Clinical malnutrition is a risk factor for HIV progression, morbidity and mortality for all HIV + patients. As HIV infection progresses, hyper-metabolism, malabsorption of nutrients, diarrhea, and anorexia can cause poor nutritional status that adversely affects adherence to and efficacy of drug treatments. The FBP goal is to provide therapeutic and supplementary feeding to malnourished HIV+ individuals at health facilities in alignment with the GHI and Government of Ethiopia (GOE) goals. In COP 2012, the program will expand NACS to approximately 100 new public health facilities, introduce NACS into private and NGO facilities, explore nutritional support to TB patients and strengthen and expand economic opportunities for 50,000 beneficiaries through linkages with ongoing PEPFAR and GOE programs, and other development platforms supported by FTF. The program will continue to enroll and support severely and moderately malnourished PLWHA, HIV + pregnant women in PMTCT programs, HIV + lactating women in the first six months post-partum, their infants, and OVC in Amhara, Oromia, SNNPR, Tigray, Harar, Dire Dawa and Addis Ababa.. As the program evolves, efforts will focus on strengthening health workers skills and NACS quality through supportive supervision and integrated quality improvement. Coordination with other partners will focus on providing technical assistance and support to proper packaging and labeling of locally produced RUTF. Lastly, with the advent of FTF, FBP will capitalize on opportunities and platforms provided by FTF, that link into a network of new programs focused on improved agriculture, economic and livelihood opportunities. Though no COP12 funds are being requested for this project, the project will continue as described using pipeline funds.

The FBP program will target 50,000 urban and peri-urban beneficiaries in COP 2012 for nutrition services and support in seven regions (Amhara, Oromia, SNNPR, Tigray, Harar, Dire Dawa and Addis Ababa). The program will strengthen its economic strengthening activities by scaling-up previously identified best practices, such as the Back to Work Initiative.Initiated by FBP, the Back to Work Initiative works with employment agencies to reintegrate HIV/AIDS infected and affected persons into the workforce. The Initiative has established links with employers in Oromia. These efforts will be scaled-up to other areas where FBP is operating. The program will also work closely with other ongoing development and PEPFAR programs funded by USAID and all levels of the GOE HIV/AIDS Program Coordinating Office (HAPCO) to identify sustainable and meaningful opportunities for program beneficiaries. HAPCO is already working with FBP to link beneficiaries to livelihood activities currently funded by the Global Fund. It is anticipated that 50% of the FBP beneficiaries will be absorbed through this mechanism. FBP will continue to link beneficiaries to ongoing USAID-funded programs such as the Urban Gardens Program, WFP and, where applicable, FTF agriculture and livelihood programs. Drawing from its pilot experience with HAPCO and local organizations, FBP will scale-up best practices in livelihood activities.In addition, the program will work with PEPFAR partners involved in income generating activities (IGAs) to develop a set of standardized guidelines for economic strengthening activities. These guidelines will be incorporated into development of a database for the GOE to track and link beneficiaries to various income generating activities and track outcomes of those activities. This database is expected to prevent duplication of services to beneficiaries and provide an evidence base for determining best practices for IGAs in Ethiopia.Lastly, the program will continue to strengthen community-facility linkages by working with key community leaders to ensure continuum of care and follow-up. In addition, as with other aspects of the program, quality improvement will be incorporated into economic strengthening activities.

Care for HIV pediatrics will remain a key component of the FBP program in COP 2012. The program will target 18,200 children infected or affected by HIV/AIDS in the urban and peri-urban areas of seven regions (Amhara, Oromia, SNNPR, Tigray, Harar, Dire Dawa and Addis Ababa) . The program represents a scale up of existing pediatric support activities into 500 public health facilities and expansion into NGO and private facilities. This includes a robust program of NACS and provision of therapeutic and/or supplementary foods to severely malnourished children infected or affected by HIV/AIDS. The program is aligned with other existingHIV/AIDS programs to promote efficiencies and integration in services. FBP will collaborate with existing USAID development platforms and FTF programs to provide complementarities in economic strengthening and food production to increase long-term food security for populations affected by HIV/AIDS.In addition, greater focus will be placed on establishing effective referral systems to economic strengthening activities for families of HIV/AIDS infected and affected children. For adolescents, the program will work to develop and implement an adolescent targeted economic strengthening strategy that takes into consideration the needs of this group. This will include providing vocational training to adolescents and providing them with links to opportunities that can utilize their skills.Like other areas of the FBP program, pediatric care and support activities will be incorporated into a quality improvement framework to ensure provision of quality services. Program monitoring will include creating a QI system, training healthcare workers in QI data collection and utilization to ensure NACS aligns with pediatric needs, supportive supervision and improving data collection, analysis and utilization.

In COP 2012, the Food by Prescription (FBP) program will continue to expand nutritional assessment counseling and support (NACS) from 400 to over 500 public facilities ,in urban and peri-urban areas of seven regions (Addis Ababa, Dire Dawa, Harari, Oromia, SNNPR, Tigray and Amhara) where the program is currently implemented. In addition, the program will expand implementation into NGO and private sector facilities in order to create standardization and efficiencies in NACS delivery throughout these regions. FBPwill continue to provide nutrition services to nearly 1300 HIV-positive pregnant and lactating women in COP 2012, including provision of therapeutic and/or supplementary food products. The program will be further expanded to provide these services to 1500 pregnant and lactating women in COP 2013.Nutritional counseling materials to be used by health workers in the context of HIV/AIDS during and after pregnancy were just developed by FBP in collaboration with the GOE. In COP 2012, FBP will roll-out training in use of these materials and work in collaboration with FANTA-III to develop quality improvement (QI) systems, indicators and approaches. During development of this system, emphasis will be on improving data utilization and quality for informed decision-making by supervisors and health facility staff. Once this system is developed, FBP will support the introduction and adoption of quality improvement tools as part of provision of NACS. .The program will take advantage of existing platforms at health facilities such as mother support groups to provide counseling on appropriate infant and young child feeding practices. Facility to community linkages will continue to be strengthened by identifying existing structures that can facilitate follow-up in the communities. In addition, FBP will collaborate with other PEPFAR partners in the regions to ensure appropriate linkages to other HIV services.

In COP 12, the program will continue to expand the nutritional assessment counseling and support (NACS) to over 500 public facilities, the NGO facilities and the private sector in urban and peri-urban areas of the seven regions (Amhara, Oromia, SNNPR, Tigray, Harar, Dire Dawa and Addis Ababa) where the program is currently implemented. The FBP program will provide technical assistance to health facilities for the roll-out and implementation of NACS including training of health workers, the provision of registers and supportive supervision. In COP 12, the program will place a strong focus on quality of services to ensure that NACS activities are maintained and sustained. This will include the introduction of quality improvement (QI) approaches involving coordination with FANTA-III to roll-out QI systems, indicators and approaches. Emphasis will be placed on improving data utilization and quality for informed decision-making.The program will provide technical assistance to local production companies of Ready-to-Use-Therapeutic Foods (RUTF) in the packaging of these products. FBP will coordinate with SCMS, TechnoServe and other stakeholders to ensure that packaging and quality and safety standards of the foods produced locally meet international standards.FBP programs will be fully integrated with other HIV/AIDS services available at the facilities where the program is implemented and will connect with other VCT, care and treatment and PMTCT PEPFAR partners providing services.