehensive high-quality HIV/AIDS services,
including ART, at 50 hospital networks and health centers in Addis Ababa, SNNPR, Gambella and
Benshangul Gumuz regions. Comprehensive technical assistance and implementation support has
strengthened essential elements of the laboratory system, and improved service quality and consistency.
JHU has helped to: conduct assessment of laboratory services, train laboratory staff (via offsite and onsite
trainings on equipment operation, preventive maintenances, and HIV-related laboratory test procedures);
establish and strengthen quality assurance (QA) programs via on-site mentorship and by developing and
implementing SOPs, develop log books and improve documentation and recording; and provide technical
and logistic support for specimen referral linkage between testing hospitals and referring hospitals and
health centers. JHU has been doing major infrastructure support to hospital laboratories including
improvement of space in the rooms within the existing footage, epoxy painting of floor and wall in the testing
rooms, standard furnishing of the labs, and improving the electric line and drainage system. JHU renovated
two regional laboratories for establishment of DNA PCR for early infant diagnosis. In collaboration with CDC
and EHNRI, JHU has provided key technical and implementation support to Early Infant Diagnosis (EID)
program at regional, and site levels.
In FY09, JHU will provide its support to 50 hospital networks in Addis Ababa, SNNPR, Gambella and
Benshangul Gumuz regions, enabling each to provide comprehensive high-quality HIV/AIDS services. In
addition, JHU will continue supporting 9 health centers in emerging regions. Intensive site-level laboratory
support is an essential component of JHU's plans, as the availability of consistent and reliable laboratory
services will ensure quality HIV prevention, care, and treatment services. Ongoing training, supervision, and
mentoring of laboratory staff and hands-on implementation support will be provided to all 59 sites. JHU will
work directly with the regional lab; hospital labs and health center personnel to implement and monitor the
quality assurance programs at the 59 sites and will support the facilities to attain the minimum standards set
by EHNRI. JHU will provide technical support for process improvement including accreditation of regional
laboratories. JHU will continue to provide technical assistance to the rollout of HIV-1 DNA PCR for infant
diagnosis at regional levels.
JHU's laboratory support activities in FY09 will include:
(1) Strengthening of site-level laboratory quality systems, with emphasis on initiation and enhancement of
quality assurance programs in partnership with CDC, EHNRI and Addis Ababa, SNNPR, Gambella and
Benshangul Gumuz regional reference laboratories. These activities will include the preparation, revision
and implementation of standard operational procedures (SOPs) for HIV disease monitoring (hematology,
clinical chemistry, and CD4), specimen management, laboratory safety, and QA/QC program. JHU will also
support the preparation and provision of standard documentation and recording formats including QC forms,
lab request forms and registers. JHU technical advisors will provide ongoing support supervision and
mentorship at all sites, ensuring the delivery of high-quality laboratory services as well as systems
strengthening, skills transfer, and capacity development. JHU in collaboration with CDC, EHNRI and
Gambella and Benshangul Regional Health Bureau will support the establishment of the regional laboratory
at Gambella and Benshangul Gumuz. In addition, JHU will work closely with the regional laboratories at
Addis Ababa and SNNPR to build local capacity as this is the exit strategy for partners and for sustainability
of programs.
(2) Technical support for uninterrupted laboratory services at all 59 ART site networks. This includes:
assisting with the development, implementation and enhancement of laboratory inventory systems in the
hospital networks and ensuring availability of continued and sufficient reagent supplies; supporting timely
preventive and troubleshooting maintenance services; building regional capacity for essential laboratory
equipment maintenance capability, and supporting human resources by facilitating the availability of
adequately trained laboratory personnel at all sites. These activities will be coordinated with supply chain
management and regional laboratories. JHU regional laboratory advisors will work closely with the regional
lab associates of SCMS
(3) Capacity building and minor renovation of facility level laboratories:
JHU will provide regular mentorship of site-level staff focusing on improving laboratory management,
laboratory organization, layout and work flow, specimen management, testing procedures, standard
documentation, record keeping and reporting, and stock and inventory management. The mentorship will
address the integrated laboratory system with emphasis on HIV, TB, OIs and malaria. JHU will also conduct
periodic site assessments and will provide necessary and appropriate support including: minor renovations
and refurbishment of site labs; laboratory accessories needed for the day-to-day delivery of integrated
laboratory services. JHU will support preventive maintenance of essential integrated laboratory service
equipment and equipment care and management at the facilities and facilitate the major equipment
maintenance; and support for national laboratory reporting systems.
(4) JHU will technically support standardized trainings using nationally approved curricula with special
emphasis on onsite training and mentorship. These site-level and regional-level trainings will include: HIV
rapid test (point of care HIV rapid test training), HIV disease monitoring (hematology, clinical chemistry, and
CD4); laboratory training on integrated diseases including common OI diagnosis. JHU will provide continued
onsite training on the new HIV rapid testing algorithm and monitor and evaluate the utilization of the
algorithm at facilities. JHU will also support regional and onsite training on TB smear microscopy and
support the implementation of TB smear microscopy EQA manual.
Activity Narrative: (5) JHU will continue to provide technical assistance and implementation support to referral laboratory
services. This will strengthen the functioning of the reference labs as they supervise QA activities at lower
tier labs and provide access to more sophisticated diagnostic assays. JHU will also support
EHNRI/Regional labs to establish systems for specimen collection at health centers and/or peripheral
hospitals, transportation to appropriate hospital and regional laboratories, patient sample tracking, reporting
of results, and implementing and ensuring that standard guidelines and procedures are followed. JHU will
support the monitoring and evaluation activities in all laboratory program areas and will support the
expansion of LIS in the regions
(6) JHU will continue to provide key technical assistance to the early infant diagnosis program and viral load
test establishment in the regions. Working at the regional, and site levels, JHU will support not only HIV
DNA PCR testing capacity in the laboratory, but the clinical systems, HMIS systems, and linkages needed
to provide high-quality services to infants and families. Based on need assessment JHU will support the
establishment of HIV DNA PCR testing capacity at one sub-regional laboratory. JHU will also support the
establishment of viral load testing capacity at regional laboratories as planned by EHNRI. These will include
minor renovation, epoxy painting of floor and furnishing with standard laboratory furniture.
(7). Integration of OI diagnosis in the HIV/AIDS laboratory support: JHU in collaboration with other
stakeholders working in the laboratory area will establish common OIs and STIs diagnostics testing services
at regional labs and hospitals. This includes training of lab personnel on common OIs and STI diagnosis,
providing TA in setting up of the test services and providing some critical reagents and diagnostic kits. JHU
will provide technical support for the establishment and functionality of TB culture at regional laboratories.
Continuing Activity: 16638
16638 10620.08 HHS/Centers for Johns Hopkins 7485 3787.08 Support for $800,000
10620 10620.07 HHS/Centers for Johns Hopkins 5484 3787.07 FMOH $300,000
Table 3.3.16:
Site Level Data Support for Hospitals
In FY08, JHU-BSPH supported 50 sites, trained two data personnel per site in basic computer skills, data
tabulation, and management, implemented electronic ART data management system (RDB) in 33 of 38
public ART sites, 10 private sites, and five additional regional sites, and trained all data clerks in RDB use,
continued to assess quality of ART care using Lot Quality Assurance Sampling, and facilitated sharing of
best practices and experiences within and between regions.
In FY09, JHU-BSPH will collaborate with other partners in rolling out and integrating the national HMIS at
the site level. Support to sites for the integration of the national HMIS will include:
•technical assistance with the collection, archiving, retrieval, and reporting of comprehensive HIV services
data on the new forms and the flow of data through the new integrated data system
•technical assistance with the collection and documentation of data on other HIV services in addition to
ART, such as pediatric ART, TB/HIV, PMTCT, VCT, PICT using the appropriate HMIS forms
•routine, data-quality assurance exercises to ensure completeness and accuracy of information on the
HMIS forms
•training on basic monitoring and evaluation
•training on basic computer skills, data management skills, including data entry, data analysis, and on
tabulating and visualizing data using tables, charts, line and bar graphs and other standard methods, and in
technical paper writing and presenting. An emphasis will be placed on analyzing and using data at the site
level for local decision making and program improvement
•on-site supervision and mentorship to enhance the quality and use of data collected
In FY09, JHU-BSPH will focus on building the capacity of sites to fully transition and integrate into the new
HMIS. In accordance with government plans, certain site-level support activities provided in FY08, such as
support for data technicians and managers, and the printing and provision of the HMIS forms and tools, will
be phased out in FY09. JHU-BSPH will work with its sites to build their capacity to fully support the HMIS
themselves.
COP08 NARRATIVE
This is a continuing activity from FY07. The major purpose of this activity is to strengthen the
implementation of the national Health Management Information System (HMIS) for comprehensive
HIV/AIDS services and to optimize the use of data for service and program strengthening in Addis Ababa,
Benishangul-Gumuz, and Gambella regions, and the Southern Nations, Nationalities, and Peoples Region
(SNNPR).
In FY07, the International Johns Hopkins University-Bloomberg School of Public Health (JHU-BSPH)
supported 50 sites in Operational Zone 2 to collect, manage, analyze and use HIV/AIDS services-related
data generated at site level for decision-making to improve clinical and program management. In addition,
JHU-BSPH has trained more than 90 health professionals and data clerks in monitoring and evaluation
(M&E) and assisted regional health bureaus (RHB) to organize experience-sharing workshops.
In FY08, JHU-BSPH will expand its site-level capacity building in M&E to further improve quality data
collection and maximize data use for continuous service quality improvements. JHU will:
1) Intensify support for efforts to fully document information for pre-ART and ART patients on the national
HIV care/ART follow-up by:
a) Continuing routine, data-quality assurance exercises to measure completeness and accuracy of
information on follow-up forms
b) Providing support to clinical teams for accurate completion of follow-up forms
c) Supporting efforts to fully document information for PMTCT, tuberculosis (TB)/HIV, voluntary counseling
and testing (VCT), and provider-initiated counseling and testing (PICT) clients on the appropriate national
d) Supporting the integration of HIV/AIDS care and treatment data with national comprehensive HMIS
through technical support at site level in archiving, retrieving, and report aggregation, supported by routine
data-quality assurance assessments
e) Train healthcare providers, data clerks, and HMIS personnel on database use, including how to enter
records, query the databases, and produce routine reports
2) Provide support for M&E support tools developed for the national M&E systems and equipment. JHU-
BSPH will work to ensure availability of computers, computer peripherals, and storage equipment and an
uninterrupted supply of the national M&E tools at all the sites
3) Strengthen supportive supervision and mentorship. On-site supervision and mentorship will be provided
to enhance collection of accurate and complete data. JHU- BSPH will also work with site-level staff to build
capacity in data analysis, and in the use of data to manage and improve program delivery.
4) Support institutions to manage and use data fully and effectively. Sites will continue to be assisted in
tabulating and visualizing their data using tables, charts, line and bar graphs and other standard methods;
optional tabulations will include aggregation of data by patient, clinic, and regional levels. Continued FY08
activities will expand the number of facility-based health providers with basic computer skills and data
management skills, including data entry, data analysis, technical paper writing, and presentations.
5) Support the national laboratory information systems to ensure communication of patient results in an
efficient manner. There will be particular emphasis on communicating results to patients whose specimens
were transported to the hospital from another facility, such as a health center. Furthermore, JHU- BSPH will
assist sites in tracking specimens of patients who need more specialized tests, such as viral load, which are
currently performed only at regional labs.
Activity Narrative: 6) Support biannual, regional review meetings to provide fora where facilities can present their data and
share lessons learned. This activity will also continue to support and strengthen the national HMIS
implementation, document best practices, and present findings and experiences at local and international
scientific and programmatic forums. Implementation mechanisms will consist of necessary modeling at site
and RHB levels.
Continuing Activity: 16640
16640 10433.08 HHS/Centers for Johns Hopkins 7485 3787.08 Support for $300,000
10433 10433.07 HHS/Centers for Johns Hopkins 5484 3787.07 FMOH $150,000
Estimated amount of funding that is planned for Human Capacity Development $50,000
Table 3.3.17:
Clinical Simulation Technology (TheraSim) to support training on ART
In FY07, this was a new activity which links to various HIV treatment services activities supported by
PEPFAR. The capacity for rapid ART scale-up is severely limited by the rapid turnover of trained and
experienced HIV clinicians. To reduce this attrition and improve the knowledge-base of urban and rural
clinicians, JHU will introduce a continuing medical education and clinical-decision support tool via TheraSim
HIV clinical care simulator. To date, in FY07, TheraSim has been deployed to 38 sites, trained nearly 200
persons, and has been used to evaluate training outcomes for a basic ART training conducted by Johns
Hopkins University - Bloomberg School of Public Health (JHU-BSPH).
In FY08, JHU-BSPH will continue to work with TheraSim to provide support to 50 ART clinical sites (hospital
and health centers) to ensure all new physician and nursing staff are oriented to the case-learning program
and receive support to complete the training. The program will also be extended to all medical residents
enrolled in Addis Ababa University and Hawassa's training programs. TheraSim, under the guidance of JHU
-BSPH, will develop three new modules to expand the case learning approach to nurses, and to incorporate
new cases dealing with pediatric HIV care, tuberculosis (TB)/HIV, and advanced cases that deal with
treatment failure and other complications, for clinicians who have completed the basic training program.
Along with increasing the number of sites, the depth of the clinical complexity of cases and extent of the
personnel involved in the training program, JHU-BSPH will design an evaluation system to assess basic
ART training through the JHU-BSPH HIV telemedicine program. The modules will be used pre- and post-
training to assess training activities. A validation study will be developed to compare patient outcomes from
the simulator versus actual patient-outcome data in the clinics. In addition, TheraSim will provide
opportunities for clinicians to submit Ethiopian-based cases to be incorporated into the training program.
Clinicians will be compensated for their efforts, and TheraSim will act as an incentive and possible retention
TheraSim was introduced because the success of the PEPFAR Ethiopia ART program depends on the
skills and stability of the ART team - doctor, nurse, pharmacist, and lab personnel. The stability of
healthcare workers in the Ethiopia HIV program has been challenged since trained clinicians often find
better-paying positions outside the public sector after graduating from medical school, and general
practitioners, who are expected to spend 2-4 years in public hospitals in isolated regions, often leave the
posts prior to completing their contracts. These clinicians report feeling cut off from learning, and they desire
increased clinical decision-making support, as consultations with more experienced clinicians are
impossible due to lack of communication technology. To improve the clinical skills of rural clinicians,
increase their capacity for appropriate decision-making, and address their desire for professional growth,
JHU-BSPH will continue its distance-learning program using TheraSim, a program for clinical-decision
support. For urban physicians, JHU-BSPH will continue to provide training centers and ART clinics with
access to the training programs via CDs or the Web. PEPFAR Ethiopia believes that improving information
transfer about HIV will reduce turnover of geographically isolated clinicians, as well as those from
overwhelmed urban clinics—thus improving HIV/AIDS care.
TheraSim, Inc. is a US-based company providing software and services internationally to measure and
improve the quality of clinical practice for HIV/AIDS and a variety of chronic and infectious diseases,
including malaria, tuberculosis (TB), hepatitis and diabetes. Capacity-building in Ethiopia faces several
challenges, including: a need for rapid scale-up of clinical capacity and expertise in treating patients with
HIV/AIDS; high cost and slow response of classroom-based learning; an ongoing need for clinically-based
mentoring following didactic training; and a general absence of empirical data after drug distribution.
TheraSim monitors and addresses gaps in clinical competence following existing classroom training and
helps improve patient outcomes in the ever-changing therapeutic environment. The TheraSim Clinical
Quality Assurance System has four key components: simulation-based assessment and intervention,
electronic medical records, decision support, and dashboard reports. The system is both Internet- and CD-
ROM-based, providing simulation of hypothetical patients in various stages of HIV/AIDS. The simulated
cases can be adapted for use by nurses, basic-level physicians (those who see few HIV/AIDS patients), and
expert-level clinicians. TheraSim uses guidelines approved by the World Health Organization (WHO) or
country-specific guidelines where they exist, and regionally-appropriate pharmacology and treatment
modalities with authentic "virtual" case studies for diagnosis and treatment of HIV/AIDS and co-morbidities.
It complements other methods, such as formal training, bedside teaching, and case discussions. Simulated
cases are used, for which diagnosis and treatment decisions must be made; the system then gives
feedback on these choices, referring to country and relevant international guidelines.
TheraSim can be adapted for training nurses and allied health professionals as needed. In the next phase
of support, TheraSim will advance existing capacity-building efforts efficiently by improving and measuring
the quality and outcome of clinical practice, including ART delivery for HIV/AIDS and the treatment of TB, in
compliance with published national treatment guidelines. TheraSim will seamlessly augment efforts begun
with CDC and other programs. For example, Washington University/I-TECH has developed training
curricula for ART, management of opportunistic infections (OI), and PMTCT with the support of international
partners and has organized numerous trainings. These training programs primarily reached health
professionals in the public sector. Various institutions have organized 2-5 day basic-training workshops on
HIV/AIDS management, one-day advanced courses for clinicians, and evening seminars on specific topics,
usually attended by clinicians from public and private sectors. However, no reliable and accessible system
exists to: assess individual health workers' skills; assess the overall effect of existing training activities;
provide ongoing mentoring and support; provide clinical support to reduce medical error; or to report clinical
skills and patient outcomes. TheraSim and JHU-BSPH will deploy TheraSim's field-tested Clinical
Performance Management computer-based decision support ("TheraSim CPM") system for rapid and
effective ongoing mentoring of healthcare workers throughout Ethiopia to support PEPFAR Ethiopia goals.
The system will continue to use regionally appropriate pharmacology and treatment modalities with
Activity Narrative: authentic case studies for diagnosis and treatment of HIV/AIDS and TB.
Continuing Activity: 16639
16639 10489.08 HHS/Centers for Johns Hopkins 7485 3787.08 Support for $180,000
10489 10489.07 HHS/Centers for Johns Hopkins 5484 3787.07 FMOH $150,000
Estimated amount of funding that is planned for Human Capacity Development $80,000
Strengthening Pre-Service Training for Medical Doctors This is a new activity in response to the critical
need and one of the highest priorities of the Ethiopian Federal Ministry of Health (FMOH) to scale up the
training of medical doctors. Problem statement Recent assessments suggest that the shortage of medical
doctors and other health professionals, poor performance, inequitable distribution of the available health
workforce among regions and health facilities are root causes for poor service delivery of health care. The
FMOH recognizes that with the existing levels of outputs from medical schools of medical doctors, surgical
specialists, anesthesia professionals, midwives, dentists and mental health professionals it will have
difficulties reaching the MDGs by 2020. While the FMOH recognizes the rapid need of medical specialties,
it stated that the existing level of output for health extension workers, health officers, nurses, pharmacists
and paramedics is sufficient and thus no major scale up is required.
The FMOH intends to scale up the number of medical doctors from the current 1,806 to 9,000 doctors in
public service thru a number of ambitious interventions. These are as follows: 1. To expand medical
training by increasing the number of medical schools from currently seven to twenty-one. Up to five teaching
facilities such as hospitals or other medical teaching centers will be attached to each new medical school.
Each of these teaching facilities will have an annual intake of 100 students. Thus, each new medical school
is expected to have an annual intake of up to 500 new students. 2. To introduce a 4 year medical training
program (for BSc holders) in addition to the existing six year program without compromising quality. 3. To
identify hospitals with adequate patient flow to be upgraded as teaching centers. 4. Utilize appropriate
Information Communication and Technology (ICT) to enhance the quality and efficiency of medical
education.
The FMOH has repeatedly requested PEPFAR Ethiopia, both informally and formally, to assist, thru US-
based universities, to scale up the training of medical doctors.
John Hopkins University (JHU) is a major US-based university partner for PEPFAR-Ethiopia. The regions in
which JHU is operational with PEPFAR funding have currently two medical schools located in the cities of
Awasa and Addis Ababa.
Thus, in FY09, major activities for JHU are to:
• Conduct needs assessment of Ethiopian public medical education institutions for implementing the
accelerated medical doctors training program.
• Provide technical, material and financial support to the FMOH, MOE, HERQA, and Universities at the
educational facility level in teaching materials development, review, publication and distribution activities as
well as in supply of essential teaching/training materials for medical education.
• Provide, based on needs assessment, limited support where feasible to faculty and infrastructure
development i.e. support to the establishment of training laboratories and learning centers, libraries and the
procurement of teaching materials to accommodate the large scale intake of new medical students.
• Monitor and evaluate the progress in the implementation of the medical doctors' education/training
programs.
• Assist in the development, local adaptation and review of curricular/training materials and modules for pre-
service education.
• Assist faculty and program managers in teaching and research, coordination, communication and
networking for medical education in the existing and upcoming public universities providing medical
education in Ethiopia.
• Assist Ethiopian medical education institutions in the development and effective application of different
models of education and training, including community-based team training and information technology for
distance learning-assisted approaches, standards-based education management and recognition, student
assessment and evaluation procedures, faculty development, establishment and/or reinforcement of
academic development centers in the universities/faculties.
• Coordinate all activities with all PEPFAR implementing partners on regional and central levels including
FMOH and HAPCO thru established mechanisms.
Table 3.3.18:
