The goals of Johns Hopkins Bloomberg School of Public Health through Technical Support to Ethiopia for HIV/AIDS Initiative (JHU-TSEHAI) include primary HIV prevention through HCT, PMTCT, male circumcision, injection safety, and PEP; improve HIV/AIDS, STIs, TB care and treatment; strengthen national, regional, and facility HIV/AIDS program management capacity; increase human resources for health (HRH) through partnerships with local universities; and improve data collection & use.

Specific objectives include increasing the number of:

individuals who receive HCT services and test results

persons with appropriate ARV prophylaxis (PMTCT, PEP)

persons with STIs treated

adults and children with advanced HIV infection started/continued on ART

persons with HIV receiving a minimum of one clinical care service

patients in HIV care/treatment programs who started TB treatment

labs with testing capacity

men receiving male circumcision

organizations that collect/use data to manage HIV program

health students, including medical students, who enter and graduate and join the workforce

JHU-TSEHAI aligns with national/regional HIV/AIDS plans towards universal access prevention, care, and treatment goals. Geographic coverage includes 75 hospitals and health centers in four regional health bureaus (RHBs), including the city of Addis Ababa, Southern Nations and Nationalties Peoples Region (SNNPR), and the "emerging regions" of Gambella and Benishangul Gumuz. It also partners with Addis Ababa and Hawassa Universities, PLWHAA associations in Addis Ababa, and the private sector. Its Advanced Clinical Monitoring project includes seven local universities, the Ethiopia Health and Nutrition Research Institute, Ministry of Science and Technology and MOH/ FHAPCO. It is part of a consortium of CDC-funded US-based universities that support sites accounting for 69% of patients on ART.

JHU-TSEHAI is a major supporter of service delivery including:

PMTCT integration into ANC and delivery for safe motherhood

Comprehensive maternal and infant care

Outreach activities to increase service access

Adherence supporters/ mother support groups to strengthen follow-up

Quality improvement approaches and teaching skills for program management

Infection prevention

Workplace improvement to expand services & retain workers

Network focused catchment meetings to improve linkages between hospitals, health centers, regional and district health offices

Support to local universities to increase capacity for pre-service training, especially medical doctors

JHU-TSEHAI coordinates with partners to maximize effective and sustainable use of resources, including:

Adherence support planning with PLHA associations

The Ethiopian Orthodox Church, Ethiopian Muslim Development Agency and Evangelical Churches Association partnership for PLHA support

The World Food Program and local NGO partnership to ensure targeted food supplementation

FANTA and UNICEF for food by prescription

Fostering integration of private sector into national ART program

Seconding technical advisors to the MOH to support national guidelines and policy development

Support for use of data for decision-making includes use of performance and QI approach to site mentoring, site level and regional health bureau (RHB) management and analysis of data, national HMIS activities at the site level, deploying multidisciplinary teams to visit sites, assisting AAU and Hawassa University faculty to prepare for professional meetings and peer-reviewed publications, and enhancing local capacity to provide support to sites.

Site-level support to build capacity includes mentoring and technical support teams, supplying small equipment, supplies, reference materials and clinical management tools, providing analysis and data feedback to multidisciplinary teams for quality improvement and problem solving, using demonstration care centers such as Gandhi Hospital integrated PMTCT/ART and St Peter's hospital integrated TB/HIV, renovating sites to meet service expansion needs, providing technical advisors to RHBs, and financial support to RHBs and universities to enable integration of clinical mentoring.

JHU-TSEHAI strengthens quality laboratory services in these regions following the health network model through which services are delivered. Quality laboratory services are as described by strategic objectives in the lab master plan and implementation strategies devised through joint planning with EHNRI and RHBs. Training and WHO accreditation of laboratories will constitute key strategies for health system strengthening and ensuring sustainability.

Cost-efficiencies are being identified through shared resources system (e.g. videoconferencing center), and collaborative procurement systems with other partners. JHU-TSEHAI coordinates service delivery with other partners in the public and private sector through collaborative pre-service trainings and curricula development, sharing training facilities/trainers, private hospital technical support to provide comprehensive services, and farm/company based partnerships for community level service provision. Program coverage is being expanded with low marginal costs through using site support systems for regional supervisory visits, and utilizing outreach PMTCT and HCT activities to provide follow-up care. PEPFAR and key process, outcome, output program indicators are used to monitor project performance, as well as through regular CoAg monitoring.

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This is a continuing activity. Since COP05, JHU-BSPH has supported the scale-up of comprehensive HIV care and treatment including the implementation of Adult ART in over 55 sites in Addis Ababa, SNNPR, Benishangul-Gumuz, and Gambella Regions. JHU-BSPH supported ART sites included public and private hospitals in Addis Ababa City Administration, public hospitals in SNNPR, and public hospitals and health centers in the emerging regions of Benishangul-Gumuz and Gambella. In COP10, JHU-BSPH will continue Adult ART support for over 60 public and private facilities in the four regions. JHU-BSPH will continue to build the capacity of RHBs in the four regions by: supporting regional review meetings, human capacity building of RHB staff in the areas of program monitoring and supervision, and providing personnel to support ART site level activities. JHU-BSPH will also continue to tailor programs to the specific needs of the regions. JHU-BSPH will continue to support the expansion of catchment meetings. JHU-BSPH will continue to provide assistance to all sites at all levels of ART provision, including multidisciplinary team mentoring, with a specific focus on mentoring for nurses involved in task shifting to support their new clinical responsibilities.

JHU-BSPH will continue to strengthen linkages between ART, CT, TB, antenatal clinics, sexually transmitted infections clinics, PMTCT services, and community-based care services. JHU-BSPH will support the transferring out of ART patients from hospital to health center. In COP10, Ethiopia's goals for expanding access to HIV/AIDS prevention, care, and treatment services consistently face common and recurring challenges, particularly with regard to human resources.

Under this activity in COP10, JHU-BSPH is allocated additional funding to carry out basic function restoration (such as ensuring consistent supplies of water and electricity) in selected care and treatment facilities in its operational zone. The partner being within PEPFAR will play its part in Global Health Initiative (GHI).

This activity has had a significant budget increase. In COP10, four activities (national HCT support, establishment of model VCT centers, Ethiopia HIV/AIDS Counselors Association [EHACA] support, and marketplace VCT) which were formerly reflected as a separate JHPIEGO entry are being subsumed under the JHU-BSPH umbrella.

JHU-BSPH will conduct basic HCT trainings for 85 community counselors and HCWs. PITC trainings will target at least 8-25 trainees per site. Trainings will ensure provision of high quality HCT and PITC. JHU-BPSH will support sites in testing 100% of in-patients and 50-80% of patient visitors. JHU-BSPH will target MARPs and hard-to-reach populations with outreach. JHU-BSPH will support promotional media activities, HCT Week and other events to promote HCT and PITC with a focus on couples and family testing. JHU-BSPH will continue support to sites to carry out case review meetings to improve quality of HCT services provided in collaboration with EHACA.

JHU-BSPH will support sites and regions to analyze CIR data to identify HCT trends and share findings. JHU-BSPH will work with ENDAN to reach the disabled and will conduct trainings for 20 signers and establish pilot sites to provide HTC to the disabled.

JHU-BSPH will conduct the following HCT interventions:

Translate HCT/PITC protocols and training materials into local languages.

Build capacity by training 24 trainers in HCT, PICT, Couples HCT, stress management, and ongoing counseling.

Use training packages developed in FY09 to conduct training in pediatric disclosure, youth and family counseling, and support the adaptation and development of a child HCT training package.

Build capacity of EHACA to support counselors through training 581 providers. EHACA will continue training in CHCT and stress management, HCT, and HCT in sign language. EHACA will establish offices in Afar and Somali and scale up marketplace HCT in the five regions.

Scale up the pilot integration of family planning with HCT in selected facilities with 22 providers in both areas; establish one new regional HCT model site will be established in Benshangul- Gumuz.

JHU-BSPH and its subpartners being within PEPFAR will play their part in the Global Health Initiative.

The budget for this activity was increased by more than 20% because of the need to expand to new facilities and improve care and support (C&S) services. In FY09, JHUBSPH supported pediatric palliative care (PC) and nutrition services in over 60 public and private facilities in Addis Ababa, Benishangul-Gumuz, Gambella, & SNNPR regions. In FY10, JHUBSPH will continue to:

Support national and regional health bureaus; assist with regional planning and guideline and material development; and participate in technical working groups.

Train providers on pediatric PC, nutrition and symptom management; carry out site level mentoring, minor renovations, and provision of IEC materials and job aids.

Ensure training, distribution, implementation, and monitoring of the pediatric preventive care package.

Ensure pediatric drug formulations; utilization of cotrimoxazole prophylaxis (pCTX); TB screening; malaria prevention and treatment including ITNs; prevention and treatment of diarrhea; linkages to immunization programs; Isoniazid prophylaxis (IPT) for HIV positive children; and promoting healthy hygiene and safe water interventions.

Promote interventions for pediatric patient pain management.

Ensure sites implement early infant HIV diagnosis using DBS techniques and all eligible HIV-positive children are promptly referred for ART care.

Ensure nutritional counseling and assessments are completed at all entry points, targeting pediatric patients and HIV exposed and infected infants through training and site level mentoring; liaise with partners to ensure availability of supplemental feeding products.

Strengthen internal and external referral linkages to identify and link HIV-positive children and OVCs to facilities for care and community-based programs for family, social and adherence support, pain management, spiritual support, and end of life care.

Establish HIV positive adolescent support groups to promote adherence and positive living.

Integrate infant feeding counseling and maternal nutrition in PMTCT programs.

Focus on quality improvement and M&E of pediatric PC and nutrition services including tool development, training and mentoring to ensure proper utilization.

The partner being within PEPFAR will play its part in Global Health Initiative (GHI)

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Recent scientific evidence indicates that male circumcision (MC) provides up to 60% protection against female-to-male HIV transmission. Ethiopia has a high MC prevalence rate for cultural and religious reasons, but there are some segments of the society where MC is not practiced routinely; these populations are disproportionately affected by HIV/AIDS. Taking the evidence into consideration, the FHAPCO/MoH has made MC a part of its HIV prevention strategy, and established a national MC TWG in 2009. (Jhpiego serves as secretary).

With its significant global experience in MC programs, Jhpiego initiated the first MC program in Ethiopia in FY08. Using a modified version of the WHO/UNAIDS/Jhpiego MC training package, Jhpiego trained a cohort of providers in MC surgical skills to commence MC services in three sites in Gambella Region. In FY09 MC services will be started in three additional in Gambella and also SNNP region. Objectives of the FY10 program will be to strengthen safe clinical MC services in the existing six sites and expand to three additional sites in both regions. The program will target sites offering the minimum package including testing and counseling services. Another 12 providers from Gambella and SNNP regions will receive in-service training in MC surgical skills and MC kits for three new sites will be procured and distributed. Six outreach MC clinics in the targeted regions will be conducted. A total of 4,000 men will be circumcised.

In collaboration with the Surgical Society of Ethiopia, Jhpiego will conduct bi-annual coaching and supportive supervision visits to all sites. To ensure quality assurance, MC clinical care standards will be introduced through the adaption and field testing of MC standards (1,000 copies of the standards will be printed and distributed).

Building on public health messaging initiatives started in FY08/09 to promote MC services, more billboards, posters and leaflets will be developed, printed and distributed. Gender sensitive community sensitization events to promote MC services will be conducted and an Amharic TV spot on MC will be developed and broadcast in collaboration with the AIDS Resource Centre. An annual review meeting on MC will also be conducted.

In FY09, JHU-BSPH assumed responsibility for infection-prevention training for facilities in Addis Ababa, SNNPR, Gambella and Benshangul Gumuz regions from national partner Jhpiego. In COP10, JHU-BSPH will continue to provide IP training to Universities, RHBs, facilities and NGOs. Activities will include:

Support national and regional IP/PEP working groups to update training, guidelines and incorporate guidance into new BPR activities at site level.

Conduct replacement IP trainings with university and region-based TOTs to ensure sustainability.

Implement a simplified training package for use in training auxiliary hospital workers, develop cost-effective methods of delivering this training to supporting staff, and work with facilities to have functional IP committees and occupational health activities.

Ensure functional PEP activities for adults and children at all sites and ensure PEP for sexual assault.

Support IP pre-service education for medical doctors and develop e-learning modules/materials.

Conduct advocacy workshops for national IP program and ensure availability of IP supplies at facilities.

Strengthen supportive supervision to facilities to ensure proper IP practices.

Partner with Jhpiego for locally produced, low-cost, personal protective equipment (PPE), antiseptic hand rubs and aprons, customized basic IP supplies. Local Technical and Vocation Education and Training institutions (TVET) will be supported to produce some selected IP supplies for healthcare facilities.

Support infection control activities as part of the 3Is for TB which will include isolation of coughers, co-horting of TB patients in the inpatient setting, and minor environmental renovations to improve air flow.

Support national MDR/X-MDR TB prevention efforts through environmental and administrative means and supply N95 masks in limited quantities to facilities.

Strengthen M&E activities, ensure sustainable supply of documentation tools and training on how to use them, and strengthen site level IP/PEP data use.

Assess the current documentation practices for IP services and propose improved mechanisms; improve the quality of services by identifying gaps using the LQAS techniques.

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Since COP07, JHU-TSEHAI has supported the implementation of facility-based STI activities in 52 sites in Addis Ababa; Benishangul-Gumuz; Gambella; and Southern Nations, Nationalities, and Peoples (SNNPR) regions.

In COP 2010, JHU-TSEHAI will work in all JHU-TSEHAI-supported ART sites to:

1. Provide onsite mentoring on the screening of all clients coming to health facilities for STI services. This will be done in every service outlet by using the STI screening questionnaire.

2. Bolster M&E, recording and reporting of STI treatment and prevention activities and site- level STI data to improve service delivery.

3. Actively participate on the national STI technical working group and provide technical assistance in the validation study and resulting revision of the STI guidelines.

4. Conduct training using innovative onsite or group-based approaches to ensure large numbers of workers are trained at the site level; focus on ensuring HIV and STI linkages at facility level.

5. Mentor healthcare providers so that they can establish a good rapport with patients and give youth, adolescent, women and MARPS-friendly service.

6. Ensure that adequate patient education and counseling is given to all patients diagnosed with STIs.

7. Verify that all clients diagnosed with STIs are offered HIV testing and all clients found positive are enrolled in HIV care.

8. Confirm that partner management is addressed for all STI cases according to guidelines.

9. Collaborate with appropriate partners to ensure that all appropriate STI drugs and supplies are available at site level.

10. Establish that condom supplies are adequate and available in all STI outlets.

JHU-TSEHAI will continue to support STI services in the private sector in Addis Ababa and it will reinforce linkages to local NGOs and community-based organizations such as the Family Guidance Association of Ethiopia (FGAE). Innovative partner referral mechanisms will also be explored. The handover of services to local partners will be secured through improved ownership of the program at site and regional levels.

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This is a continuing activity with a new goal emphasis and should be part of the COP 2010 streamlined submission. In FY09, JHU-BSPH provided comprehensive HIV/AIDS services to 64 hospitals and health centers in Addis Ababa, SNNPR, Gambella, and Benshangul-Gumuz Regions. JHU-BSPH conducted site assessments, provided trainings, established and strengthened QA programs, supported specimen referral linkage between testing hospitals, referring hospitals and health centers, and assisted implementation of electronic laboratory information systems. JHU-BSPH supported the integration of laboratory systems and assisted in the establishment of regional laboratories in Gambella and Benshangul Gumuz. JHU-BSPH supported renovation and furnishing of laboratories for DNA PCR, viral load and TB culture. JHU-BSPH, along with FIND and EHNRI, supported the establishment of MDR-TB diagnostic laboratory in St. Peter's Hospital.

In FY10, JHU-BSPH will provide comprehensive laboratory technical assistance and support to all 64 sites. These activities include:

Strengthening of site-level laboratory quality systems, with emphasis on initiation and expansion of quality assurance programs through preparation of SOPs for integrated laboratory testing procedures.

Providing ongoing supportive supervision, coaching and mentorship on good laboratory practice and management, testing procedures, safety, and QA/QC programs.

Supporting seven sites in the preparation of WHO/AFRO step-wise accreditation process.

Renovating and laboratories and assisting with the preventive maintenance of laboratory equipment.

Rolling out standardized trainings for in-service and pre-service programs.

Supporting specimen referral system for different tiered laboratory networks.

Providing technical assistance to support HIV DNA PCR, viral load and MDR-TB testing capacity in regional labs.

Developing, implementing and enhancing laboratory inventory systems in hospital networks and ensuring availability of reagents and consumable supplies.

Assisting in the expansion of electronic and paper-based laboratory information system and proper data collection, storage, analysis, and reporting systems.

Ensuring sustainability by working closely on joint planning and implementation mechanisms with EHNRI and regional health bureaus.

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