The USAID Comprehensive HIV/AIDS Treatment, Care and Support Program (CHAT-CS), now the Ethiopia Network of HIV/AIDS Treatment, Care and Support (ENHAT-CS), has the overall goal to improve the quality of treatment, care and support services in health facilities in Tigray and Amhara regions. The program objectives are to: 1) Improve provision of comprehensive and quality HIV/AIDS prevention, treatment, care and support services; 2) Improve integration and linkages of HIV/AIDS services with other health and social services; 3) Strengthen health facilities for HIV/AIDS services provision; and 4) Increase evidenced-based decision-making with strategic information. With COP 2012 funding, ENHAT-CS will support the expansion of ART in about 52 health facilities, while improving quality, integrated HIV/AIDS service delivery in existing 215 health centers. Strategies and implementation will focus on integration of primary health care services including maternal and child, nutrition, family planning, reproductive health, tuberculosis, etc. The program will focus on a family-centered approach to address services for PLHIVs. This program is aligned with GHI principles, particularly the women-centered approach. It will also address host-country ownership through local organizations and GOE involvement. Operations research will be conducted to inform new interventions by closely working with Mekele and Bahirdar universities. This program will leverage funding from programs such as HEAL TB, World Visions PCP program and others to increase efficiency and improve service outcomes. COP12 fund not requested, and pipeline funds will be used to implement this program.

ENHAT-CS will be implementing facility as well as community-based care and support activities in Amhara and Tigray administrative regions of Ethiopia. Care and support services include: prevention of diarrheal diseases, ensuring access to safe drinking water through supply of home-based drinking water treatment methods and safe storage, nutrition assessment, counseling and support (NACS), Positive Health Dignity and Prevention (PHDP) services, psychosocial support including mental health services and economic strengthening activities including income-generating activities (IGA). CHAT-CS will be targeting all HIV infected and affected populations of the two regions with particular emphasis on women, adolescents, Orphans and Vulnerable Children (OVCs), Most-at-risk-Populations (MARPs) and other vulnerable populations. This is aligned with the GHI strategy promoting host-government ownership, research and a women-centered approach. Services will be implemented with a focus on the continuum of care that includes bidirectional referral and follow-up between the community/household and HC/hospital ,complementary care services (ANC, MNCH, RH, WASH promotion) and linkages to other community health services. ENHAT-CS will be addressing client retention and referral through a number of mechanisms: decentralization of the service to more health centers, increased access and proximity of services, provision of quality adherence counseling by case managers and follow-up by community volunteers for those who miss appointments. The Fully Functional Service Delivery Point -FFSDP ( which is a method used by health facility heads and health workers to identify and work towards addressing barriers to deliver quality and comprehensive services) and other QA and QI processes developed previously byMSH/HCSP will be used to monitor the quality of the service delivery. Pipeline fund will be used to impelemt these activities.

A key focus of the Comprehensive HIV Treatment, Care and Support Program is to support the targeted health centers to provide quality comprehensive HIV/AIDS services, including TB/HIV services, in Tigray and Amhara.

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

The program has supported training of health workers on HIV/TB collaborative activities and will continue to provide this training to ensure each HC has an adequate number of health workers to provide comprehensive and quality TB/HIV services. Infection control and INH prophylaxis activities will be taken to scale in COP 2012. The GoE deployed Health Development Army (HDA), trained in community TB screening and infection control will continue to support these activities at community level. The program will train more than 400 HDAs in the 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 focusing on 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 services and outcomes.

Program regional laboratory advisors are providing on-site support in TB and malaria microscopy reading, quality assurance, HIV testing, and other opportunistic infection laboratory investigations.

Senior program technical staff 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 2012.

MSH will continue coordination among its HIV treatment, care and support project, HEAL TB project and other PEPFAR partners to ensure efficiency.

MSH/ENHAT-CS will support the provision of comprehensive pediatric HIV/AIDS care and support services in health centers of Tigray and Amhara regions with FY 2012 target of 2000 HIV-exposed/infected infants/children. The service package will include Provider-Initiated HIV Testing and Counseling (PITC); Early Infant Diagnosis (EID); prevention and treatment of common/opportunistic infections; pain and symptom relief; nutritional assessment, care and support (NACS); and psychosocial support. All the infants/children that test positive will be assessed and started on ART as per the standard care and treatment guidelines. To ensure continuum of care, all the HIV-exposed/infected infants/children will be linked to community-based OVC services. Case Managers (CM) and Mother Support Groups (MSG) will continue to play a critical role in pediatric care and support by providing adherence support; follow-up of HIV-exposed/infected infants in collaboration with kebele-oriented outreach workers (KOOWs) and health extension workers (HEW); and linkage with community-based OVC services. The family-centered approach will be promoted as an appropriate and effective model for increasing pediatric HIV case detection through index patient; and for service provision. Furthermore, MSH/ENHAT-CS will support health centers to integrate in a phased manner - pediatric HIV/AIDS care and support services into the overall Maternal, Neonatal and Child Health (MNCH) services. With increasing number of HIV-positive adolescents owing to long term survival of children on ART, MSH/ENHAT-CS will work with GoE & ANECCA to support development and scale-up of adolescent-friendly HIV care and support services. The services will include adherence support and peer support groups. MSH/ENHAT-CS will continue to provide technical assistance to health centers - as part of the health systems strengthening strategy - through in-service training; provision of resource materials including job aids; mentorship; and supportive supervision. This should result into program effectiveness and continuous quality improvement.

The MSH/ENHAT-CS program supports the GOEs expansion of comprehensive HIV/AIDS services by supporting 215 health centers, of which 159 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 215 health centers provide laboratory support. These laboratories are located in Tigray and Amhara regions. 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 program. The Program will support other health centers labs in their geographical areas. The project will support lab infrastructure such as tables, chairs, and point of care CD4 testing machines, chemistry and haematology analyzers for selected health centers. The program has provided more than 200 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 provide refresher training for about 300 laboratory professionals based on EHNRI developed training manual that will include EQA for TB, Malaria and HIV labs. In addition, a quarterly EQA for the 215 health center laboratories will be conducted covering TB, Malaria and HIV tests. The program has one senior laboratory advisor to support regional laboratories in EQA and on-site lab mentors helping health centers implement the quality performance monitoring and improvement measure, the Fully Functional Service Delivery Point tool. The program will also provide supplies to fill gaps. At the national level, senior MSH technical staff will continue to work closely with EHNRI and PEPFAR and non-PEPFAR partners to develop/update the national training manuals and guidelines, standard operation procedures and EQA systems for HIV tests, TB microscopy, malaria and OIs. Senior program technical staffs have been involved in the development of a revised EHNRI EQA strategy for TB, HIV tests and malaria will assist the GOE in the implementation of the EQAs.

Strategic Information budget allocation in the ENHAT-CS program will support health facilities monitoring and evaluation activities including routine data collection, analysis, reporting and data use for decision-making in targeted sites in Tigray and Amhara regions. The main SI strategy is to strengthen the capacity of health workers to collect, analyse and use data for decision making through targeted training and support for deployment of data clerks through recruitment and payment, based on GOE salary scale. In the 154-supported health centers providing ART services, the already established SI systems will be strengthened to ensure no parallel system to the GoE-led Health Management Information System. The program will continue monthly one-on-one on the job training/mentorship by a team of MSH as well as GoE mentors to strengthen the capacity of HC staff and monitor quality of services, which includes SI. Mentors will continue to monitor the data clerks performance and in collaboration with the Regional Program Monitoring &Evaluation Advisors, provide technical assistance in SI data collection, data management, quality data checks, analysis, and reporting. Health Facility-led multi-disciplinary team meetings will also be used for strengthening the capacity of health care workers on strategic information as well as catchment area meetings that join together representatives from health facilities, woreda offices, zonal health departments, PEPFAR and non-PEPFAR partners, and other stakeholders. Senior program M&E staff will continue to ensure the quality of SI provided by the health facilities and share and disseminate key data stakeholders, including the GOE (at woreda, regional and national levels), USAID, and PEPFAR partners. Senior program technical staff will support the implementation and scale-up of GOEs Community Health Information System.

A key focus of ENHAT-CS is to support integration of HIV prevention within a continuum of care that links health centers with community-based care and support for targeted populations in Tigray and Amhara targeting PLHIV and the general population. Through health centers, ENHAT-CS 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. Case managers provide health education and preventive counseling to PLHIV. At the community level, the program will target 5,250 individuals for training on HIV/AIDS prevention including school teachers, students, religious leaders, the programs community volunteers, KOOWs, kebele HIV desk officers, and HEWs. The program will continue community-level promotion of AB through six NGO partners (including Ethiopian Interfaith Forum for Development Dialogue and Action which carries out AB promotion initiatives in churches and mosques, and Dawn Hope Ethiopia which produces a quarterly newspaper highlighting HIV/AIDS topics and information. ENHAT-CS will adapt IEC/BCC materials from other PEPFAR partners to ensure they complement AB activities. ENHAT-CS will train an additional 461 community health and para-social workers on HIV/AIDS and 400 rural HEWs to support an intensified community outreach initiative in 80 high prevalence woredas served by supported HCs. Following the GOEs voluntary community anti-AIDS promoters (VICAP) approach, they will then orient 11,000 volunteers to mobilize their families and neighbors in HIV/AIDS, including prevention through AB.

Quality assurance will be ensured through supportive supervision and use of nationally standardized IEC/BCC materials.

HIV Testing and Counseling budget allocations will have a key focus to increase the number of persons who know their HIV status in Tigray and Amhara, through different testing approaches which target the general population of the two regions. This will be accomplished through strengthened capacity of health workers to provide comprehensive and quality CT through training being provided by GOE certified trainers and on-site visits by program mentors, and community outreach activities. Trainings will be conducted to train 108 health workers during COP 2012 with national CT curricula for VCT and PITC that encompasses point of care testing (to ensure CT is completed in one room by one professional using the national algorithm). This will be complemented with monthly one-on-one mentorship and quarterly supportive supervision. Mentors oversee QA at VCT clinics 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-positive and use of the family focused approach, which employs a family matrix to promote couple counseling and the bringing of family members for CT. ENHAT-CS supports CT outreach during religious festivals, weekends, and other events in high prevalence areas. The program will implement a community outreach CT initiative that will reach the 80 highest prevalence woredas served by supported HCs. the program will focus on refferals and linkages of HIV positives to HIV/AIDS care and treatment services. Over 210 rural HEWs supervisors will be trained to provide orientation for HEWs and volunteers who will organize outreach days to mobilize the community for CT. Special attention will be on populations likely to be HIV-positive (i.e. MARPS). Facility-based health service providers will provide CT and couples counseling for these outreaches. The program will also support the GOEs new Urban Health Extension Program (UHEP) initiative that uses task-shifting with employed nurses to provide, among other health services, CT at the household level in Amhara and Tigray regions.

A key focus of ENHAT-CSs other sexual prevention component will be to reach community members with high risk sexual behavior especially PLHIV and repeat HIV testers who continue to engage in risky behavior in Tigray and Amhara regions. Through health centers, the program trains health workers to provide health education to every person receiving CT including topics such as condom use and reducing multiple and concurrent partners. In COP2012, particular attention will given to CT clients who are receiving repeat testing. The programs HC 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 in other community forums such as community conversations and coffee ceremonies. ENHAT-CS provides unlimited, free condoms to clients at all supported health facilities as well as HIV counseling and testing services. ENHAT-CS in partnership with PSI will train health workers on proper condom use. At the community level, in collaboration with Population Services International, ENHAT-CS will provide condoms to over 100 health posts managed by HEWs for free distribution to the community. Over 6,000 KOOWs and community volunteers will directly participate in community condom distributions to ensure community level access to condoms. In addition, ENHAT-CS will train 2,000 rural HEWs to support an intensified community outreach initiatives in 80 high HIV prevalence woredas. Using the GOEs VICAP approach, they will then cascade the training to volunteers to mobilize their family and neighbors around HIV/AIDS OP issues. At the community level, the program will train around 150 individuals (school teachers, students, religious leaders, KOOWs, and others) on HIV/AIDS topics. ENHAT-CS will continue community level promotion of OP through six NGO partners.

ENHAT-CS supports PMTCT services in health centers in Tigray and Amhara regions. The main strategies are increasing awareness and uptake for integrated PMTCT/ANC services by mothers and strengthening the capacity of HCW to provide integrated quality PMTCT/ANC services through training and ongoing mentorship support by program mentors. The program goal is to test 223,524 pregnant mothers in COP FY 2012 and an additional 245,876 in COP FY2013. About 70% of HIV positive pregnant mothers will be targeted to receive ARV prophylaxis, up by 30% from previous 40% reach. In order to make the program more effective and also to increase ANC attendance, ENHAT-CS will implement a community outreach CT initiative and encourage increased use of ANC/PMTCT services through IEC/BCC strategies. The program will continue to support Mother Support Groups and volunteers that provide peer counseling on testing and prophylaxis, adherence for mother and infant, ensure follow-up of mother-infant pairs, link HIV exposed infants to Early Infant Diagnosis services and improve infant and young child feeding practices through provision of or referral to other nutrition support services. ENHAT-CS will support the training of HCW using national PMTCT Guidelines with emphasis on group counseling and opt-out testing with same day results. Point-of-care CD4 testing machine for ANC, labor and postpartum clients will be provided for selected high volume health centrers. Families of HIV-positive women will be linked to HCT and other services, such as OVC and NACS, using the family matrix model. ENHAT-CS will continue providing more efficacious ARV regimens-including AZT from 14 weeks and 3TC + sdNVP at onset of labor as well as the required infant ARV prophylaxis dosing. ENHAT-CS will prioritize identifying and providing HAART through clinical staging and CD4 testing for an estimated 30% of women who will need it. Eligible women will be linked to ART services. Other support includes facilitation of timely replenishment of test kits and drugs for PMTCT prophylaxis. ENHAT-CS will actively participate in the National PMTCT TWG.

In COP2012, the ENHAT-CS Program will support provision of ART services in 206 health centers in Tigray and Amhara regions. For adult treatment main strategies include: (1) Strengthened capacity of health workers to provide adult HIV/AIDS care and treatment (through training on natl comprehensive management of OIs and AR and on-site mentorship and (2) strengthened adherence to treatment. The predecessor of ENHAT-CS, HCSP, has trained 3,360 health workers (in 5 regions) and additional 1,183 HCW will be trained in COP 2012 in Amhara and Tigray. ENHAT-CS will collaborate with the USG-nutrition partners (WFP, SC/FBP, and SC/ENGINE) to ensure health care providers are providing NACS and nutrition needs of clients are addressed. The program will continue providing monthly on-site, one-on-one mentorship, backed up by telephone consultation, to build the knowledge and skill of HC staff in managing ART patients and monitoring quality of service. Mentors will also actively participate in catchment area meetings to discuss implementation issues including referrals, achievements, and challenges. Clinical outcomes of patients will be monitored using clinical and immunological responses to treatment. To promote adherence, ENHAT-CS has recruited, trained, and deployed more than 150 case managers, with a minimum of 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 HEWs. Currently, supported HCs report a lost-to-follow-up rate of 9%, well below a national average of 20%. Under COP 2012, ENHAT-CS will train additional case managers to ensure all facilities supported by ENHAT-CS have adequate coverage. ENHAT-CS will continue to expand to more high-HIV burden sites that provide HIV treatment and care services and will ensure all patients enrolled in care also receive a comprehensive preventive package including ART, CPT, and TB screening and INH preventive therapy. ENHAT-CS is implementing M&E activities using the Fully Functional Service Delivery Points (FFSDP) quality improvement tool which focuses on data quality.

MSH/ENHAT-CS will continue to support the scale up of quality comprehensive pediatric HIV treatment services health centers in Tigray and Amhara regions. For the two regions, by end of March 2011 (2011 SAPR), a total of 1,549 children (0-15 years of age) had ever been enrolled on ART; 1,800 children were on treatment and 416 children had been enrolled on treatment during the previous six months. The target for FY 2012 and FY 2013 is to enroll 820 and 850 children on treatment, respectively; and increase the children currently on treatment to 2,600 and 3,400, respectively.

The programs main strategies are: (1) Build the capacity of health workers to provide pediatric treatment through in-service training; provision of resource materials, mentorship, and supportive supervision; (2) Ensure that the children that test HIV positive are promptly assessed and initiated on treatment; (3) Retain patients through adherence support and follow-up with Case Managers; (4) Strengthen intra- and inter-facility referrals; and (5) Build capacity of GoE in managing pediatric treatment programs.

MSH is currently participating in the adaptation of the 2010 WHO pediatric treatment guidelines and will continue to support their roll out in FY 2012. Children on treatment will be linked to nutrition programs including the USAID-supported Food by Prescription; World Food Program, and Empowering New Generation to Improve Nutrition and Economic Opportunities (ENGINE). MSH will also continue to work with GoE on integration of pediatric treatment into the overall Maternal, Neonatal and Child Health (MNCH) services.

With increasing access to CD4 count services, MSH will continue to support HC in using CD4 count to monitor patients on ART. Viral load services that are currently available at regional level will be particularly useful for patients with suspected treatment failure. With increasing number of HIV-positive adolescents, MSH will work with GoE to develop and scale up adolescent-friendly treatment services. MSH will also support HC and GoE in data collection, analysis/interpretations for continuous quality improvement.