Positive Change: Children Communities and Care/PC3 Follow-on

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS

This activity will be a competitive procurement and USAID/Ethiopia will inform OGAC upon selection of the

winning partner.

This activity will integrate with MSH, ICAP, WFP, CCF, Pact, and OSSA, and will relate to other activities

across the range of HIV/AIDS partners.

The OVC Services within a Family-centered Care and Support (FCS) activity will serve as the follow-on

activity for the five-year community based capacity development program of Save the Children that ends

September 2009. The Positive Change: Children, Communities, and Care (PC3) program strengthened the

capacity of over 550 local and national entities to provide comprehensive and coordinated care to 500,000

orphans and vulnerable children (OVC). The FCS activity will assume responsibility of the OVC served

under PC3 and continuing to need support. The infrastructure and networks built under PC3, especially

between government and civil society, will be engaged and expanded.

A program design change emerged from the evaluation of PC3. To most effectively reach the greatest

number of OVC, including children living with HIV, family-centered care and support must be the guiding

framework. Keep parents alive and economically viable and children free from HIV.

An interdependent network of local stakeholders will be needed to meet the needs of the most vulnerable

families and to identify and assist families or households prior to the point of extreme vulnerability.

Through FCS activity, community stakeholders supporting family wellbeing will agree upon a common

framework for providing a continuum of care and support. The hallmark of a successfully applied framework

is a functional community and clinical care referral system that accommodates the needs of the majority of

vulnerable families affected by HIV/AIDS. This includes provision of the seven service areas within the

Standards of Services for OVC in Ethiopia, case management for clinical and community care and support,

and comprehensive provision of HIV/AIDS services for the most people, especially prevention services. For

example, PEPFAR clinical and community care and support partners will review and discuss community

data on counseling and testing, PMTCT uptake, ART adherence, and pediatric AIDS and then set

community-wide targets that require stakeholders to work together to reach the targets.

HIV/AIDS issues such as stigma, especially relating to HIV disclosure, male involvement, and early

marriage along with child protection issues will be particularly challenging. Through community exchanges

and documentation, promising practices on meeting these challenges will be explored and applied.

Leadership at the national, regional, and local levels will be needed across health and social service sectors

to fully achieve comprehensive, family center-care and support. USG will convene a series of stakeholder

strategy sessions to map out who needs to what do, when, where and how. Two sessions were held in

September 2008. One covered strategies for increasing HIV service uptake through OVC programs and the

other session addressed food and nutrition security for families affected by HIV/AIDS. USG will use the

outputs from these and additional sessions to clarify expectations, calibrate results, guide partner work plan

development and implementation, and improve use of PEPFAR resources.

Investments in national leadership will continue under the FCS activity to include seconding of two OVC

experts to Federal HAPCO and one to the Ministry of Women's Affairs. The seconded staff has enabled

improved integration of effort across government ministries and with civil society. The National OVC Task

Force now meets regularly to move on essential actions such as advocacy, policy reform, resource

mobilization, and data demand and use. For example, HAPCO will be supporting with Global Fund monies

a national OVC situation analysis on behalf of the OVC Task Force, which is lead by the Ministry of

Women's Affairs.

The Family-centered Care and Support activity will be comprised of four technical and management areas:

community capacity, centers of excellence, partnerships/networks, and data-driven actions.

A hallmark of a top performing community, or a geographically defined area, is a well functioning network of

stakeholders that have mobilized to form an interdependent system for providing comprehensive, family-

centered care and support. Best use of local and external resources and capacity standards would be

evident in such communities. For example, such a network system would be capable of providing

emergency food support that may rely upon external inputs (e.g., from WFP) that are complemented by a

graduation strategy to transition households into more sustainable means for food and nutrition security.

Stakeholder inputs would vary, but the totality of their contributions would facilitate sustainable approaches

to achieving food and nutrition security in the community. The use of external inputs may be on-going but

the type and amount of inputs would likely vary over time and context.

A process will be implemented to build stakeholder consensus on defining, measuring and improving

community capacity to deliver on family-centered care and support. Technical expertise and lessons

learned from the PEPFAR Quality Improvement Initiative will be built upon to develop and apply standards

for good-enough community capacity. These standards would outline the critical minimum needed in terms

of skills, knowledge, and practices. A focus on achieving outcomes would be an essential component of

each capacity standard. For example: 1) levels of critical minimum for skills and knowledge might include:

human capacity development policies in place and implemented; 2) case management training extends to

Health Extension Workers (HEWs), traditional birth attendants, community outreach workers, and

parasocial workers; strategies are data-driven or evidence-based; 3) updated referral site directory

available; referral sites are certified as family-centered; 4) and expertise available to address needs of

special or at-risk populations.

The critical minimum for practices will likely state that each stakeholder advocates and checks for the

practice of family-centered care and HIV/AIDS stigma reduction actions, especially making HIV/AIDS

disclosure safe and acceptable. Additional minimum practices could include: case management system

functional, client satisfaction measured, outcomes in family wellbeing tracked, local resources mobilized,

multi-sector partnerships engaged, and age and developmentally appropriate care provided.

Meeting capacity standards will require engaged leadership at multiple levels and communication channels

that reach the general population to encourage demand for family-center care and support options.

A barometer or index will be used to measure compliance with standards for good-enough community

capacity. The index would relate to the capacity standards and include items such as comprehensive social

and clinical care access, functioning referral sites, case management for community and clinical care,

tracking of service supply and demand, human capacity development, and stigma reduction strategies.

Similar to the PEPFAR Quality Improvement Initiative and the Child Status Index, communities will

Activity Narrative: determine how they rate and compare with other communities in the provision of family-centered care and

support and exchange on best practices.

The capacity index will be used to "certify" communities as top performers. Communities that achieve this

status will receive government recognition and will have increased access to external inputs for improving

their care and support system. They would also be eligible for hosting a Center of Excellence.

A Center of Excellence serves as a technical resource hub for other communities seeking to be top

performers in provision of care and support to families affected by HIV/AIDS. Such centers provide a

means for scaling up promising practices through community exchanges. Communities (i.e., geographically

defined areas) wanting to host a Center of Excellence will have demonstrated ways for achieving "good

enough" community capacity in providing family-centered care and support. Alternatively, a center of

excellence could focus on a particular area such as proven practices for linking community and clinical care

and support that have resulted in outcomes in family wellbeing. A Center of Excellence would not depend

on the capacities of international or national entities. The high rate of staff turnover among such entities

further justifies the need to promote community-to-community technical and management exchanges.

Centers of Excellence will assist communities to meet the critical minimum in skills, knowledge, and

practices, or capacity standards, needed to indicate that family-centered care and support is provided in the

community. The learning exchanges approach used for implementing OVC service standards will serve as

model for how Centers of Excellence will help communities meet capacity standards.

A Center of Excellence will engage the capacities of multiple stakeholders and will require a primary

leadership and management function housed within a top performing community. Financial and human

resources will be needed to support Centers of Excellence and its provision of technical support to other

communities. Priority technical areas to be demonstrated by Center of Excellence include: good enough

community capacity especially in the areas of food and nutritional security, education for OVC, household

economic strengthening, and functioning referral system or case management of family-centered care.

Lessons learned and the evaluation from the PC3 program point to the need for redefining partnerships and

networks focused on family-centered care and support. Three areas of emphasis are needed: choice of

partners, the relationship between community and external entities, and clinical-community care and

support networks.

The benefits of PEPFAR investments need to be sustained along with making better use of limited

resources. This demands increased consideration of non-traditional HIV/AIDS partners and the approach to

wrap-around programming. Sectors such as economic growth, child survival, agriculture, and community

development have, in many places, established infrastructure and programming. There is no reason for

PEPFAR resources to be used to re-construct or re-invent the systems already in place across the multiple

sectors needed to improve family and child wellbeing. The FCS activity will tap into existing systems to

reduce level of programming effort needed and increase number of children reached. This will be an

evolved approach to "wrap-around" programming by being more explicit about "buying a place at an existing

table" versus constructing the PEPFAR approach to, for example, household economic strengthening. The

FCS activity will be able to tap into several existing PEPFAR Ethiopia mechanisms that are with the

economic growth and education sectors.

The most significant change to be addressed by the Family-centered Care and Support activity will be

redefining how international and local NGOs collaborate to support community-level care and support

systems. A technical- assistance-on-demand structure will be established to empower indigenous civil

society entities and government to identify what type of assistance they need and how they would like to

receive this assistance. Local networks, such as OVC forums, ask for technical input or assistance based

on a menu of options that external agents can provide in relation to achieving compliance with capacity

standards. These external entities would be "hired" by the local stakeholders. For example, offering skills

training in resource mobilization and case management; and how to improve or expand upon existing

structures like the HAPCO system of care and support. External entities would focus on the strengths and

opportunities, versus only gaps that need filling, within a community and make suggestions on how to

maximize what is currently in place. External entities will not develop separate systems of care and support

within a community. This will be a major paradigm shift in how external and community entities relate to

each other.

The FCS activity will facilitate establishing or strengthening local networks of community and clinical care

service providers that work interdependently to mitigate the impacts of HIV/AIDS on families. A "win-win"

relationship will be needed to reinforce the contributions made by a range of community stakeholders to

provide comprehensive care to OVC. The successes existing referral systems will be promoted through

centers of excellence model. Networking practices will be expanded to focus more on family-centered care

and support. For example, a Center of Excellence can walk community stakeholders through a decision-

tree process to determine how community care and support partners can help their clinical care colleagues

with improving ART adherence and loss to follow-up.

The Family-centered Care and Support activity will build upon the community data management system

implemented under the PC3 program. This system allows for the rapid collection, organizing, and reporting

of data among community stakeholders. Several community networks have effectively mobilized additional

resources by using this data to justify needed funding. Coaching and supportive supervision are essential

actions for helping communities improve data quality and use. Centers of Excellence can assist with this

type of support. Support to GOE will be needed to strengthen capacity in monitoring information systems.

The community data management system will support and feed into larger GOE efforts to monitor and

report on services to OVC. For example, assistance will be provided to make use of findings from the

national OVC situational analysis to inform the prioritizing of policies and interventions.

The implementation of both service and capacity standards will inform data demand and use. Outcomes in

child and family wellbeing are part of each standard and will be determined based on what is realistic and

meaningful to community stakeholders, especially community and clinical care service providers. For

example, these local providers can meet periodically to discuss progress in meeting outcomes and

determine any needed improvements in activities. Both short and long-term outcomes may be needed to

better inform actions needed.

Special studies may be undertaken to provide evidence on promising practices especially in priority areas of

household economic strengthening, education for OVC, and food and nutrition security.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18779

Continued Associated Activity Information

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

System ID System ID

18779 18779.08 U.S. Agency for To Be Determined 8248 8248.08 Public Health

International Evaluations

Development

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

* Increasing women's access to income and productive resources

* Increasing women's legal rights

* Reducing violence and coercion

Health-related Wraparound Programs

* Child Survival Activities

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Estimated amount of funding that is planned for Economic Strengthening

Education

Estimated amount of funding that is planned for Education

Water

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $13,291,152

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 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).

After receiving valuable feedback from the core team visit, taking into account the Government of Ethiopia's (GOE) strategies and

reduced PEPFAR 2009 resources the PEPFAR/Ethiopia team has decided to take a multi-tiered targeted approach. Urban areas

are at the center of our target, with the highest prevalence and the greatest concentration of potential beneficiaries. Here, the

PEPFAR team has concentrated USG resources. Just outside the center are periurban areas and at the outer most ring of the

target are rural areas of Ethiopia with much lower prevalence (0.9%), but where 85% of the population resides. In these rural we

will attend to the prevention needs of important bridge populations to address the spread of HIV/AIDS from higher concentration to

lower prevalence rural areas. It is with this strategy that the PEPFAR team will maximize our impact on the HIV/AIDS epidemic for

the over 78 million people of currently living in Ethiopia.

Background

PEPFAR Ethiopia has supported the Government of Ethiopia's goal of universal access by focusing our HCT support in urban and

periurban areas and a few rural "hot-spots". PEPFAR Ethiopia has engaged both the public and private sectors at hospitals,

health centers, model centers, stand-alone VCT sites, and outreach programs, such as mobile VCT for MARP and uniformed

personnel. To date a total of 4.5 million people were tested in PEPFAR supported sites out of a total of approximately 7.8 million

people tested throughout the country since 2004. This means that 10% of the population of the country has been tested for HIV.

Among the individuals who were tested, 436,572 people were positive for HIV, and 257,750 (59%) are currently registered at

health facilities for care and treatment.

One of the GOE strategies that PEPFAR has supported is The Millennium AIDS Campaign (MAC) which was started in December

2006 ended in August 2008. In the next phase of HIV programming, HAPCO plans to transition from a campaign to a regular

operations approach, while maintaining the momentum of the MAC campaign as it has created a huge demand for HIV counseling

and testing services. PEPFAR will continue to support HAPCO in this approach through its implementing partners.

Major Achievements from 2008

Overall in FY 2008 PEPFAR has utilized a strategic mix of HCT approaches in mobile, public/private hospitals, health centers and

engagement of medium to large businesses. Innovative approaches included mobile VCT targeting MARP, home-based voluntary

counseling and testing (HBVCT), weekend outreach services and work place VCT. For the fourth consecutive year PEPFAR

supported National VCT day this year youth were the target group, one of the MARP in Ethiopia.

Human Resource Development: Task shifting has been a priority in the HCT PEPFAR portfolio. To that end, a total of 700

community/lay counselors were trained in VCT and deployed to public health facilities. Task shifting also included supporting the

scale up HIV rapid test using finger prick Rapid Test Kits (RTK) and use of laboratory technicians to oversea the quality of HIV

testing through regular supervision. Community counselors brought a major difference in the uptake of HCT service in the public

facilities. Support the ‘National HIV Counselors Association' established regional associations in the Amhara, Oromiya, Tigray and

SNNPR regions. The association plays a major role in assuring the quality of counseling at the facility level.

PEPFAR provided technical and financial support to develop counseling and testing training materials, including VCT, PITC and

development of training curricula and training packages for community counselors/lay counselors. In addition PEPFAR support to

the Federal Ministry of Health (MOH) and HIV/AIDS Prevention and Control Office (HAPCO) included: 1) development of the

training package for Urban Health Extension Workers to strengthen family centered counseling and testing including PMTCT and

pediatric HCT and 2) distribution and implementation of the new ‘National HCT Guidelines and Policies' in order to promote

standardization of services. Additionally, training for healthcare providers and their supervisors was provided to strengthen PITC

and HIV rapid testing at national and regional levels.

Expansion: New sites were assessed to initiate HCT services in the facilities. Partners provided site level technical support which

included mentoring and training. Also material support provided to health facilities to initiate or expand and improve the existing

services. This included a smooth transition from FHI supported HCT sites to MSH supported ones including expansion to a total of

486 public health centers providing HCT was accomplished. Overall, an improvement in the referral linkage of clients from HCT

sites to Care, Support and Treatment services was achieved.

Key Challenges

HCT services in the country faced challenges including: 1) an inconsistent supply of test kits; 2) attrition of trained counselors from

facilities; 3) limited space for expansion of VCT services within existing facilities; 4) low rate of couples' HIV testing; 5) inadequate

pediatric HCT and disclosure of results; 6) weak data management systems at the facilities; 7) insufficient use of data for

improvement at site-level and; 8) low partner disclosure and referral for testing. Of the eight major challenges faced, referral

linkages remains the greatest challenge as 41% of individuals testing HIV positive did not receive post test services.

Planned Program Priorities 2009

FY 2009, will mark the beginning of the second phase of PEPFAR. The reauthorization of PEPFAR II will expand the U.S.

Government commitment to this successful program for five additional years, from 2009 through 2013. The HCT program is a key

entry point into HIV prevention, care, and treatment services individuals or couples testing HIV positive will be linked to PMTCT,

Care & support, ARV services and children to OVC services.

Support to the MoH: The second Accelerated Access to HIV/AIDS Prevention, Care Treatment, and Road Map 2007 - 2010 plans

to provide counseling and testing to more than 25 million individuals and couples. HAPCO plans to provide HCT services close to

7.2 million people under universal access in 2009. Currently there are 1336 HCT sites providing service and the MOH plans to

increase those to more than 3000. PEPFAR Ethiopia has been the lead partner in strengthening existing and expansion of HCT

services in the country and has assisted the MOH/HAPCO and Regional Health Bureaus/Regional HAPCO since 2001. We will

continue to offer support to strengthen and improve coordination of HCT programs and services, in urban and periurban areas

and selected rural areas known to have relatively higher HIV prevalence.

In response to 2008 challenges the HCT portfolio will focus on the following:

1) In order to address inconsistent supply of test kits, PEPFAR Ethiopia will work with The Global Fund to Fight AIDS,

Tuberculosis and Malaria to procure test kits and other lab supplies.

2) In order to address the attrition of trained counselors PEPFAR Ethiopia will continue to support the MoH in development of a

comprehensive compensation package for health workers with the HCSP activity. Task shifting will continue with training of lay

counselors and training of Urban HEWs a cadre of workers which will be drawn from out of work private nursing school graduates.

HCT program will work closely with the laboratory program in training of service providers on HIV rapid test and quality assurance

to ensure continued and smooth roll out of RTK to all appropriate facilities.

3) In order to address the limited space within existing facilities PEPFAR Ethiopia will continue to use funds to provide technical

assistance and refurbish counseling rooms.

4) Family centered approaches will be used to strengthen our rate of couples, pediatric HCT and uptake of PMTCT. This will

include strengthening of linkages of individuals with care and support activities both including community based activities in the

OVC portfolio and in the care and treatment portfolios.

6) Data management systems at facilities and use of data for program improvements will be addressed through continued support

from the SI team. This will include a number of programs designed to strengthen onsite data management. The d national

registration formats will be finalized and implemented in partnership with MOH/HAPCO and PEPFAR SI program

During FY 2009, PEPFAR Ethiopia will give due emphasis to promoting a strategic mix of clinical and community-based

HCT approaches. The program will work towards sustainability in COP 09 through strengthening the capacity of local organization

including government, civil societies and private organizations. Continuing activities with the Private Sector Program and linkages

to the Civil Society activity will strengthen our involvement with civil society and private sector entities.

Taking into account the current HIV prevalence rate, the HCT service will be more focused on MARP through targeted referrals

and through targeted Mobile HCT services. 90 % of individuals testing positive for HIV will be linked to care and support services

ensuring that they have access to services. Special services will be provided for discordant couples to prevent HIV. Individuals

testing negative will be provided with ongoing preventive education and other services to reduce their risk taking behavior, along

transportation corridors this will be done by linking individuals with the Transportation Corridor Program. Disclosure of HIV status

and partner referral will continue to be a major focus as in the previous years. All PEPFAR Ethiopia-supported sites will continue

to provide PITC both for inpatient and outpatient clients. Use of ‘opt out' PICT will be strengthened in facilities. In FY 2009,

PEPFAR will support diverse VCT models, such as fixed sites, mobile sites, Home Based VCT, and youth-friendly service, as well

as offering HCT in workplaces, schools, prisons, information centers, health-integrated model (Public or Private). Using these

diverse models targeting MARP will remain a focus area in 2009.

PEPFAR will support efforts to ensure that there are adequate quality assurance systems for testing services. This includes

proficiency testing and regular onsite monitoring by the Regional and National Reference Laboratories. PEPFAR will also support

the provision of high-quality counseling services in public, private, and NGO sites. We will institute peer support systems and case

conferences, we will also conduct continuing education for counselors and supervisors to maintain quality.

We have learned that focusing on the benefits and importance of testing, and on varied media promotion are effective ways to

create demand for VCT and decrease stigma around HIV testing. PEPFAR supports HAPCO endeavor to strengthen social

mobilization initiatives that focus on MARP. In FY 2009, PEPFAR Ethiopia will support the country in expanding the geographic

coverage of all mechanisms of HCT promotion to create demand.

Table 3.3.14: