Comprehensive goals and objectives: The 'Strengthening Communities' Response to HIV/AIDS' (SCRHA) project will continue activities to:

1) Provide expert organizational and institutional strengthening technical support to Civil Society Organizations (CSOs) including National level Implementing Partners (NIPs), so that they can take on the role of technical support organizationsmentoring and overseeing other organizations and associations, and

2) Increase awareness of and access to high-quality and more affordable HIV and related services through local CSOs.

Over the program years, including three base years and two optional years, PATH and partners will scale up support for CSOs through a sub-grant program and technical assistance in areas of organizational and human resources, community and home-based palliative care, economic strengthening, and counseling and testing. Community-based DOTS services will be provided in the context of a comprehensive community-based palliative care model to benefit both PLWHAA and HIV negative TB patients identified through SCRHA activities. SCRHA will also work with stakeholders to improve linkages and referrals between community care and the health system/facilities across HIV services.

Geographic coverage and target population: The PATH-led partnership will support the delivery of services by CSOs in urban/peri-urban areas where ART services are availablespecifically, for towns in Afar, Amhara, Benishangul Gumuz, Dire Dawa, Oromia, SNNP, Gambella, and Tigray regions. Priority scale-up or transition sites have been/are being identified in collaboration with the regional Federal HIV/AIDS Prevention and Control (HAPCO) offices and USAID. Over the life of the program, PATH will support work of CSOs in 300 towns in Ethiopia. This is a family and community-focused project, and the populations reached will include adults and children, men and women.

Health systems strengthening: This project strengthens the health system in a variety of ways. It helps support the development of community-based care and linkages with facility level care, particularly in the areas of palliative care, household testing and counseling, and economic strengthening through capacity building of CSOs working in the community. It will also equip social workers in training (pre-service training) and newly graduating social workers (post-service training) with up-to-date knowledge in the above areas, and internship/fellowships opportunities.

Cross-cutting programs and key issues: This project addresses a number of cross-cutting programs and key issues, including (1) human resources for health, (2) economic strengthening, (3) TB, (4) end of program evaluation and (5) gender. In reference to cross-cutting areas, this project has a strong focus on capacity-strengthening of CSO staff as well as social workers. It addresses in-service training, pre-service training, and management and leadership development, among others. The project will design and implement economic strengthening interventions that are market-driven and contextually relevant. Finally, the project will draw on lessons learned from existing community based DOTS program to increase access to high quality TB diagnosis and treatment services at community level. The project will ensure gender equity in HIV/AIDS activities and services.

Cost efficiency: PATH plans to directly purchase supplies and limited stop-gap commodities, as required for CSO grantees. This purchasing will be done through bulk order procurements to realize cost savings. Such supplies may include LCD projectors, mobile phones, and bicycles, and commodities may include test kits, infection prevention materials, and distribution bags. The SCRHA Project will also continue to lead the bi-monthly PEPFAR partner meetings in Addis Ababa to ensure close coordination of regional HIV/AIDS service delivery coverage. This effort should help PATH and its partners to realize improved cost efficiencies in the use of specific PEPFAR resources.

Monitoring & Evaluation (M & E) Plans: Routine monitoring of activities such as data collection, reporting, analysis and dissemination will be carried out by using the adopted/adapted M&E tools designed for community level HIV/AIDS intervention. By using the quality assurance manual, all data collected in each intervention areas (such as abstinence, other prevention methods, care and support for adult and children and OVC care), will be reviewed for completeness, reliability and validity. The project will develop a tool to measure the change in quality as a function of the program's interventions, which will provide quantitative indicators of quality for all intervention areas. Mid-term and final evaluations will be conducted Improvements in the quality of live for PLWHAPLWHAA, orphans and changes in risky behavior related to HIV/AIDS prevention will be the key outcome indicators to be evaluated against the available baseline data.

The SCRHA project will strengthen and expand adult care and support activities, through community-based palliative care programs in urban and peri-urban areas. Care and support services delivered at the community and household level by volunteers include nursing care, symptom and pain management, nutrition counseling, preventive education, referral for opportunistic infections, TB and STI screening and referral, social support (through support groups), psychological support (mental health counseling, support for disclosure, and referral for psychiatric illnesses), spiritual support (religious support and life review and counseling) and end of life care. In COP 2010, SCRHA will reach 375, 000 PLWHAA beneficiaries. The project will use community services map to be developed in COP 2010 in targeted regions to facilitate referral of beneficiaries for food, family planning, economic support and other related services. Community engagement workshops (by Alliance) and quarterly review meetings will also be conducted to strengthen client referral and stakeholder collaboration. This will contribute for better client follow-up and retention. The project will work through local CSOs by building technical and organizational capacity to implement community-based care programs. CSOs will receive training in delivering family-centered palliative care with a focus on the priorities set by the family through its active participation in identifying problems that compromise its health and well-being. Adult care and support activities will be implemented in the eight regional states (Afar, Amhara, Benishangul Gumuz, Diredawa, Gambella, Oromia, SNNP, and Tigray) in 200 urban and peri-urban towns with high HIV/AIDS prevalence.

Quality assurance of services and products will be a critical component of this program. SCRHA will work closely with PLWH and volunteers to ensure confidentiality is observed as well as appropriate disposal of medical waste. SCRHA will apply a tool to measure the quality of services provided by CSOs as a function of program interventions. Routine data will be collected using community based HIV/AIDS service provision recording format. Supportive supervision as well as regular meetings to analyze collected data and use it for decision making will ensure data quality.

SCRHA priority areas are OVC household/family strengthening, promoting community support/coordination and improving quality of services. In family strengthening, this project will provide economic strengthening. OVC support services will include educational support for school OVC, financial support for food, nutrition counseling, psychosocial support and healthcare (medical refund). To this end, OVC volunteers will be deployed to support the children for an effective outcome of each service. OVC will also benefit from the economic strengthening program of SCRHA project. In this case, economic strengthening strategies may include linking to vocational training centers, support for business plan development, and/or linkages to ongoing efforts in agricultural areas. To strengthen community support and coordination, this project intends to organize anti-stigma events among community members of targeted towns. Both male and female preschool children, school children and adolescents will be beneficiaries of the OVC package of this project. The project intends to reach 15,000 OVC in 200 towns across eight regions of Ethiopia (Afar, Amhara, Benishangul Gumuz, Diredawa, Gambella, Oromia, SNNP, and Tigray). Families and OVC will also receive information on needed referrals and linkages to programs, such as food and nutrition support, clinical health services, and legal aid. SCRHA will work to strengthen the organizational and technical capacities of local implementing partners to implement and monitor economic strengthening activities. The SCRHA project recognizes that assuring the quality of services and the quality of the data which is collected, transmitted, and used in reporting as being inseparable. To ensure this, a data quality assurance (DQA) tool will be used during facilitative supervision. In addition, a quality of service (QoS) monitoring tool for CSO activities will be used. This will permit the supervisors to monitor the changes in the quality of CSO services as a function of the project's interventions. Data collection, analysis, and reports will be generated by using a standardized care/support format which will capture OVC separately or through a standardized economic strengthening format.

SCRHA project will mainly focus on promotion of adherence to HIV treatment, referral for TB and STI treatment, and referral for treatment of HIV/treatment complications. Adherence promotion will be provided by PC volunteers. For effective adherence promotion, volunteers will apply the 5As (Assess, Advise, Agree, Assist and Arrange) approach stipulated in the integrated management of adult and adolescent illness (IMAI) guideline for Ethiopia. In doing so, volunteers will help clients to develop their individual plans to address problems of non-adherence. This individual plan will be monitored regularly by the volunteers to refine and materialize it. Techniques like memory box will also be piloted in some beneficiaries of this project. Among the 374,400 PLHA beneficiaries of this project, all patients who started or are on ART will be provided with adherence promotion and counseling. Clinical mentoring for adherence support and other treatment services will be provided by part time mentors in each town. SCRHA will also work with all stakeholders at the district level to improve linkages between community care and the health system. Adherence suport will be implemented in the 8 regional states (Afar, Amhara, Benishangul Gumuz, Diredawa, Gambella, Oromia, SNNP, and Tigray) in 200 urban and peri-urban towns with high HIV/AIDS prevelance. SCRHA project will use family-centred palliative care services model. The project activities will also address treatment adherence for children. The SCRHA activities will promote HIV testing for family members. PC volunteers will be trained on how to deal with confidentiality matters. SCRHA program will have reqular meeting with facilities to assist with tracing of treatment defaulters and linkages of pre-ART patients to clinical services. The project's Quality of Services (QoS) diagnostic tool will be used to monitor quality based on the training and supervision manual for care and support. Data Quality Assurance (DQA) tool and supportive supervision will assure data quality. CSO as well as volunteers will be encouraged and capacitated to use the routinely collected data for decision making. SCRHA will also endeavor to ensure linkages of community information system with HMIS.

Strengthening Communities' Response to HIV/AIDS (SCRHA) will provide capacity strengthening for HIV/AIDS CT services in community and household settings through local community-based organizations, using household-based strategies, home-based services, and information campaigns. Activities target the families of HIV positive individuals and households in target communities. The communities include 150 towns in urban and periurban areas with high HIV/AIDS prevalence rates and relatively large population sizes, in eight regions (Afar, Amhara, Benishangul Gumuz, Diredawa, Gambella, Oromia, SNNPR, and Tigray). The project will work closely with urban health extension workers to increase CT access in populations not currently accessing facility-based CT. This activity will expand CT services at the community level to ensure the provision of effective and quality HCT services; develop referral and network linkages to care services in facilities and address testing needs; and reach higher numbers of at-risk populations in high-prevalence areas. SCRHA will use a data quality assurance (DQA) tool during facilitative supervision. A key activity will be to increase the capacity of data/service providers in better interpreting and using data for management and quality improvement. SCRHA will ensure that counselors receive appropriate knowledge, skills and training approved by MOH; the physical space for providing HCT affords confidentiality; CT supplies are available; CT is conducted as per the national protocols and appropriate client flow. Burnout of CT providers will be prevented through supportive supervision and work place programs. HIV testing will be done using serial test algorithm with test kits validated by EHNRI. Testing materials will be stored appropriately and IP practice will be in place. In addition, the CHCT team will deliver samples for EQC to the respective local health facilities, to be forwarded to the EQC Lab. HIV positive clients will be referred and linked to the nearest health facility for HIV care/support and treatment. Data collection, analysis, and reports will be generated using standardized HCT recording and reporting format adopted/developed for this community-level HIV/AIDS intervention.

SCRHA will provide pediatric care and support services at household level for HIV positive infants and children, including: symptom management, in particular pain; nursing care; adherence counseling; referral; preventive health education; and nutrition counseling. With technical support from part-time mentors and civil society organizations (CSO), palliative care volunteers will be responsible for providing these services at the household level.

HIV positive children will be identified and provided with pediatric care/support services. Among the 15,000 orphans and other vulnerable children, all children who are HIV positive will get pediatric care services. Within the palliative care framework, infants born from HIV positive women will be referred for early infant diagnosis, prophylaxis, and treatment of opportunistic infections. A system to track and follow up pre-antiretroviral children will be developed to ensure a continuum of care.

Quarterly review meetings among pediatric care service providers will be conducted to improve referral for food, education, and other services. The project will work through local CSOs by building technical and organizational capacity to implement community-based care programs. Civil society organizations will receive training in delivering family-centered palliative care with a focus on the priorities set by the family.

SCRHA will also work with all stakeholders at the district level to improve linkages between community care and the health system for routine pediatric care, nutrition services, and maternal health services. Pediatric care and support activities will be implemented in 200 towns in the eight regional states (Afar, Amhara, Benishangul Gumuz, Diredawa, Gambella, Oromia, SNNP, and Tigray).

Quality assurance tool will be used to assure quality of CSOs services, such as referrals and accompanying caregivers or children to a health clinic, or work with health extension workers to facilitate their visits to the child's home for clinical care and follow-up. A community based information system will be used to routinely collect data and will also be linked to the HMIS.

This is a new activity.

The activity will support community level non health and health related HIV/AIDS information management and use at sites where PATH is implementing comprehensive HIV/AIDS care and support program. The activity will be implemented in urban/peri-urban areas in Afar, Amhara, Benishangul Gumuz, Dire Dawa, Oromia, SNNP, Gambella and Tigray regions.

Specific activities include identifying selected community level indicators to track health and non health related data on communities' responses to HIV/AIDS including for palliative care, Economic Strengthening, and community TB DOTs; build the capacity of CSOs and GOE stakeholders in the generation, analysis and utilization of site level data for decision making, and put in place a mechanism to ensure the quality of data reported from community programs. The partner will also support the generation of strategic information from community interventions and will facilitate timely dissemination of such information. The SCRHA Program will collaborate with other partners and stakeholders in supporting the design and implementation of Community Based Health Information System (CBHMIS) in the country.

This activity addresses two system barriers: lack of a comprehensive, coordinated and strategic approach to providing community care; and a shortage of social workers. Given the dearth of social workers and the newness of the program, the scope of practice and the role of the social worker still need to be clarified. Also, the lack of comprehensive integration of HIV/AIDS prevention, care, and treatment in the pre-service curricula of most cadres of health care workers is an obstacle to rapid scale up of quality programs. Inadequate infrastructure, faculty, and resources at training institutions also hamper the delivery of quality education. This activity addresses these barriers in a broad and systemic manner, including infrastructure support, training of faculty (and perhaps also hiring of faculty), curriculum revisions and enhancement, clarification of scope of practice, and support of a professional body for social workers; all this in addition to classroom and practical training of students. Strengthening Communities' Response to HIV/AIDS (SCRHA) will provide support to pre-service social work education and training to ensure PLWHAA, those vulnerable to HIV infection and OVC have better access to comprehensive social support services at the community level. This will alleviate the burden at health facilities, which are often required to provide psycho-social care and support. The intervention will also improve community-level HIV/AIDS information management which contributes to improved health service planning and decision making. SCRHA will enhance curricula (based on needs assessments), and support integration of community-based palliative care guidelines and support materials into private and public social work training institutions. SCRHA will recruit, place, and support the first cohort of student interns and post-graduate fellows within CSOs, directly linking this increased health worker capacity with organizations working in communities. SCRHA will develop a reporting format and system on pre-service strengthening at educational institutions. When interns and fellows are working with CSOs, SCRHAs standardized, regular data collection , analysis, and reports will monitor performance.

This is a continuing activity. AB sexual prevention messages will be provided by community home-based palliative care providers (CHBPCPs) to PLWHAA and families at the household level. Strengthening Communities' Response to HIV/AIDS (SCRHA) intends to reach 200 towns in eight regions (Afar, Amhara, Benishangul Gumuz, Diredawa, Gambella, Oromia, SNNP, and Tigray. AB messages will be provided along with information on other prevention and health messages that support healthy living among PLWHAA and their families. In reaching PLWHAA, AB messages will promote secondary abstinence and prevent risky behaviors such as multiple sexual partnerships, concurrent relationships and alcohol addiction. AB primary prevention messages will reach both males and females of all ages (perhaps as young as 10 with more emphasis on females) who have a variety of potential behavioral risks. CHBPCPs will use BCC pamphlets and cue cards to help meet information needs during household visits. AB messages will also be integrated into community mobilization activities promoting palliative care services through coffee ceremonies and other community gatherings. SCRHA has planned to organize PLWHAA and community support groups in each target town. In each support group, two sessions will be conducted in each month where AB messages will also be included. AB messages will be part of a community mobilization module which will be used as a tool to facilitate community support groups. For PLWHAA support group sessions, lead PLWHAA members will be trained on AB. SCRHA will work to strengthen the organizational and technical capacity of local implementing partners to implement and monitor the provision of accurate and consistent AB information and messages. The quality of AB messages and services will be ensured through training of CHBPCPs on interpersonal communication skills and provision of cue cards. SCRHA will continue to work closely with other partners to ensure AB messages are reinforced while planned frequent home visits will ensure repeated dosages are received.

SCRHA will continue to collaborate with other partners to ensure community-based information systems are strengthened and linked to HMIS. Volunteers participating in the program will routinely collect data.

The Strengthening Communities' Response to HIV/AIDS (SCRHA) project is a continuing activity. Through provision of subgrants to local organizations, other sexual prevention messages will be part of the overall package of palliative care information and services provided by community home-based palliative care providers (CHBPCP) to families and individuals at the household level and as a counseling topic as part of HIV counseling and testing supported by SCRHA. SCRHA intends to reach 200 towns in eight focus regions (Afar, Amhara, Benishangul Gumuz, Diredawa, Gambella, Oromia, SNNP, and Tigray) during the year. Other sexual prevention messages will target sexually active males and females. SCRHA's development of other prevention messaging will carefully consider issues related to gender norms and stigma. HIV prevention messages and condom information will also be integrated into community mobilization activities. SCRHA will work to strengthen the organizational and technical capacity of local implementing partners to implement and monitor provision of accurate and consistent HIV prevention information and messages. CHBPCPs will also provide linkages and referrals to other large-scale prevention efforts, such as TransACTION.

Quality Assurance of service delivery for HVOP includes QA components such as interpersonal communication skills (IPC), completeness and accuracy of the messages delivered, and privacy. These and other components are all addressed through the project's training and in the QA supervision manuals being developed. Because this prevention area also includes sale/purchase of and proper use of condoms, specific behavior change to promote prevention, and changing cultural norms, these issues are addressed in the project's training and supervision.

Monitoring and evaluation of this intervention is largely focused on routine data collection and analyzing tends over time (number of beneficiaries with each intervention methods). By combining with other methods of prevention, this will strengthen to measure change in behavior created in a certain geographical areas (persistent condom usage, willingness to be treated for STIs and others.

None

The SCRHA project is a continuing activity, building on the existing community-based DOTS model and partner experience to increase access to priority TB case detection, diagnosis and treatment services. SCRHA will build capacity among local CSOs for DOTS and TB/HIV services. The services will primarily reach PLWHAAs, and their families. SCHRA will train and deploy community DOTS agents for the provision of these services. SCRHA will develop a standardized tool to assess readiness for community-based DOTS at district level that will provide key information for planning and rolling out services. Specific services include home-based TB symptom screening, TB infection control, home- and community-based DOTS, and referral for HIV care and treatment services available through other CSOs and/or local public or private health facilities. Delivery of community and home based TB DOTS services will commence in Tigray and South regions followed by phased roll out to all the eight regions (Afar, Amhara, Benishangul Gumuz, Diredawa, Gambella, Oromia, SNNP, and Tigray) are covered. SCRHA will also work with all stakeholders at the district level to improve linkages between community care and the health system across TB and HIV services. The quality of TB/HIV services will be addressed through ongoing mentoring, supportive supervision and review meetings with the CSOs and community-based palliative care teams. This will include regular coaching of TB DOTS agents, routine on-the-job training, needs assessment and provision of refresher trainings to maintain screening, adherence counseling, treatment support, health education and referral skills. Data quality assessment will be key element of supportive supervision, particularly routine checking of standard DOTS recording and reporting forms. Data collection, analysis, and reporting will be supported with a standardized palliative care format that includes key data elements to monitor implementation of TB/HIV services at the community level. These data elements will be harmonized with routine requirements of the National TB Program and the national Health Management Information System to ensure that SCRHA provides necessary inputs for monitoring DOTS implementation in Ethiopia.