Male Circumcision

THIS IS A NEW ACTIVITY FOR COP09.

Male circumcision has been found in clinical trials to provide a 60% reduction in HIV infection risk to men.

WHO has recommended that MC be targeted to younger men and to men in high risk groups. While MC is

practiced widely in Ethiopia there are geographic regions which have low levels of MC. The military recruits

men from all over Ethiopia for military service, including those geographic regions with low levels of MC.

Hence, having MC available at training bases for young recruits would reach a high risk population with

many men that would benefit from MC and be able to be provided with comprehensive prevention services

including C/T, STI evaluation and treatment, prevention counseling, etc.

The planned HIV prevalence and risk survey includes items on MC so there will be some information

regarding current levels of MC and factors associated with MC among the ENDF which will provide some

formative information.

This activity will provide funding for commodities, adaptation of IEC materials to include MC information and

messaging, training for clinicians in MC surgical techniques and follow-up care.

ENDF will not start MC until this is approved by the MOH.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

Refugees/Internally Displaced Persons

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $24,826,529

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Know Your Epidemic" is paramount to the success of the PEPFAR/Ethiopia Team. The 2008 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). The Ethiopian Ministry of Health (MOH) has set an ambitious target of reaching universal access for HIV care and

treatment by the end of 2010. While PEPFAR supports this goal, resource limitations result in a need to focus PEPFAR resources

on higher prevalence urban and periurban areas, as well as rural "hot spots".

The Ethiopian National ART program began implementation in July 2003 and has made remarkable progress with coverage in all

regions of the country. As of August 2008 the MOH's HIV/AIDS Prevention and Control Office (HAPCO) report shows 365 ART

sites operational in the country, including 120 hospitals, 242 health centers, and three non-governmental organization clinics. The

facility based care and support activities are complemented by community based services, since the service model relies on

networks, referrals, and linkages. The services are being decentralized rapidly in order to make them more accessible to patients.

The number of PLWH receiving care and treatment at the 365 sites was 275,890 enrolled in care, 155,075 ever-started on

treatment, and 114,125 currently receiving treatment. Services included the delivery of clinical care, including treatment for

opportunistic infections and symptom management; psychological care through peer support groups; spiritual support through

linkages with faith-based organizations; and delivery of elements of the preventive care package, including cotrimoxazole

prophylaxis, long lasting insecticide treated nets to prevent malaria, screening for tuberculosis, prevention-for-positives

counseling, condoms, referral of household contacts for HIV counseling and testing, safe water and hygiene, nutrition counseling,

and multivitamin supplementation.

The proportion of ART clients currently receiving ART is 73.6% of all patients that have ever been started on ART. Of the total

number of patients that were started on ART, 26.4% have either died or been lost-to-follow-up. Of those who have ever been

started on ART, 82.5% of patients were started on ART at hospitals and 17.5% started at health centers. Among those ART

patients currently receiving ART, 75.5% are getting the service at hospitals and 24.5% are at health centers. A large proportion of

ART patients are still being served by a small number of hospital sites, even though the number of ART sites has been

significantly increased. The 20 largest public hospital sites are currently providing ART services to 42.5% of the total ART patient

load.

Before FY 2006, palliative care and support activities in Ethiopia focused mainly on end-of-life care and distribution of

commodities to PLWH. With the advent of free ART and improved access to HIV/AIDS services, "palliative care and support" has

become "care and support" and is increasingly perceived as a part of the continuum of care, including social support and

prevention services. For COP 2009 the Ethiopia team will focus on strengthening community based care and support options for

PLWH emphasizing prevention with positives for discordant couples and risk reduction messaging as part of the community care

package. The focus on care and support will include a scale up of IGA activities, the sale of safe water will be explored as a

possible venue for beneficiaries.

In FY 2008, PEPFAR partners and other stakeholders, continued to support the national effort to standardize training materials for

hospitals, health centers, and communities; in FY 2009, these partners will synchronize these materials with the integrated ART

training package, and will coordinate training activities provided by different partners. In collaboration with HAPCO and other

PEPFAR partner organizations, ITECH has developed training modules to standardize palliative care and the development of the

national pain management guideline which is being used as a resource material. PEPFAR Ethiopia will continue to support the

MOH and HAPCO in revising the national policy on opioid use as it has been a major challenge in pain management practice.

The National Guideline on Nutritional and HIV/AIDS is being revised and the Guide to Clinical Nutrition Care for Children 6

Months-14 Years Old and Adults Living with HIV training manual will be released. The program will emphasize strengthening

access to community based supplemental feeding, skills development, and IGA options for referral of PLWH graduating from

these programs. As Ethiopia is categorized as a focus country for food and nutrition, PEPFAR Ethiopia has identified nutrition

support as a priority palliative care and support service that 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) in selected hospitals and

health centers. 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.

Currently, most of the service delivery and patient load is limited to a small proportion of the sites. Transferring stable patients to

health centers that are closer to patients' homes and community services has been a challenge, with factors including fear of

stigma and discrimination, poor referral linkages, and reports of inadequate services at lower levels, among others, contributing to

the slower-than-desired decentralization. With the rapid scale-up and expansion of the ART program, the issue of retaining

patients in care and treatment services has also emerged as a serious problem. The proportion of patients "lost-to-follow-up" in

Ethiopia is unacceptably high.

There is lack of reliable, quality data on patient mortality, transfer, drop-out and lost-to-follow-up rates in the Ethiopian ART

program. Data from short term patient tracking at a few hospital sites by some implementing partners has indicated that the 12

month ART patient mortality was in the range of 7.5 - 9%, whereas, there was a 14-17 % rate of "lost-to-follow-up". Among those

reported as "lost-to-follow-up", patients outcomes are not known in about half of the cases. At health centers, where it has been

possible to implement more effective information systems from the beginning of the decentralization, similar patient mortality has

been found, but with lower lost-to-follow-up rates, around 4.2% since the beginning of ART provision in 2006. Program

evaluations need to be undertaken to determine the magnitude of the problem and to analyze why patients discontinue treatment,

as well as to identify interventions to promote retention in care and treatment services. To this end, Ethiopia will participate in a

multi-country Public Health Evaluation (PHE) that will assess interventions that reduce ART patient mortality.

Efforts will be made to decrease lost-to-follow-up, including improved adherence counseling, case management, patient tracing,

encouraging disclosure, adherence support at community level, care and support services including nutritional support,

communication activities to patients, care providers, the general public and media, as well as involvement of faith based

organizations (FBOs) and community based organizations (CBOs). Improving the network function, establishing and/or

strengthening catchment meetings and strengthening multi-disciplinary teams at all facilities and improving the linkage among the

different services within the facility is also essential.

There is neither a structured model of care for pre-ART patients (who are not yet eligible for ART), nor is there reliable data on the

actual number of patients and their outcomes. However, efforts are underway to define the minimum package of care for service

counting in accordance with the latest guidance from OGAC. Tools will be developed to standardize counting of clients receiving

care and support services at facility, community, and at home, and to link monitoring systems in each setting. Moreover, PEPFAR

partners will strive to integrate ART with other primary-care services and involve PLWH in delivery of services at various levels.

Ethiopia will take part in a multi-country public health evaluation (PHE) to address the issue of the optimum model of service

delivery for pre-ART patients to ensure retention in care and treatment services.

PEPFAR will continue to use a variety of strategies to support human capacity development, including task shifting, pre-service

training, and creation of retention mechanisms for trained staff. PEPFAR will also work towards building indigenous capacity as

part of its exit strategy. PEPFAR partners, as part of this exit strategy, will work closely with local universities, regional health

bureaus and health facilities to build institutional capacity.

In FY 2009, PEPFAR Ethiopia will build on the achievements of the past four years, continuing to work with national and regional

programs to ensure sustainability of ART services. In collaboration with the Government of Ethiopia and other major donors like

the GFATM, PEPFAR Ethiopia will support renovation and expansion in high impact/high yield hospitals and health centers.

PEPFAR Ethiopia will work to increase access to comprehensive, quality HIV care and support services for those in need through

integration and functional referral systems. PEPFAR will continue to work with regions and districts to plan, prioritize, and

implement HIV/AIDS prevention, care, and treatment services. Support at the regional level includes building regional capacity to

support, monitor, and evaluate the implementation of services, as well as developing regional master training teams to train facility

-level staff to scale up services.

To strengthen prevention with positives, PEPFAR is standardizing the effort by adopting a high quality training manual from the

Centers for Disease Control and Prevention‘s Global AIDS Program. The program will help HIV infected patients prevent the

spread of HIV to their sex partners and help them protect their own health. While the program will strengthen clinic-based

interventions initially, in FY2009 the material will be adapted for community care providers and PLWH. As prevention with

positives is identified as a priority intervention in Ethiopia, PEPFAR Ethiopia will support the development of a strategic framework

on positive prevention through a participatory process with key stakeholders with a view toward integration of the program in the

national comprehensive prevention strategy.

The detection and treatment of precancerous cervical lesions can prevent progression to cervical cancer. Cervical cancer is the

leading cause of cancer among Ethiopian women between 15 and 44 years of age, the same age group with the highest HIV

prevalence, and most of this is occurring among HIV positive women. The Ethiopian government is working to establish an

effective screening program and to develop surveillance mechanisms for cervical cancer. Therefore, PEPFAR Ethiopia will join

this effort by sponsoring cervical cancer screening services along with on the spot treatment for HIV positive women in some 14

health facilities during FY 2009. This pilot activity will build on resources already committed by the Ethiopian Government and

other partners.

PEPFAR will continue to work closely with the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to implement the

PEPFAR-GFATM Memorandum of Understanding and their joint plan of action, and will foster collaboration with the World Bank

and other major partners.

PEPFAR partners will address human-capacity needs by task-shifting and by expanding the numbers of new cadres including

nurse ART providers, case managers and volunteers (Ethiopians in Diaspora, U.S. Infectious Disease Fellows, Peace Corps

volunteers, and local university students). Training to health providers is being standardized at national level. In particular, training

of nurses in the provision of ART has already been standardized by integrating the IMAI training and the HIV/AIDS Nurse

Specialist (HANS) nurse training. Training to ART providers will be regionalized.

PEPFAR renovation partners including the State Department's Regional Procurement Support Office (RPSO) will provide support

in ART site renovations and technical assistance to the Ministry of Health's Program and Planning Department in

construction/renovation. The MOH will again be supported in its efforts to expand access to HIV/AIDS services through expansion

of the number of health centers from the current 671 to 3,153. However, given budget constraints, PEPFAR efforts will focus on

high prevalence areas with potential for higher impact on HIV.

PEPFAR Partners operating at hospital level (US based university partners) and at health center level (Management Sciences for

Health) will further harmonize their support to establish a functional referral system that fosters effective transfer and movement of

patients between facilities. At the six small and emerging regions of the country, the university partners will continue to provide

support at both health center and hospital levels for comprehensive HIV care and treatment services. PEPFAR Ethiopia will

support facility accreditation for ART services in all 11 regions. Partners will strengthen the nurse-centered care model by

upgrading the training of nurses, as well as by expanding mainstreaming of ART in health professionals' pre-service training.

PEPFAR's Treatment Technical Working Group (TWG) promotes the implementation of ART services using the health network

model. Assisted by the Strategic Information (SI) TWG, it monitors the functionality and effectiveness of the network. Care and

treatment activities will be linked with entry points to services, including counseling and testing services, antenatal clinics and

PMTCT programs, TB clinics, and in-patient wards. Activities will also be linked to services for family planning, TB/HIV, and

sexually transmitted infections. Prevention will be integrated into care and treatment.

ARV drugs and commodities are provided with support from PEPFAR partners. Care and treatment activities are closely linked to

laboratory activities, including diagnosis, treatment eligibility assessment, patient monitoring, diagnosis of opportunistic and

sexually transmitted infections, and HIV drug resistance surveillance.

Table 3.3.08:

Ethiopian National Defense Force HIV Bio-Behavioral Surveillance

ACTIVITY HAS BEEN CHANGED IN THE FOLLOWING WAYS

A database will be created and limited analysis will be completed.

COP08 NARRATIVE

Ethiopia's National HIV prevalence estimate has recently been updated with a national single-point

prevalence estimate of 2.1%. This estimate is derived from prevalence data from recent antenatal clinic

(ANC) surveillance (3.5%), the 2005 Ethiopian Demographic and Health Survey (1.4%), and other key data

sources. The data reveals an epidemic that is far less generalized than previously believed, with

prevalence concentrated in urban and peri-urban areas, as well as along major transport corridors.

Although the data indicates that HIV is likely largely concentrated among key risk groups, there is little

prevalence or risk behavior data on subpopulations in Ethiopia. Notably, though the military has long been

considered a high-risk group in Ethiopia due to their means and mobility, HIV prevalence has not been

estimated in the Ethiopian National Defense Forces (ENDF).

As prevalence and risk-factor data are critical to programming, planning, and tracking HIV rates, prevention

programs, care, and treatment programming, the ENDF will undertake an HIV prevalence survey linked with

a behavioral survey. Health services authorities will be able to assess the data for strategic planning

purposes, and presentations on the data collected that is digestible to high-ranking ENDF officials will make

the data more usable for military policymakers.

HIV testing will occur in counseling and testing environments, and referrals to care/treatment will be made

for all testing positive. Participation in the survey will be voluntary and reviewed by an Institutional Review

Board. The survey will use international indicators of HIV risk so that the military data may be compared to

that of other militaries in the region, as well as to other subpopulations that may be the subject of

surveillance in Ethiopia. In addition to international indicators and military-related risk factors, this survey

expects to include questions regarding circumcision, women's risk in the military and male norms. The

Department of Defense (DOD) will work with the ENDF to conduct all phases of the survey including survey

adaptation, data collection, data analysis, and dissemination. A sample size of 1,500 will be sought.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18049

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

18049 18049.08 Department of To Be Determined 8159 8159.08 ENDF

Defense Surveillance

Survey

Table 3.3.17: