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
Food by Prescription (FPB) For Pregnant and Lactating Women, Exposed Infants
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
This is a continuing activity. The 40% increase in budget is essential to maintain COP08 target with a 10%
increase and to mitigate the 40% rise in food price. PEPFAR Ethiopia will start to implement therapeutic
feeding in the form of Food by Prescription (FBP) in selected hospitals and health centers. The program will
expand to more sites and enroll severely malnourished people living with HIV/AIDS (PLWH), HIV-positive
pregnant women in PMTCT programs, HIV-positive lactating women in the first six months post-partum,
their infants, and OVC. Food by Prescription for PMTCT clients is part of comprehensive PMTCT services
at health facilities that include: prevention, treatment, and care and support. Food by Prescription is a care
and support service. In view of the low PMTCT uptake in the country, the initiation of the Food by
Prescription program may play a key role in encouraging pregnant and lactating mothers to use health
facility services.
COP08 ACTIVITY NARRATIVE
The Food by Prescription (FBP) activity is a continuing activity designed in FY07 that aims to target 8,000
HIV-positive pregnant women and their infants over six months of age. For FY08, FBP activities total $4.6
million ($1 million in palliative care, $3 million in treatment, and $600,000 in PMTCT) which leverages
$31,900,000 in food.
Studies have established clinical malnutrition as a risk factor for HIV progression and mortality for pre-ART
and ART patients, as well as for birth outcomes among HIV-positive women. As HIV infection progresses,
hyper-metabolism, mal-absorption of nutrients, diarrhea, and anorexia can all become severe challenges to
maintenance of adequate nutritional status. In addition, poor nutritional status and inadequate dietary intake
can adversely affect adherence to and efficacy of drug treatments. According to the World Health
Organization (WHO), energy requirements are increased by 10% in asymptomatic adults, 20-30% in
symptomatic adults and as much as 50-100% in infected children with growth faltering. According to WHO,
dietary protein levels should be maintained at 12-15% of total energy intake (approximately twice the level
typically found in cereal- or tuber-based diets with minimal animal-source food intake), and a single RDA
level of essential vitamins and minerals (which many PLWH in resource-limited settings are unable to
consume through their regular diets) is needed.
This situation, combined with the very high levels of malnutrition and food insecurity present in Ethiopia,
implies that clinically malnourished PLWH in care and treatment programs in Ethiopia have an immediate
and critical need for nutrient-dense foods that can be readily and safely prepared and consumed to improve
their nutritional and immunological status, especially as an adjunct to ART.
In response to this situation, PEPFAR Ethiopia included a FBP program in FY07 on a pilot basis in 20
hospitals and 25 health centers. This will involve expanding to approximately 30 new health facilities,
bringing the total number of targeted facilities to 75. The targets will be adjusted depending on actual unit
costs for food, as well as on observed levels of operational costs.
The program involves procurement and distribution of a ready-to-use therapeutic food (RUTF) and a
nutrient-dense, blended flour product to targeted health facilities, from where the food is provided to
severely malnourished ART and pre-ART clients and to HIV-positive pregnant and lactating women.
Anthropometric entry and exit criteria based on WHO classification of malnutrition are used. The program is
being implemented by partners in Ethiopia in coordination with the Ministry of Health (MOH)/HIV/AIDS
Prevention and Control Office (HAPCO) and with technical assistance from Food and Nutrition Technical
Assistance Project (FANTA, HBHC-10571.08).
Based on the experience and results of the pilot program, PEPFAR Ethiopia will scale up the program to
reach a larger target group of health facilities and eligible beneficiaries. In addition, an assessment of the
acceptability of RUTF among adult clients will be carried out, and based on the results the use of food
products may be refined and improved if needed. As part of the broader technical assistance activity for
nutrition and HIV, the pilot program will be assessed and lessons will be used to inform refinement of the
program for scale-up. Lastly, this activity will extend support to strengthen therapeutic feeding services for
pediatric HIV patients and OVC and extend these services to areas of high HIV prevalence. Malnutrition is a
severe problem among pediatric HIV patients in Ethiopia and PEPFAR will support partners experienced in
addressing child malnutrition to ensure pediatric HIV clients and OVC are covered in therapeutic feeding
and care services. The program seeks to refer beneficiaries to household food assistance and livelihood
support, where such services are available.
Supplementary food will be provided on a monthly basis for women in select PMTCT programs during
pregnancy until the infant in weaned (~4-6 months of age), at which time food will continue to be provided
on a monthly basis for the infant until two years of age. FANTA will assist in establishing the product
specifications and production standards (e.g., good manufacturing practices and safety) for the low-cost,
nutrient dense supplementary food(s) to be procured under this activity.
A significant part of this activity will focus on linkages and coordination with the MOH/HAPCO, UNICEF,
World Food Program (WFP), and other implementing partners to ensure that the FBP activity will not cause
negative consequences in health facilities. Since the food can only be provided to PLWH, the FBP activity
seeks to coordinate with other partners, where available, to help provide comprehensive food and nutritional
services for beneficiaries not targeted by the FBP activity.
Pregnant and lactating women will be provided with FBP to generate routine attendance at antenatal care
(ANC), assisted delivery and postpartum follow-up. Through PEPFAR support, the FBP program has the
opportunity to decrease malnutrition rates among HIV-positive pregnant and lactating women. This activity
will provide food support to approximately 8,000 HIV-positive women and their infants over six months at
Activity Narrative: HIV care and treatment facilities, contributing to improved functioning, quality of life, and treatment
outcomes. The activity aims to improve ARV adherence and the nutritional status of the beneficiaries.
The food provided to PMTCT clients at health centers may serve as an incentive for them to return for
counseling and ANC since often they are provided drugs at hospitals, but the counseling and ANC occurs at
the health centers. By ensuring that the food needs of malnourished PLWH are met, this activity will
strengthen the care and support, ART, and other services that PEPFAR Ethiopia is supporting through the
care-and-support contracts and the ART scale-up activities listed above. Implementing partners will work
closely with the partners for these activities to ensure coordination in integrating food into these clinical
services. Partners will also coordinate with UNICEF, WFP, the Clinton Foundation HIV/AIDS Initiative, and
other partners providing nutritional support to HIV-affected populations to ensure coordinated coverage and
consistent approaches and protocols.
The food program will also serve as a critical component of PEPFAR Ethiopia's broader effort to strengthen
integration of nutrition into HIV services, and the assessment and counseling services offered through that
integration effort are important components of the FBP program.
Severely malnourished PLWH (ART and pre-ART clients), and HIV-positive pregnant women will be
reached with food support and complementary services at hospitals and health centers. Service providers
will be trained to assess clients' eligibility for food, provide FBP, and counsel clients in use of the food and in
related nutritional practices. This activity will target women in urban and peri-urban sites in Ethiopia and also
infants, who are priorities for PEPFAR.
In response to the urgent need for food to support successful care and treatment, PEPFAR resources will
be used to provide therapeutic food to malnourished PLWH, including pregnant and lactating women and
OVC. The activity also seeks to enhance nutritional assessment, training and counseling to promote
adherence and improve nutritional care among the beneficiaries.
Through the provision of food, this activity will increase attendance at ANC clinics, therefore improving
maternal and child health issues.
New/Continuing Activity: Continuing Activity
Continuing Activity: 16590
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
16590 10640.08 U.S. Agency for To Be Determined 7597 7597.08 Food by
International Prescription
Development
10640 10640.07 U.S. Agency for To Be Determined 5474 683.07 *
International
Emphasis Areas
Health-related Wraparound Programs
* Child Survival Activities
* Safe Motherhood
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
Food by Prescription in HIV Care and Treatment
This is a continuous activity. The proposed budget increase for COP09 is to mitigate the 40 % rise in food
costs and procurement. Ethiopia is categorized as a focus country for food and nutrition, PEPFAR Ethiopia
has identified nutrition support as a priority to provide care and support services which is critical to improve
ART adherence and treatment outcomes. PEPFAR Ethiopia will start to implement therapeutic feeding in
the form of Food by Prescription (FBP) at selected hospitals and health centers that have high volume
number of high risk cases. The program will expand to more sites and enroll severely malnourished PLWH,
HIV-positive pregnant women in PMTCT programs, HIV-positive lactating women in the first six months post
-partum, their infants, and OVC.
COP 08 Narratives:
The Food by Prescription (FBP) activity is a continuing activity designed in FY07 and is expected to
increase care and support to 14,000 malnourished PLWHA at 80 health facilities in Ethiopia. This is an
increase from 45 health facilities in COP07.
symptomatic adults and as much as 50-100% in infected children with growth faltering. WHO data reports
that dietary protein levels should be maintained at 12-15% of total energy intake (approximately twice the
level typically found in cereal- or tuber-based diets with minimal animal-source food intake), and a single
recommended daily allowance (RDA) level is needed of essential vitamins and minerals (which many
PLWHA in resource limited settings are unable to consume through their regular diets).
implies that clinically malnourished PLWHA in care and treatment programs in Ethiopia have an immediate
In response to this situation, PEPFAR Ethiopia included an FBP program in FY07 on a pilot basis in 20
hospitals and 25 health centers. The new activity will involve expanding to approximately 35 new health
facilities that have a high ART patient load, bringing the total number of targeted facilities to 80. The
program involves procurement and distribution of a ready-to-use therapeutic food (RUTF) and a nutrient-
dense blended flour product to targeted health facilities, from where the food is provided to severely
malnourished ART and pre-ART clients and to HIV-infected pregnant and lactating women. Anthropometric
entry and exit criteria based on WHO classification of malnutrition are used. Beneficiaries will also receive
nutritional counseling and education.
The program is being implemented by partners in Ethiopia in coordination with the Ministry of Health
(MOH)/HIV/AIDS Prevention and Control Office (HAPCO) and with technical assistance from the Food and
Nutrition Technical Assistance (FANTA) Project (HBHC-10571.08).
WFP, Clinton Foundation and other implanting partners to ensure that the FBP activity will not cause
negative consequences in health facilities. Since the food can only be targeted to PLWHA, the FBP activity
This activity will provide food support to approximately 14,000 malnourished PLWHA at 80 HIV care and
treatment facilities, contributing to improved functioning, quality of life, and treatment outcomes. The activity
aims to improve ARV adherence and the nutritional status of the beneficiaries.
By ensuring that the food needs of malnourished PLWHA are met, this activity will strengthen the care and
support, ART, and other services that PEPFAR Ethiopia is supporting through the Care and Support Project
(CSP) and the ART Scale-Up activities listed above. Implementing partners will work closely with the
partners for these activities to ensure coordination in integrating food into these clinical services. Partners
will also coordinate with UNICEF, the World Food Program, Clinton Foundation HIV/AIDS Initiative, and
Activity Narrative: integration of nutrition into HIV services, and the assessment and counseling services offered through that
integration effort are important components of the Food by Prescription program.
Severely malnourished PLWHA (ART and pre-ART clients), and HIV-infected pregnant women will be
will be trained to assess clients' eligibility for food, provide food by prescription, and counsel clients in use of
the food and in related nutritional practices.
be used to provide therapeutic food malnourished PLWHA. The activity also seeks to enhance nutritional
assessment, training and counseling to promote adherence and improve nutritional care among the
beneficiaries.
Continuing Activity: 16597
16597 5616.08 U.S. Agency for To Be Determined 7597 7597.08 Food by
10398 5616.07 U.S. Agency for To Be Determined 5474 683.07 *
5616 5616.06 U.S. Agency for Management 3798 3798.06 $327,000
International Sciences for
Development Health
Gender
* Increasing gender equity in HIV/AIDS programs
* Increasing women's access to income and productive resources
Estimated amount of funding that is planned for Human Capacity Development
Estimated amount of funding that is planned for Food and Nutrition: Commodities
Table 3.3.08:
April 2009 Reprogramming:
Activity Title: Malaria HIV Co-infection
Ethiopia improved access to preventive and curative services against HIV and malaria at the primary health
care level but malaria remains among the top three causes of morbidity. There are multiple ad hoc
evidences that suggest Malaria infection is one of the leading causes of morbidity and probably mortality
among HIV infected patients. Globally, it is well established that such co-infection leads to worsening of
HIV/AIDS progress and amplified transmission of Malaria among the general community. It is also well
documented that the co-infections increase the chance of malaria drug resistance, including the current life
saving ones.
The ultimate goal of HIV/AIDS care and treatment programs is to improve the quality and span of life among
persons living with HIV/AIDS; but without appropriate organized systematic response to malaria, the
ultimate goal will be challenged to be realized in Malaria endemic or epidemic-prone areas.
Strengthening the existing Presidential Malaria Initiative wraparound activity with PEPFAR the activity will
assess the level of Malaria and HIV coinfection including a pilot implementation with the following activities
in an area of high HIV prevalence and endemic or epidemic prone areas of Ethiopia:
Raising the level of sensitiveness of health workers in diagnosing and treating malaria among Pre- and
ART patients
Regular screening for malaria in selected areas and high malaria transmission zones
Malaria treatment as per the national guideline
Developing a study protocol, that can also be used for other similar studies
Site selection (representative across different HIV and malaria transmission zone), sampling and
development of tools
Longitudinal data collection at least over two high malaria transmission periods
Data storage and analysis stratified at different epidemiological zones
Write-up and dissemination
New/Continuing Activity: New Activity
Continuing Activity:
Food by Prescription
This is a continuing activity from COP 2008. The activity was divided into Adult and Pediatric treatment
sections. This section focuses on the Adult treatment interventions with a proposed 85% of the base
budget increase of $3 million for COP09. The budget increase for the Adult treatment mitigates the 40 %
rise in world food costs and procurement, ensuring that we can continue to reach present benficiaries with
an additional 10% increase to reach those most in need.
COP 08 Narrative:
Activity Narrative: Severely malnourished PLWHA (ART and pre-ART clients), and HIV-infected pregnant women will be
Continuing Activity: 17712
17712 17712.08 U.S. Agency for To Be Determined 7597 7597.08 Food by
Program Budget Code: 10 - PDCS Care: Pediatric Care and Support
Total Planned Funding for Program Budget Code: $3,081,122
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
PEDIATRIC CARE &TREATMENT
Program Area Context
In general, most childhood diseases are preventable communicable diseases. Ethiopia's under-five mortality rate is among the top
30 in the world, and around 70% of the morbidity and mortality in infants and young children is accounted for by a few common
childhood illnesses, including HIV/AIDS. Over 90% of all children that are HIV positive acquire it as a result of mother-to-child
HIV transmission (MTCT). In resource rich settings, Highly Active Antiretroviral Therapy (HAART) has helped in improving the
Pediatric HIV scenario. HIV-infected children can now survive to adolescence and adulthood.
Though Pediatric HIV/AIDS is preventable through a strong prevention of mother-to-child HIV transmission (PMTCT) program,
coverage with PMTCT service coverage in Ethiopia is less than 10%. In 2007 alone, there were about 75,420 HIV positive
pregnancies in the country with an estimated 14,148 HIV positive births. PMTCT has been made a top priority by PEPFAR
Ethiopia in FY09 to address areas of under-performance.
Relatively few children living with HIV/AIDS have access to HIV care and treatment services. In 2007, about 64,813 children
(under the age of 15 years) were living with HIV/AIDS (CLWH) in Ethiopia (6.6% of the estimated 980,000 PLWH in Ethiopia), and
out of these, 25,000 CLWH (10% of the estimated 250,000 PLWH in need of ART) were estimated to be eligible for antiretroviral
therapy (ART). According to July 2008 Federal HIV/AIDS Prevention and Control Office (HAPCO) statistics, only 6,100 (5.5%)
children were on ART out of the 110,000 Ethiopians on ART, including just 503 (8.2%) children under 18 months of age. Further
more, 17,396 CLWH were receiving care and support services, including 2,156 infants under 18 months of age.
As part of the pediatric care and treatment program, 111 hospitals (77.6% of the 143 hospitals nationwide) and 37 health centers
(5.6% % of the 690 health centers nationwide) are currently providing comprehensive pediatric care and treatment services in all
regions in the country.
Though the experience in pediatric HIV/AIDS care and treatment in Ethiopia is limited, the Government of Ethiopia (GOE), with
the support from PEPFAR and other stake holders is striving to improve the situation. The GOE's policy focuses on
decentralization of Pediatric ART services to health center level. This is in line with their overall goal of Universal Access by 2010.
The Universal Access road map for 2007-2010 recognizes that pediatric care and treatment deserves special attention. PEPFAR
Ethiopia will work to ensure that pediatric ART is at least available wherever adult ART is available. Some key strategies being
used are: promotion of active and early detection of exposed/infected children by health care providers during all clinical
encounters (under-five clinic, OPD, in-patients, etc); expansion of diagnostic PCR capacity; expansion of the number of sites
delivering pediatric care and treatment services; establishment of more effective referral networks; and utilizing family-based
linkages for adults and siblings enrolled in chronic care and treatment for HIV/AIDS.
The Road map to universal access anticipates that by 2010 a total of 2,245,436 children will have been tested and, consequently,
expects to have identified 80,616 CLWH. According to the plan, 67,528 CLWH will be in care, and 26,347 CLWH will be on
treatment. The number of health facilities providing pediatric HIV care and treatment services is expected to expand to reach 1355
health facilities, including hospitals and health centers. Due to limited resources and capacity, PEPFAR Ethiopia will need to
prioritize support to those areas and sites having the largest burden of CLWH.
PEPFAR supports provision of comprehensive services to the HIV exposed/infected children including: early infant HIV diagnosis
(EID) using age appropriate test (DNA PCR or Rapid Antibody test) and enrollment into care; growth monitoring and
developmental assessment; counseling on infant feeding, maternal and child nutrition and support; co-trimoxazole preventive
therapy (CPT); TB risk assessment and isoniazid preventive therapy following TB exposure; OI prevention and management;
routine preventive pediatric services including immunization; psycho-social support of the child and the family; and early diagnosis
and treatment of common infections. So far, PEPFAR has supported the establishment of six laboratory centers that provide the
EID service in hospitals and health centers various regions and will expand to six additional sites in FY09.
PEPFAR implementing partners include the University of Washington (I_TECH); Columbia University International Center for
AIDS Programs (I-CAP); Management Sciences for Health (MSH); John Hopkins University (JHU-TSEHAI); University of
California, San Diego (UCSD); and the African Network for Care of Children Affected by HIV/AIDS (ANECCA). The University
partners work at both hospital level and health centers in emerging and administrative regions whereas MSH and ANECCA
support health centers in the rest of the country. I-CAP-Ethiopia, being the lead for pediatrics among the PEPFAR partners, has
spearheaded development of the national pediatric care and treatment program and played a central role in establishing a strong
national pediatric Technical Working Group (TWG) responsible for providing guidance to the pediatric care and treatment service
in the country.
With the support from PEPFAR, training manuals on pediatric care and treatment have been standardized for use at a national
level. Recently, a new training manual on pediatric HIV care and treatment service for nurses was developed and training is being
undertaken in different regions. Furthermore, the Ethiopian national pediatric care and treatment guidelines have been recently
revised to adopt the new WHO recommendations for early initiation of treatment in HIV infected children.
The major obstacles for scaling up pediatric care and treatment in Ethiopia include: lack of human resources and scarcity of
pediatric providers; limited systematic effort to identify and follow HIV-exposed infants and limited availability of virological tests
(DNA-PCR) for children under 18 months of age; missed opportunities for testing children; insufficient advocacy and
understanding that ART is efficacious in children; and limited experience with program implementation to provide pediatric
HIV/AIDS care and treatment. Regional Health Bureaus (RHB) still lack expertise to implement and supervise pediatric care and
treatment programs. The severe shortage of health care providers is compounded by the fact that only a few of them have been
trained to provide care and treatment to children living with HIV/AIDS. Furthermore, while nurses represent the majority of the
child health service workforce in the public sector, currently comprehensive pediatric HIV care and treatment service is only widely
available at hospitals where medical doctors are primarily responsible.
In FY09, PEPFAR Ethiopia plans to address some of the challenges and continue the assistance to GOE to achieve the road map
targets. To this effect, PEPFAR-Ethiopia will employ a number of strategies including: increasing demand for pediatric HIV/AIDS
services among the general population; increasing physical accessibility of services; promoting pediatric HIV case detection; and
improving the quality of pediatric HIV/AIDS services.
Linkage between pediatric HIV prevention and care/treatment services including PMTCT, HIV Counseling and Testing (HCT),
TB/HIV and others will also be emphasized. Importantly too, is the connection between care/treatment and support services at
both community and facility levels. Strengthening linkage between OVC and facility based care and treatment services will be one
of the areas of focus in FY09. Moreover, sensitization of the community on the benefits of early infant HIV diagnosis and
enrolment into care/treatment through resource persons such as community volunteers, mother support groups, case managers,
Health Extension Workers, and Community-Oriented Outreach Workers (COOWs) is expected to improve enrolment in paediatric
care and treatment services. Such approaches would ensure continuum of care and treatment for the HIV-exposed/infected child
and better health outcome.
PEPFAR Ethiopia recognises that the HIV-exposed/infected child should be cared for in a holistic manner addressing their
physical, social, psychological, and spiritual needs. Furthermore, it is cognizant of the dependence of the child on the family and
hence the need to provide the care and treatment services from a family perspective and focuses on expanding a family-centred
approach. In FY09 PEPFAR Ethiopia will continue to support provision of pediatric care and treatment services to the HIV-
exposed/infected children in a comprehensive manner in a family setting, which improves adherence and prolongs the survival of
parents and caregivers living with HIV/AIDS. In addition, the preventive care package for the HIV-exposed/infected children will be
emphasized. Furthermore, HIV-exposed/infected children and their families will be given nutritional support through programs
including Urban HIV/AIDS and Food by Prescription programs. The Food and Nutrition Technical Assistance (FANTA) program
will provide the required technical support.
PEPFAR Ethiopia will make use of the existing non-PEPFAR wrap-around programs to ensure provision of comprehensive
pediatric HIV prevention, care and treatment services. Notably, is the Academy for Educational Development (AED
Communication for Change (C-Change) program under the Presidential Malaria Initiative (PMI). This program will be instrumental
in provision of ITN to HIV-exposed/infected children. Nutritional support to HIV-exposed/infected children and their families will be
complemented by nutritional programs implemented by Catholic Relief Services (CRS) and Relief Society of Tigray under the US-
supported program Assets and Livelihoods Transition (ALT) Office. Another wrap-around program of importance will be the
Pathfinder International Newborn and Child Health (NBCH) program. It will augment the PEPFAR's efforts in the increasing
access to safe water for children living with HIV/AIDS and their families. PEPFAR Ethiopia will also work with the Royal
Netherlands TB Foundation program in pediatric TB prevention, case detection and treatment among the HIV-exposed/infected
children.
In FY09, PEPFAR Ethiopia will put an increased emphasis on monitoring and evaluation. Information will be collected through
reports, field visits, surveys, mid-term evaluation, end of project evaluation and partner performance reviews among other ways.
The indicators provided by Office of the Global AIDS Coordinator (OGAC) will be part of the performance measures for the
pediatric HIV/AIDS programs.
In order to improve access to pediatric HIV/AIDS services, the capacity of first-level care providers to identify and manage HIV-
exposed/infected children must be enhanced. In FY09, PEPFAR Ethiopia will continue to support the task shifting strategy to
make the service available at primary health care level in high-burden areas. In FY09, capacity building will be a focus through
strengthening of training on pediatric HIV/AIDS care and treatment at hospital level and rollout of the newly developed training
package for health professionals working at high-burden health centers.
PEPFAR Ethiopia is cognizant of the reality that provision of pediatric HIV/AIDS services requires a concerted effort of various
players within the GOE framework. PEPFAR Ethiopia will therefore continue to play a supportive role to the GOE in collaboration
with other international and bilateral organizations. The Global Fund for AIDS, TB and Malaria (GFATM) will complement PEPFAR
efforts especially in the provision of drugs for opportunistic infections. The Clinton HIV/AIDS Initiative (CHAI)/Ethiopia will continue
to be instrumental in pediatric HIV laboratory support and provision of pediatric ARVs; among others. International organizations
such as World Health Organization (WHO) and United Nations Children's Fund (UNICEF) will participate in provision of technical
support.
To ensure sustainability of pediatric HIV/AIDS services in Ethiopia, exit strategies for PEPFAR Ethiopia-supported FY 09 pediatric
HIV/AIDS programs will be given due prominence. Emphasis will be put on capacity building for managing pediatric HIV/AIDS
programs while at the same time promoting government program ownership and sustainability.
Table 3.3.10:
Food by Prescription in HIV Care and Treatment Facilities
sections. This section focuses on the Pediatric treatment interventions with a proposed 15% of the base
budget increase of $3 million for COP09. The budget increase for the Pediatric treatment mitigates the 40
% rise in world food costs and procurement, ensuring that we can continue to reach present targets with an
additional 10% increase to reach those most in need.
COP08 NARRATIVE
increase the efficacy and effectiveness of ARV for patients on ART treatment in Ethiopia. For FY08, FBP
activities will total $4.6 million ($2 million in palliative care, $2 million in treatment and $600,000 in PMTCT)
which leverages $31,900,000 in food.
High levels of malnutrition combined with food insecurity present in Ethiopia, implies that clinically
malnourished PLWH in care and treatment programs in Ethiopia have an immediate and critical need for
nutrient-dense foods that can be readily and safely prepared and consumed to improve their nutritional and
immunological status, especially as an adjunct to ART.
malnourished ART and pre-ART clients and to HIV-positive pregnant and lactating women. Anthropometric
The logistics of the FBP Program could potentially be managed by Supply Chain Management System
(SCMS). The organization is currently handling supply of drugs and other clinical materials to health
facilities. SCMS will also have to examine the storage capacity at pharmacy stores, which are usually
limited and often full.
The program is being implemented by partners in Ethiopia in coordination with Ministry of Health/HIV/AIDS
Prevention and Control Office (MOH/HAPCO) and with technical assistance from the USAID/GH/HIDN
Food and Nutrition Technical Assistance (FANTA) Project.
World Food Program (WFP), Clinton Foundation and other implanting partners to ensure that the FBP
activity will not cause negative consequences in health facilities. Since the food can only be targeted to
PLWH, the FBP activity seeks to coordinate with other partners, where available, to help provide
comprehensive food and nutritional services for beneficiaries not targeted by the FBP activity. SCMS can
work with these groups to try and ensure that food resources are distributed evenly.
This activity will provide food support to approximately 14,000 malnourished PLWH at 80 HIV care and
treatment facilities, contributing to improved functioning, quality of life, and treatment outcomes. The targets
will be adjusted depending on actual unit costs for food, as well as on observed levels of operational costs.
The activity aims to improve ARV adherence and the nutritional status of the beneficiaries.
By ensuring that the food needs of malnourished PLWH are met, this activity will strengthen the care and
support, ART, and other services that PEPFAR Ethiopia is supporting through the Care and Support
Program and the ART Scale-Up activities listed above. Implementing partners will work closely with the
will also coordinate with UNICEF, WFP, Clinton Foundation HIV/AIDS Initiative, and other partners
providing nutritional support to HIV-affected populations to ensure coordinated coverage and consistent
approaches and protocols.
Activity Narrative: In response to the urgent need for food to support successful care and treatment, PEPFAR resources will
be used to provide therapeutic food malnourished PLWH. The activity also seeks to enhance nutritional
beneficiaries
Program Budget Code: 12 - HVTB Care: TB/HIV
Total Planned Funding for Program Budget Code: $8,944,854
"Know Your Epidemic" is paramount to the success of the PEPFAR/Ethiopia Team. The 2007 estimate indicates a low-level
generalized epidemic for Ethiopia with an overall HIV prevalence of 2.2%. This prevalence estimate does not, however, tell the full
story of the epidemic here where the majority of infections occur in urban settings. The 2007 single point prevalence study
estimates urban prevalence is 7.7% (602,740 persons living with HIV and AIDS (PLWH)) and rural prevalence is 0.9% (374,654
PLWH). Yet specific information on the association between HIV and TB in Ethiopia is very limited. According to the WHO 2007
Global TB Control Report, the national estimate of adult TB cases infected with HIV is 11%. Scientific evidence shows that an HIV
positive individual who has latent TB infection has a 5 -10% annual and a 30% life-time risk of developing active TB disease.
According to the WHO Global TB Control Report issued in 2008, Ethiopia ranks 7th out of the top 22 High TB Burden Countries in
terms of total number of TB cases notified in 2006. The estimated incidence of all forms of TB and Smear Positive Pulmonary
Tuberculosis (PTB+) was 379 and 168/100,000, respectively. The case detection rate of PTB+ cases was 27%, less than half of
the global target of 70%. DOTS treatment success rate for sputum positive pulmonary TB cases was 78% in 2006 showing good
progress compared to the status in 2004
In FY08, annual TB/HIV collaborative activity work plan has been developed by the national TB/HIV technical advisory body to
coordinate implementation and resources at national level. Through active involvement in the national TB/HIV technical working
group, USG agencies and partners have assisted the establishment of TB/HIV Advisory Committee (THAC) at all Regional Health
Bureaus to ensure close collaboration and coordination of TB and HIV control programs at all levels. Technical and financial
support has been provided in the development and review of the TB/HIV implementation guideline, the TB and leprosy control
manual, standardized national TB/HIV training manual and national TB/HIV surveillance guidelines. The TB unit register has been
revised to enable capturing of HIV related information and the TB/HIV reporting format has also been revised. Development of
TB/HIV IEC/BCC materials is underway. PEPFAR also assisted MOH's initiative in the MDR-TB management pilot project by
closely collaborating in the MDR TB management technical working group in the development of proposal for the green light
committee and MDR-TB management implementation guideline as well as assisting in second line drug selection and
quantification for procurement. More over in FY08 (up to first quarter) the TB/HIV collaborative activities have been implemented
in 446 public facilities at national level. PSP and USG universities have initiated TB/HIV services at 148 private hospitals and
health centers.
The TB/HIV activities will continue to strengthen hospitals, health centers and health posts, the latter two categories being the
facilities that deliver most preventive and curative health services throughout Ethiopia. As part of the ART health network,
Management Sciences for Health (MSH)/Care and Support Program (CSP) will link with network hospitals for referrals and work
with clients and their families in the community. It is anticipated that health centers will continue receiving TB referrals from
hospitals. Urban areas will remain our focus with the highest prevalence and the greatest concentration of potential beneficiaries
for TB/HIV collaborative activities by public and private facilities.
Complicated TB cases and HIV-positive cases with complex clinical conditions requiring specialized diagnostic workup and
management will be referred to hospitals. By September 2009, MSH/CSP will support TB/HIV collaborative activities in 500 health
centers linked to the 161 ART hospitals. Many of the health centers providing TB/HIV service also support counseling and testing
(CT) services, preventive care package and ART services.
During FY08, TB/HIV collaborative activities will be further consolidated in the hospitals and health centers delivering the service.
There will be a scale up to include all the ART hospitals (161) and 500 health centers( 350 ART and 150 non ART Health centers)
TB/HIV services will be further scaled up to the private sector facilities. PITC will also be strengthened at all levels. Hospital level
TB/HIV work will be coordinated with the health center level using the Health Network Model. This will be supported by the four
US Universities, CSP, Private Sector Partnership/Abt Associates, and other USG partners. Resources will be leveraged with other
initiatives, including the TB/HIV initiative, WHO TB/HIV support provided by PEPFAR.
According to the observations during site visits, and from partners' progress report as well as few program evaluation reports of
partners it was shown that HCT provided to TB patients registered in the PEPFAR supported sites has reached more than 80 -90
percent in most areas. CPT and ART uptake is very high. However, the report coming to the national level through the routine TB
reporting system was of poor quality and in most instants there is under reporting of HIV related information and the actual
achievement is not reflected.
Several challenges have been encountered in implementing TB/HIV collaborative activities that included, among others, human
resource constraints and high turnover, difficulty of diagnosing TB in HIV positive persons, poor TB microscopy quality control and
very low utilization of Isoniazid (INH) mainly due to interruption of INH supply, Poor TB infection control in the era of M(X) DR-TB.
In general the poor TB/HIV monitoring and evaluation still remains to be the major bottle neck for the program implementation.
Encouragingly, the National Technical working group which was organized to function under the TB/HIV advisory Committee is
playing a major role in trying to coordinate activities, efforts and resources to overcome the challenged listed above. PEPFAR
Ethiopia is an active member of both the Advisory and technical working committee and is playing a key role.
Hospitals and health centers are major venues for case detection, diagnosis, care and treatment in Ethiopia. Community outreach
activities are also believed to play a major role toward increasing involvement of health extension workers at health posts level
especially in TB case detection treatment adherence and defaulter tracing at community level. The key TB/HIV site level activities
in FY 09 include 1) screening all HIV-positive persons coming to different clinics (ART,PMTCT, STI, etc.) for active tuberculosis,
2) provision of TB treatment for cases diagnosed with active tuberculosis, 3) Implement Isoniazid (INH) Preventive Therapy (IPT)
for HIV-positive clients found to be free from active TB in all ART and Infection Control (IC) facilities and sites, 4) Screening all TB
patients at the TB clinic for HIV with provider initiated counseling and testing (PICT), 5) Provision of Cotrimoxazole Prophylactic
Treatment (CPT) for all TB/HIV patients, 6) Provision of HIV prevention with positive package services with in the TB/HIV clinics 7)
Strengthening and establishing referral linkages to different service areas and between Hospitals and health centers in provision
of TB/HIV clinical services, and 8) provision of ART for eligible cases and 9) coordinate and leverage resources with TBCAP and
Global Fund(GF) to strengthen TB program, 10)Implement IC practices to prevent TB transmission, 11) Expand Private Public Mix
(PPM) DOTS to more private for profit facilities in Ethiopia12) Conduct surveillance for Extensively Drug resistance TB ( XDR-TB)
at selected sites and pilot community DOTS/TB/HIV activities using Health extension workers; 13)) monitoring and evaluation.
In FY09 PEPFAR Ethiopia will continue to be a major player in supporting MOH to strengthen and scale up TB/HIV collaborative
activities at national level. The coordination between US Universities, the MSH/CSP, WHO and other major partners like the
Global Fund to Fight AIDS, TB and Malaria (GFATM) will be further strengthened in FY09.
WHO has been awarded a COP07 plus up fund to support the MDR-TB management initiative, human resource development in
TB/HIV programs and TB infection control areas and this program has continued in COP08. In FY09 WHO will further strengthen
its support towards the MDR-TB management expansion plan to regional referral hospitals, and human resource capacity building
and TB and HIV infection control activities as well as supporting TB/HIV M&E by hiring TB/HIV M&E experts and supporting
regional and national review meetings and undertaking supportive supervisions.
Resources will be leveraged from GFTAM to support key TB/HIV activities which include procurement of first-line and limited
second line anti-TB drugs, INH for IPT, laboratory reagents and equipment, capacity building including training, expansion of
community-based DOTS and expansion of Private Public Mix (PPM)/Directly Observed Therapy, Short course (DOTS). Other
donors for TB and TB/HIV prevention and control in Ethiopia include WHO (through regular funding), German Leprosy and TB
Relief Agency (GLRA), Italian Cooperation, and the Royal Netherlands Embassy.
In FY09 there will be a scale up of TB/HIV services to include all the ART hospitals (161) and 500 health centers (350 ART and
150 non ART Health centers, all activities initiated in the previous years will be consolidated and expanded. PITC will be scaled up
and screening for TB in HIV positive persons strengthened. More support will be provided to strengthen the routine TB/HIV
recording and reporting, revised TB, pre ART and ART registers will be distributed to the facilities. USG Partners will assist the
piloting and roll out of the national TB/HIV surveillance at national level. Emphasis will be given in addressing the human resource
constraint, surveillance and management of MDR TB, infection control, improving TB diagnosis in HIV positive persons by
introducing additional diagnostic methods. Public Health Evaluations (PHE) focusing on improving care and treatment services for
TB/HIV patients will also be conducted.
In FY09 more emphasis will be given to improve TB case detection among HIV positives and their contacts. A standardized
screening tool will be introduced to screen HIV positives, family members and contacts of patients with active TB. The roll out of
TB microscopy training, and TB smear microscopy EQA as well as the continuous capacity building provided to facilities and
regional laboratories to increase access to X-ray, fluorescent microscope and mycobacterium culture diagnostic services will
further support the effort to improve intensified case finding. Active TB case finding and HCT at the congregate settings will further
compliment the case finding.
Pediatric TB/HIV will be given more emphasis. A standard TB screening tool and algorithm will be used to screen pediatric HIV
infected and exposed infants for TB. National level advocacy and sensitization will be made to make tuberculin skin test available
for screening pediatric patients for latent TB infection. IPT and CPT will be provided for all eligible HIV exposed/ infected pediatric
clients. Pediatric TB/HIV topic will be included in the standard TB/HIV training materials and more emphasis will be given to
pediatric HIV screening and TB diagnosis during site level mentorship. To inform program planning to address TB/HIV among
children, CDC-DTBE-IRPB will collaborate with CDC-Ethiopia and Columbia University to enhance routine monitoring and
evaluation through a surveillance evaluation of new TB registers and recording and reporting by revised age categories (0-4 years
old, 5-14 years old) at selected sites. This will help to characterize the epidemiology of childhood TB as well as TB/HIV co-
infection in Ethiopia, to describe the reach of TB/HIV collaborative activities to the pediatric population, and to identify challenges
in childhood TB diagnosis/treatment and recording and reporting. With the initiation and scaling up of pediatric care and treatment
services at health center level, pediatric HIV screening and TB diagnosis will be done by HCSP to address TB/HIV collaborative
activities benefiting children.
Patient waiting areas in most facilities are poorly ventilated and there is high chance for spread of TB and other diseases through
respiratory route. In COP09 different infection control measures will be introduced at the facilities including cough triage,
educating patients to cover mouth, separation of infectious TB patients in the wards as well as renovation of patient examination
rooms and waiting areas to improve ventilation and lighting. A comprehensive infection control guideline will be developed by
MOH to standardize infection control practices at various levels of health care. CDC Ethiopia in collaboration with CDC Atlanta
and Johns Hopkins University will establish a system for monitoring and evaluation of TB among facility staff at PEPFAR-
supported HIV care & treatment pilot sites. This will help to determine the infection control needs for the country as well as help to
determine the efficacy of planned interventions.
All PEPFAR and non PEPFAR TB/HIV activities will be coordinated through the national TB/HIV advisory Committee and
technical working group and all activities will be part and parcel of the annual TB/HIV collaborative activity work plan.
Table 3.3.12:
