As a result of the recent reorganization of the Ethiopian Federal Ministry of Health (MoH), the EHNRI has been tasked to assume the lead for i) national laboratory services, ii) coordination, implementation, and knowledge transfer for all health-related research, surveys and public health surveillance activities in the country, and iii) public health emergency management. CDC currently has a significant co-location of all programmatic staff at the EHNRI headquarters, but will retain only the laboratory and strategic information branches at EHNRI once the new embassy compound is completed in 2010.

To better coordinate and strengthen laboratory activities, EHNRI developed a five year integrated laboratory master plan with clear objectives. PEPFAR supports the plan and, through close engagement by co-location of CDC's laboratory team at EHNRI, provides daily support to address standardization of laboratory services within the health network model, targeted training programs, integration of services, regional laboratory capacity development for sustainability, improvement of lab commodities procurement/distribution, strengthening and expansion of the national laboratory quality systems, management of equipment maintenance services, laboratory networking and sample referral from health centers and hospitals, development of an efficient data management system, laboratory workforce development, lab manager mentorship and coaching skills, and evaluation of new technologies that inform policy decision. PEPFAR will support EHNRI to lead accreditation efforts of 26 laboratories using the WHO/AFRO accreditation scheme. CDC's co-location with EHNRI greatly facilitates implementation, timely and targetted capacity building, country ownership and sustainability. And the CoAg providing direct-funding to this local institution enhances cost efficiency and leveraging of funds with the Global Fund, eg, for the purchase of laboratory equipment that is part of the national platform for hospitals down to health centers.

Strategic information is crucial particularly since the HIV/AIDS epidemic in Ethiopia is one of substantial geographic and population heterogeneity. There is a pressing need to generate more accurate and timely estimates on trends in prevalence, incidence, MARPS, and the impact of interventions. With support from PEPFAR, EHNRI recently developed a new five-year (2010-2014) strategic plan for HIV surveillance. The goals of this plan are two-fold: 1) to provide high-quality timely information from national surveillance activities and surveys that monitor HIV prevalence, incidence, and HIV-related risk behaviors; and 2) to support evidence-based decision making for program management and policy formulation. EHNRI requires considerable capacity-building support from PEPFAR to operationalize this critical plan. Co-location of the CDC SI team and the CoAg for direct-funding to support surveillance activities will facilitate this process.

EHNRI, with support from PEPFAR, has produced and disseminated the "AIDS in Ethiopia" report using mostly results of previous rounds of ANC-based HIV surveillance activities. EHNRI conducted country-wide trainings for the 2009 round of sentinel ANC surveillance, and data and specimen collection is being finalized from the 115 sentinel sites. Also with PEPFAR support, EHNRI developed the TB/HIV and STI/HIV surveillance protocols through local technical working groups. In COP09, site assessment and selection for TB/HIV sentinel surveillance in 35 health facilities was completed and regional-level Training of Trainers will begin in early FY10. A major development in mid-2009 was a new request from EHNRI for PEPFAR to support Ethiopia's first national population-based survey on HIV, Hepatitis B/ C, and Herpes Simplex Type II. Led by EHNRI, funding is being leveraged with the Global Fund and extensive technical assistance is being provided by CDC to conduct this critical survey in 2010.

Though public health emergency management is not a focus of PEPFAR, EHNRI is the major implementing partner along with Addis Ababa University for the PEPFAR-funded Field Epidemiology and Laboratory Training Program that is funded through the Ethiopia Public Health Association. PEPFAR funds are also leveraged with pandemic influenza funds from CDC to develop this new cadre of epidemiologists and public health leaders, an important undertaking for human resource development.

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This activity comprises of two seperate entities: (1) This is a continuing activity with expansion of targets and an increase in budget and should be part of the COP10 streamlined submission.

Equipment preventative maintenance and curative maintenance play critical roles in ensuring quality laboratory testing and uninterrupted service delivery as care and ART services are rolled out. While preventive and curative equipment maintenance constitute a key strategic objective in the national laboratory strategic plan, implementation remains a major challenge. The Maputo Declaration is being implemented; all ART laboratories are receiving limited maintenance service of equipment, inventory laboratory management and on-site practical training. However, significant gaps and challenges remain as ART services roll-out to more than 200 health centers.

In FY09, EHNRI conducted 286 curative maintenance services for ART monitoring instruments. Six engineers were hired by EHNRI and provided with training on maintenance of different platforms. EHNRI has developed standard operating procedures for equipment preventative maintenance and for use in instrument operations that are routinely used. EHNRI has provided training on equipment maintenance and tool kits to 23 lab technicians. EHNRI is also pursuing 'bundling' of maintenance services with procurement of reagents with the vendor of Facscount and Facscalibur. Several spare parts were bought for repair and scheduled maintenance of ART equipment. However, the establishment of a permanent service contract still poses a challenge, largely due to foreign exchange restrictions in Ethiopia.

In FY10, EHNRI will continue building local capacity for the preventative and curative maintenance of major and ancillary equipments. EHNRI will hire 30 engineers for national and regional maintenance workshop centers. The purchase of spare parts and tools for local engineers in building of regional equipment maintenance capacity along with training at national and regional levels will continue. EHNRI, through SCMS, will pursue and expand 'bundling' to include other equipment vendors. EHNRI's establishment of service maintenance contracts with vendors is imperative for major and sensitive pieces of equipment. EHNRI will support improved mechanisms for proper documentation and reporting of damaged equipment and their repair from regional and reference laboratories. (2) This activity has had a significant budget increase. EHNRI has supported hospital laboratories with its electronic and paper-based Laboratory Information Management System (LIMS). For this purpose, a site level LIS license, Polytech LIS software, computers and accessories have been procured and distributed to four pilot sites and 20 expansion sites. Thus far, the system is operating at 24 hospital laboratories. More than 70 technical and administrative laboratory personnel have been trained as "end-users" and "super-users". EHNRI, in collaboration with APHL, is managing the LIS and IT support contract. In COP10, EHNRI, along with APHL, CDC-Ethiopia, university partners, and regional health bureaus, will expand LIMS to 30 sites. These sites will support routine laboratory operations and quality assurance activities in regional and hospital laboratories. LIMS will enable sites to have quality data and generate reports. This will also contribute to national laboratory monitoring and evaluation of program, as well as the implementation of WHO/AFRO's Step-Wise Laboratory Accreditation. In COP10, the following LIMS expansion work will be accomplished: (1) procurement of an additional 120 sets of LIMS software and site licenses for 30 sites; (2) procurement of 30 barcode printers, 120 barcode readers and 75 barcode printer papers; (3) training of 120 laboratory technicians and 30 receptionists in LIMS; (4) procurement and provision of 120 computers and accessories; (5) design and implementation of a peer-to-peer network for selected regional and hospital laboratories; (6) installation and configuration of LIMS in selected regional and hospital laboratories, including linking the hospital laboratories via dial-up with their respective regional laboratories, and linking regional laboratories with the EHNRI reference laboratory; (7) installation of telephone lines at regional and hospitals laboratories to support implementation of LIMS; (8) technical support to COP09-funded LIMS sites; (9) support for local travel to carry out technical support and international travel for experience sharing with APHL facilities on LIMS; and (10) planning for evaluation of the system and a further expansion phase.

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