The USAID HIV/AIDS Care and Support Program supports health centers in Tigray, Amhara, Oromia, the Southern Nations, Nationalities and Peoples Region and Addis Ababa. It is implemented by MSH with its partners: Save the Children USA, IntraHealth International, Dawn of Hope Ethiopia and the Ethiopian Interfaith Forum for Dialogue, Development and Action. The program's objectives are: 1) To strengthen capacity of health centers to provide comprehensive HIV/AIDS services, including VCT, PITC, TB/HIV, lab support, PMTCT, and ART; 2) To deploy personalized case managers to task shift adherence counseling and support to lay counselors; 3) To deploy community outreach workers to support community-level care and support services; and 4) To integrate prevention into health center and community interventions, focusing on Prevention with Positives and ABC.

Under COP 2010, the program will support startup of ART in additional health centers, while improving service quality in health centers with earlier established comprehensive HIV/AIDS services. The program will place increased emphasis on PMTCT and pediatric care and treatment while exploring, in partnership with GOE, more cost-effective and sustainable modalities of key health center focused areas of intervention, including case management, collection of SI and mentoring.

Key activities during COP 2010 that encompass health system strengthening, include: (a) training of health workers in HIV/TB, CT and ART, including PMTCT and pediatrics care and treatment, relying on certified GOE staff trainers; (b) training of health center case managers; (c) on-site training and monitoring of health centers by program mentors using clinical service quality indicators; (c) on-site technical support to health center laboratories by lab advisors; and (d) data clerks at ART health centers to collect and report SI. The program will utilize SI collected by strengthened health centers to monitor and evaluate its progress towards meeting targets as well as share SI with key stakeholders.

The program will continue to leverage other key interventions. It has established PITC at FP, U5 and EPI clinics, which supports child survival initiatives. It has established referral of HIV-positive patients to FP and pediatric patients to the U5 and EPI clinics. It will leverage PMI funding for strengthening health center laboratories to improve diagnosis capacity and PSI support for bed nets to infected and affected households. The program will leverage TBCAP for health center support, including the training of health workers and carrying out of joint DOTs adherence initiatives.

The program will continue to support a continuum of care from hospital, health center and community and continue to facilitate referrals of stable patients from over-loaded hospitals to health centers and complicated cases to hospitals. The program will continue active participation in catchment area meetings, collaborating with GOE and PEPFAR and non-PEPFAR partners, to foster greater inter-facility coordination.

The HCSP will continue to facilitate health center - community integration, linking health center case managers with community-level volunteers and HEWs, including the new urban HEWs. The case manager is the key health center contact for its community and support networks. The case manager provides HIV-positive patients psychosocial support and adherence counseling, promotes positive living and family CT, and provides links to health center based mother support groups and community support. They lead case-finding of patients who have missed their appointments, primarily in partnership with the program's community volunteers, called kebele-oriented outreach workers (KOOWs), and HEWs. During COP 2010, the program will train and deploy additional case managers to ensure one per ART health center.

The program will also train and deploy additional KOOWs to health center served kebeles. KOOWS provide a number of invaluable community services, including psychological support to infected/affected households, home based care, health center referrals, community resource mapping and links for the infected/affected, community mobilization for prevention and CT, adherence counseling, and community tracing of patients who have stopped ART.

During COP 2010, HCSP will continue to support local organizations through performance-based contracts to support key community initiatives such as uptake of health center services, education on stigma reduction, mobilization of community members on family-centered care, deployment of HBC providers in high-prevalence areas, and testimonials for youth and women on positive living and adherence.

The program will continue to actively participate in national HIV/AIDS TWGs, within which senior program technical staff will collaborate with GOE, PEPFAR and non-PEPFAR partners to design policies, strategies and implementation modalities; develop training manuals; and participate in evaluations.

Finally, under COP 2010, a key cross cutting area, gender, will be promoted through initiatives such as promoting a practical guide on mainstreaming gender into HIV/AIDS programs, complementing GOE gender manuals.

MSH-HCSP will participate as needed in the Global Health Initiative.

The HIV Care and Support Program supports health center's provision of comprehensive HIV/AIDS services, including appropriate collection, sharing and analysis of strategic information (SI) in Tigray, Amhara, Oromia, the Southern Nations, Nationalities and Peoples Region and Addis Ababa.

The program's main strategies are: 1) Build the capacity of health workers to provide comprehensive and quality HIV/AIDS services, which includes SI, through training and deploying data clerks and conducting site visits and mentoring; and 2) Provide SI training to key stakeholders.

In the 350 supported health centers providing ART services, SI systems have been established, and data clerks have been recruited, trained and deployed. In COP 2010, HCSP will support refresher training for data clerks.

The program will continue monthly in-service and one-on-one mentorship to build the capacity of health center staff and monitor quality of services, which includes SI. They will continue to monitor the data collectors' performance and, with the support of regional program M&E advisors, provide technical assistance in SI collection, entry, quality checks, analysis and reporting. The mentors will also support health center health providers with analyzing and using their SI with the health centers' multi-disciplinary team meeting, a key discussion forum.

The mentors will continue to participate in and share SI in catchment area meetings, which provide a discussion forum for representatives from health centers, hospitals and woreda offices, PEPFAR and non-PEPFAR partners, and other stakeholders.

Senior HCSP M&E staff will continue to check the quality of SI provided by the health centers and channel it to key stakeholders, including the GOE (at woreda, regional and national levels), USAID, and PEPFAR partners.

In COP 2010, the program anticipates supporting the MOH's implementation of a national HMIS. This would include training of over 1,000 health center staff, coupled with the program's earlier provision of 350 computers (one per program-supported health center providing ART services). Senior HCSP technical staff will support the GOE's efforts to develop an SI system that captures community-level HIV/AIDS care and support initiatives.

In COP 20 10, the HIV/AIDS Care and Support Program (HCSP) will support 350 health centers to provide antiretroviral therapy (ART) services in Tigray, Amhara, Oromia, the Southern Nations, Nationalities and Peoples Region, and Addis Ababa.

Main program main strategies are: (1) Build the capacity of health workers to provide adult HIV/AIDS care and treatment through training provided by certified government staff and on-site visits by program mentors; and (2) ensure proactive treatment adherence. The program supports training of health workers on comprehensive management of opportunistic infections and ART. HCSP has trained 3,360 health workers; another 950 will be trained. HCSP will collaborate with FANTA, to ensure health care providers are proficient in nutrition assessment, and with the World Food Program and USAID Food by Prescription, among others, to address nutrition needs of ART patients.

The program will continue providing monthly on-site, one-to-one mentorship, backed up by telephone consultation, to build knowledge and skill of health center staff in managing ART patients and monitoring quality of service. Mentors will also actively participate in catchment area meetings to discuss referrals, achievements, and challenges.

To promote adherence, the HCSP has recruited, trained, and deployed 331 case managers, ensuring one per supported ART health center. Case managers counsel patients on ART adherence and trace patients who miss their appointments in partnership with community volunteers, kebele-oriented outreach workers, and health extension workers. Currently, supported health centers report a lost-to-follow-up rate of 7%, well below a national average of over 20%. Under COP 2010, the HCSP will train additional case managers to ensure all facilities supported by HCSP have adequate coverage.

As of June 2009, program supported health centers have 45,612 patients receiving ART. In addition to ART, these patients are also receiving treatment package including cotrimoxazole prophylaxis and TB screening. Program is implementing M&E activities, which focus on data quality as well ensuring high level quality services are delivered using fully functional service delivery point quality assessment tool.

A key focus of the HIV Care and Support Program will be to increase the number of persons who know their HIV status in Tigray, Amhara, Oromia, SNNPR and Addis Ababa, through different testing approaches. The program's main strategies are: 1) Build the capacity of health workers to provide comprehensive and quality CT through training provided by GOE certified staff and on-site visits by program mentors; and 2) Community outreach.

The program has supported over 4,000 health workers to receive training on the national CT curriculum, including three-week training on VCT and six-day training for PITC. Training encompasses point of care testing to ensure CT is completed in one room by one professional using national algorithm. Over 4,000 additional health workers will receive training.

The program will continue monthly in-service, one-to-one mentorship and supportive supervision. Mentors oversee the VCT clinic as well as provision of PITC at the other clinics, including outpatient, U5, EPI, FP, TB, ANC and labor and delivery. Case managers' implementation of PWP will include counseling of all patients testing HIV+ and use the family focused approach, which employs a family matrix to promote couple counseling and the bringing of family members for CT.

The program supports CT outreach during such events as religious festivals and on weekends in high prevalent areas. In FY 2009, 1.5 million people received CT and their results. In COP 2010, the program will implement a community outreach CT initiative that will reach into the 80 highest prevalence woredas served by supported health centers. Efforts will be made to ensure linkages to services for those testing positive using referrals. Over 2,000 rural HEWs will be trained. They will provide orientation of the volunteers who will mobilize the community and organize outreach days. Special attention will be on population likely to be HIV+. Local health center professionals will provide the CT and couple counseling. In COP 2010, the program will support the GOE's new urban HEW initiative, which will employ nurses to provide, amongst other health services, CT at the household level.

HCSP supports the provision of comprehensive HIV/AIDS services through a continuum of care that directly links health centers with served communities, of which pediatric care and support is a key component. The program supports health centers in Tigray, Amhara, Oromia, the SNNPR, and Addis Ababa.

Health centers receive program support for training and ongoing mentoring visits. They receive support for prevention of mother to child transmission, testing at under-five and EPI clinics, and community outreach. Health providers at antiretroviral therapy (ART) providing health centers are trained on Dried Blood Spot (DBS) tests for early infant diagnosis and on treatment of HIV positive infants and children for opportunistic infections and other HIV/AIDS complications, pain, symptom relief, and nutrition assessment. Under COP 2010, the program will train over 850 health workers on pediatrics care and support, including nutritional assessment.

By COP 2010, the program intends to reach 5,700 HIV positive infants and children with care and support services. Case managers will be key in pediatric care and support by ensuring referral and linkage of families with positive infants and children to community resources, preparing families for ART adherence, providing psychosocial support, and promoting positive living and family counseling and testing (CT). Case managers will also lead in tracing patients who miss their appointments, in partnership with kebele-oriented outreach workers (KOOWs) and health extension workers. The program will train an additional 50 case managers.

The program will train 2,256 KOOWs, for a total of 6,350, who will support 1,270 high prevalence kebeles. KOOWs provide key community services, including community mobilization for CT, psychological support, adherence counseling, and tracing of lost patients. KOOWs will map local resources and link families with infected children to services for such critical needs as food, clothing, and income generating activities. The program will collaborate with the World Food Program and the upcoming USAID Food by Prescription project and with PSI for provision of basic household supplies.

The HIV/AIDS Care and Support Program (HCSP) supported health centers have provided antiretroviral therapy (ART) to 960 infants in Tigray, Amhara, Oromia, SNNPR and Addis Ababa. The program objective is to reach 2,880 in treatment and 5,700 in care and support in the same regions.

The program's main strategies are: (1) Build the capacity of health workers to provide pediatric care and treatment through training provided by certified Government of Ethiopia (GOE) staff trainers and on-site visits by program mentors; (2) Strengthen health centers' linkages for supporting pediatric care and treatment; and (3) Ensure HIV exposed infants access for early infant diagnosis (EID) to increase the number of under-12 month old children on treatment.

The program has supported 3,360 health workers to receive ART training that includes two weeks on pediatric care and treatment. The program also plans to train another 950 health workers and to continuing training health providers in DBS tests, including timely acquisition of results from regional labs. The program will collaborate with the FANTA project to provide training on pediatric nutrition. The program will also collaborate with World Food Program and the USAID Food by Prescription project, among others.

The program will continue monthly in-service and one-to-one mentorship. USAID is supporting the ANECCA to partner with the program in mentoring and trainings. ANECCA's mentors work alongside HCSP mentors, who will cascade pediatric mentorship.

The mentors will emphasize greater linkages between counseling and testing, prevention of mother to child transmission, EPI and under-five clinics, as these are the main sources of pediatric patients. A major emphasis will be integration of routine pediatric care in other services. The program will use family focused approaches to promote HIV testing of all family members.

Both HCSP and ANECCA mentors will actively participate in supportive supervision and catchment area meetings to discuss referrals, achievements, and challenges. Senior technical staff will actively participate in technical working groups to help design policies, strategies, training, and monitoring guidelines.

The HIV Care and Support Program supports health center's provision of comprehensive HIV/AIDS services, including appropriate collection, sharing and analysis of strategic information (SI) in Tigray, Amhara, Oromia, the Southern Nations, Nationalities and Peoples Region and Addis Ababa.

The program's main strategies are: 1) Build the capacity of health workers to provide comprehensive and quality HIV/AIDS services, which includes SI, through training and deploying data clerks and conducting site visits and mentoring; and 2) Provide SI training to key stakeholders.

In the 350 supported health centers providing ART services, SI systems have been established, and data clerks have been recruited, trained and deployed. In COP 2010, HCSP will support refresher training for data clerks.

The program will continue monthly in-service and one-on-one mentorship to build the capacity of health center staff and monitor quality of services, which includes SI. They will continue to monitor the data collectors' performance and, with the support of regional program M&E advisors, provide technical assistance in SI collection, entry, quality checks, analysis and reporting. The mentors will also support health center health providers with analyzing and using their SI with the health centers' multi-disciplinary team meeting, a key discussion forum.

The mentors will continue to participate in and share SI in catchment area meetings, which provide a discussion forum for representatives from health centers, hospitals and woreda offices, PEPFAR and non-PEPFAR partners, and other stakeholders.

Senior HCSP M&E staff will continue to check the quality of SI provided by the health centers and channel it to key stakeholders, including the GOE (at woreda, regional and national levels), USAID, and PEPFAR partners.

In COP 2010, the program anticipates supporting the MOH's implementation of a national HMIS. This would include training of over 1,000 health center staff, coupled with the program's earlier provision of 350 computers (one per program-supported health center providing ART services). Senior HCSP technical staff will support the GOE's efforts to develop an SI system that captures community-level HIV/AIDS care and support initiatives.

A key focus of the HIV Care and Support Program is to support health centers to provide comprehensive HIV/AIDS services that include integration of prevention within a continuum of care that links health centers with community level care and support. The program supports health centers in Tigray, Amhara, Oromia, SNNPR, and Addis Ababa. Target population in health centers is PLWHAPLWHAA, while in the community, it is the general population.

At health centers, the program trains health workers to provide health education to every person receiving CT, including AB topics, such as secondary abstinence, fidelity and reducing multiple and concurrent partners. During pre-marital screening for HIV, health workers provide messages to couples on being faithful. The program's health center case managers provide health education and preventive counseling to PLWHAPLWHAA that includes prevention through AB messages.

At the community level, the program has trained around 5,250 individuals on HIV/AIDS prevention that includes AB, including school teachers, students, religious leaders, the program's community volunteers, KOOWs, kebele HIV desk officers, and HEWs.

The program will continue community level promotion of AB through six NGO partners. The Ethiopian Interfaith Forum for Development Dialogue and Action (EIFDDA) carries out AB promotion initiatives in churches and mosques and Dawn Hope Ethiopia produces a quarterly newspaper highlighting HIV/AIDS topics and information, including AB. The HCSP also adapts IEC/BCC materials from other PEPFAR partners to complement the AB activities. Last year alone, the program assisted the GOE to reach nearly 1.3 million individuals through community outreach that promotes HIV/AIDS prevention, including AB.

The program will train an additional 2,350 KOOWs on HIV/AIDS, including prevention through AB, and 2,000 rural HEWs will be trained to support an intensified community outreach initiative in 80 high prevalence woredas served by supported health centers. Following the GOE's voluntary community anti-AIDS promoters (VICAP) approach, they will then orient 66,000 volunteers to mobilize their families and neighbors in HIV/AIDS, including prevention through AB.

A key focus of the HIV Care and Support Program (HCSP) will be to reach community members with risky sexual behavior, in particular those having repeat HIV testing and PLWHAPLWHAA who continue to engage in risky behavior. The program supports health centers in Tigray, Amhara, Oromia, Southern Nations Nationalities and Peoples Regions and Addis Ababa.

At health centers, the program trains health worker to provide health education to every person receiving CT that includes OP topics, such as condom use and reducing multiple and concurrent partners. In COP 2010, particular attention will be made for the CT clients who are having repeat testing. The program's health center case managers will provide health education and preventive counseling to reduce transmission among discordant couples. Reinforcement of messages will be achieved by providing IEC/BCC materials to other community forums such as community conversations and coffee ceremonies.

The program facilitates availability and access to condoms at health centers, where condoms are available at their clinics, all of which conduct CT counseling and where patients can take whatever they want. The HCSP in partnership with PSI will train health workers on proper condom use.

At the community level, the PSI collaboration will provide condoms to over 100 health posts managed by HEWs for free distribution to the community. Over 6,000 of the program's community volunteers, KOOW, will directly participate in the condom distribution ensuring access to condoms at community level.

The program will train 2,000 rural HEWs to support an intensified community outreach initiative in 80 high prevalence woredas. Using the GOE's VICAP approach, they will then train 66,000 volunteers to mobilize their family and neighbors around HIV/AIDS, OP.

At the community level, the program has trained around 5,250 individuals on HIV/AIDS that includes OP, including school teachers, students, religious leaders and KOOWs. The program will continue community level promotion of OP through six NGO partners. For example, the Dawn Hope Ethiopia produces a quarterly news paper highlighting HIV/AIDS topics and information, including on OP.

The HCSP supports health centers in Tigray, Amhara, Oromia, SNNPR and Addis Ababa for PMTCT services. The program's main strategies are to build the capacity of health workers to provide integrated quality PMTCT/ANC services through training and ongoing site visits by program mentors and increase awareness and uptake of integrated ANC/PMTCT by mothers.

HCSP will support the training of 1,350 health workers from 550 health centers using national PMTCT guidelines and will emphasize group counseling and opt out testing with same day results at point-of-care (ANC, labor and postpartum period). The families of HIV-positive women will be linked to HCT and other services, such as OVC and nutrition, using the MATRIX model. HCSP will scale up activities and continue providing more efficacious ARV regimens-AZT from 28 weeks and 3TC + sdNVP at onset of labor as well as the required infant ARV prophylaxis dosing. sdNVP will be given only at first point of contact when the woman doesn't return and if identified in L&D. HCSP will prioritize identifying and providing HAART for an estimated 30% of women who will need it for their health through clinical staging and CD4 testing by logging samples to laboratories in the region. Eligible women will be linked to ART; CTX and FP. Male partners will be tested using invitation letters and opinion leaders.

Clinical mentors will provide supportive supervision through monthly on-site visits and by telephone consultation. Other support includes the provision of standard operating procedures and facilitation of timely replenishment of test kits and drugs for PMTCT prophylaxis. Nationally, HCSP will actively participate in the PMTCT TWG.

HCSP will encourage increased use of ANC/PMTCT services through IEC/BCC strategies and has trained HCWs to counsel mothers for CT. The program supports 115 MSGs that provide peer counseling on testing and prophylaxis adherence for mother and infant. MSGs and other volunteers will work to ensure follow-up of mother-infant pairs and linkages of HIV exposed infants to EID services and improve infant feeding practices.

To increase ANC attendance, the program will implement a community outreach CT initiative targeting mothers and children in 80 high prevalence woredas, relying on support from HEWs and cadre of community volunteers.

The HIV Care and Support Program supports the GOE's nationwide expansion of comprehensive HIV/AIDS services by supporting 550 health centers, of which 350 currently provide ART. A key focus of the program is to support health centers provision of comprehensive HIV/AIDS services of which laboratory support is a key component. Currently 550 health centers provide laboratory support. These laboratories are located in Tigray, Amhara, Oromia, the Southern Nations, Nationalities and Peoples Region and Addis Ababa.

The main strategy of the program is to build the capacity of health centers to provide quality laboratory services through staff training, partnering with regional laboratories and GOE external quality assurance.

The program has provided 400 laboratory professionals with a practical laboratory refresher training that includes OI, Malaria diagnosis, DBS taking and transportation for early infant diagnosis, HIV rapid test kits and TB microscopy. The program will further provide ENNRI developed refresher training to over 800 laboratory professionals that will include EQA for TB, Malaria, HIV and other OIs. In addition, a quarterly EQA for 550 health center laboratories will be conducted covering TB, Malaria and HIV tests, with certificates given.

The program has one laboratory advisor in each region to support regional laboratories in EQA and on-site mentors helping health centers implement the quality performance monitoring and improvement measure, the Fully Functional Service Delivery Point tool. They also support gap filling provision of supplies to health centers.

At the national level, senior HCSP technical staff is working closely with EHNRI and PEPFAR and non-PEPFAR partners to develop a national training manual with guidelines, standard operation procedures and EQA systems for HIV tests, TB microscopy, malaria and other OIs.

Senior program technical staffs have been involved in the development of a revised EHNRI EQA strategy for TB, HIV testes, malaria and will assist the GOE in the implementation of the EQAs.

A key focus of the HIV Care and Support Program is to support the targeted health centers to provide quality comprehensive HIV/AIDS services, including TB/HIV services, in Tigray, Amhara, Oromia, the Southern Nations, Nationalities and Peoples Region, and Addis Ababa.

Main program strategies are: (1) Build the capacity of health workers to provide quality TB/HIV services through training provided by certified government staff trainers and ongoing mentoring site visits; (2) Support strengthening health center laboratories; and (3) Provide community TB screening.

The program has supported training of 3,993 health workers on HIV/TB counseling and testing, with another 550 planned. Currently, nearly 15,000 TB patients have received treatment, with over 95% tested for HIV. TB screening, diagnosis, and treatment rates, though increasing, are still quite low. Infection control and INH prophylaxis activities will be taken to scale in COP 2010. Kebele-oriented outreach workers (KOOWs) trained in community TB screening and infection control will continue to support these activities at community level. The program will train 2,000 KOOWs in 80 high prevalence woredas and will integrate the new urban health extension workers into its community TB screening activities.

Clinical mentorship will continue, with program mentors providing clinical care support in TB screening, diagnosis and treatment. During visits, they will continue to carry out history-taking, physical examination, and case reviews, and will use clinical care indicators to measure quality of service and outcomes.

The program has also provided 330 laboratory professionals with practical refresher training on TB microscopy. Program regional laboratory advisors are providing on-site support in TB and malaria microscopy reading, quality assurance, HIV tests, and other opportunistic infection laboratory investigations.

Senior program technical staffs were involved in development of a revised Ethiopian Health and Nutrition Research Institute external quality assurance (EQA) strategy involving a decentralized, four-tier system of TB microscopy EQA and will assist the government in implementing it in COP 2010, as it includes hospitals providing EQA to health centers.