This is a modified activity of the cooperative agreement with the Ethiopia National Defense Force (NDFE). The NDFE and CDC Cooperative Agreement expires in COP 2012 and a new single source eligibility Funding Opportunity Announcement (FOA) has been announced. Ethiopian soldiers are at higher risk for HIV infection. An evaluation of the Modeling and Reinforcement to Combat HIV/AIDS (MARCH) suggests that the implementation of the MARCH program at the NDFE is justified and has proven to be successful. Both quantitative and qualitative data analysis show that the outcome variables of condom use and HIV testing are significantly associated with exposure to MARCH. In addition, the MARCH evaluation showed that nearly two-thirds of single recruits had contact with a sex worker in the last year.

The overall objective of the NDFE HIV/AIDS program is to implement a comprehensive strategy of prevention, care and treatment that combines behavioral, biomedical and structural approaches to treat existing infections and prevent new HIV infections among soldiers and their family members. In COP 2013, NDFE will consolidate MARCH and other activities and will focus on new recruits through peer education using Print Serial Dramas (PSDs) and the peer leadership manuals. Those reached through prevention activities will be linked to services for HIV. The NDFE program follows the GOE guidance on the implementation of a minimum package of prevention services for the Uniformed Services and supports the goals of the GOE's National Strategic Plan (SPMII). The activity falls under the combination prevention framework of the USG HIV prevention portfolio, is aligned with the goals of the GOE and the USG HIV/AIDS Partnership Framework, and the Global Health Initiative.

The NDFE will recruit or assign a care and support focal person, who will oversee the implementation of adult care and support related activities and take responsibility for the activities being supported by UCSD. In COP 2013, NDFE will undertake the following activities:

Provide nutritional assessment and counseling services, and provide nutritional support to those malnourished PLHIV in collaboration with partners working on nutritional support.

Intensify prescription of co-trimoxazole prophylactic therapy (CPT) to eligible PLHIV; consider CPT as one of the quality monitoring indicators and review its performance regularly.

Strengthen pain assessment and management services for PLHIV and improve their access to pain medication including morphine.

Strengthen the civil-military (USE) alliance in order to increase two-way referrals and linkages among USE health facilities and community-based care and support services. This will also help to make updated care and support service directories available in supported health facilities.

Strengthen Cervical Cancer Prevention (CCP) services at the Armed Forces Referral and Teaching Hospital (AFRTH).

Coordinate and oversee the scale-up and integration of mental health services into chronic care units in NDFE referral hospitals.

Ensure availability, distribution, and utilization of Basic Preventive Care package (BPCP) in the NDFE, and train health professionals on PBCP.

Strengthen PwP prevention messages and services in the NDFE

In COP 2013, NDFE will strengthen its capacity to support and monitor the TB/HIV program and service integration at defense facilities in a sustainable manner through training,integrated mentorship activities, and ensuring quality of TB/HIV care.

In COP 2013 NDFE will:

Develop a costed strategic plan for TB/HIV program support as part of the comprehensive HIV/AIDS program plan.

Strengthen TB and HIV control program coordination and integration at command and sub-command health care structures.

Undertake assessment of the TB and TB/HIV program to identify key program gaps and focus areas for the regional TB control program.

Strengthen TB program management and human resource capacity at command and sub-command level through training of TB and TB/HIV control program staff.

Undertake regular supportive supervision and review meetings to monitor the TB/HIV programs.

Organize a pool of core trainer teams for comprehensive TB-Leprosy, TB/HIV, and MDR-TB training at the central program level.

Organize TOTs and in-service trainings on comprehensive TB andTB/HIV, in collaboration with defense universities and partners.

Organize mentorship teams composed of program management, health facility, local university, and partner staff. Provide mentorship on the comprehensive TB and TB/HIV control programs to defense health facilities in collaboration with partners.

Undertake TB and TB/HIV related program evaluations.

Strengthen TB diagnostic service and EQA in collaboration with EHNRI, regional laboratories, and partners.

Strengthen the patient referral network across TB/HIV delivery sites within the defense health system.

Print and distribute TB/HIV guidance and job aids.

Support TB and TB/HIV Advocacy Communication and Social Mobilization (ACSM) activities

In COP 2013, the NDFE will build its managerial and technical capacity to manage the pediatric care and treatment program in preparation for a full transition of the support by 2015. NDFE will collaborate with UCSD to take over certain site level activities in the implementation of the pediatric care and support services.

In COP 2013, NDFE will work with UCSD to: :

Participate in the development of guidelines and training materials at the national level.

Train the multidisciplinary team on palliative care and the preventive care package for children.

Facilitate site-level clinical mentoring, enhancement of data collection and reporting, and supportive supervision to pediatric care and support services.

Improve the skills of staff at the facilities through training in collaboration with Defense University.

Work to ensure provision of nutritional assessment and counseling services for HIV exposed/infected children and infants, and supply job aids

Ensure provision of micronutrients and nutrition supplementation.

Support sites to perform early infant diagnosis,

Promote prophylaxis and treatment for opportunistic infections in accordance with national guidelines.

Use pCTX for HIV-positive children and for HIV-exposed infants, especially at those sites not yet providing ART.

Provide screening and isoniazid prophylaxis (IPT), which will be promoted and provided for HIV-positive children.

Strengthen referrals and linkages with community-based support groups for adherence, counseling, and psychosocial support.

Ensure a regular supply of drugs for OI and pain management, malaria prevention, and de-worming, and also work to sensitize the community on PC care through preparation and distribution of IEC/BCC on pediatric care and support materials targeting children.

In COP2013, NDFE will build its managerial and technical capacity to manage the pediatric care and treatment program in preparation for a full transition of support by 2015. Moreover, NDFE will gain experience by working with UCSD to:

Provide technical support to national and regional working groups in the area of guideline development, training curricula, and other job aids.

Improve pediatric case-finding and referrals to care and treatment services with strong linkages to PMTCT; strengthen implementation of PITC at the under-5 clinics, pediatric inpatient facilities, TB clinics, and EPI clinics.

Ensure the implementation of family-focused care and family testing in all sites,

Provide trainings for health workers in Uniformed Service facilities on comprehensive pediatric HIV care/ART in collaboration with Defense University.

Promote advocacy to improve the approach of health professionals, and create awareness in the community on the importance and benefit of pediatric ART services.

Improve the quality of service (growth monitoring, TB screening, CPT, determination of infection status) provided for HIV exposed infants in the follow up clinic with on-the-job refresher trainings and regular mentorship, as well as through the provision of job aids to all the facilities.

Focus on regular site level support through clinical mentoring, on-the-job refresher trainings and supportive supervision.

Assess and improve the quality of services for pediatric care and treatment through a standardized QI approach.

Work to establish and strengthen strategies to integrate pediatric HIV services with MNCH and other child survival program interventions.

Identify potential challenges in implementing the program related to the unusual structure of the Uniformed Services and provide solutions.

The overall aim of this PEPFAR support is to enable the different levels of the NDFE to effectively monitor the performance and quality of HIV/AIDS/TB/STI services and programs under its management.

In COP 2013, NDFE will establish and implement strong routine monitoring systems that will enable it to track the implementation of prevention, care and treatment activities effectively. NDFE will work with UCSD to adapt, print and distribute M&E tools that are in line with the national HMIS, including patient registers, charts, data-capturing and reporting formats.

COP 2013 support will also be used to recruit, train and deploy M&E officers for the NDFE national HIV/AIDS/TB/STI program coordinating office, as well as data entry clerks/Health Information Technicians (HITs) for health facilities that implement programs. Furthermore, the NDFE HIV/AIDS Program Coordination Office, and similar intermediate health offices and program implementing health facilities under NDFE, will be able to routinely capture, generate, analyze, report, and utilize PEPFAR supported HIV/AIDS/TB/STI program data in a timely manner. Different levels of health/HIV/AIDS programs of the NDFE will also be supported to plan and conduct timely and regular supportive supervision visits and organize meetings to review the performance and quality of their programs and services based upon data generated from the system.

Medical Injection/Infection Prevention (IP) procedures are important components for providing quality health care services and to prevent the transmission of HIV and other diseases. Since 2009, UCSD has been implementing various activities in health facilities through the National Defense Force of Ethiopia, which include technical support through training, provision of basic IP/personal safety equipment, ISS and clinical mentoring, as well as other infection prevention activities.

In COP 2013, some of the IP and patient safety activities will be transitioned from the international Technical Assistance (TA) partner to the NDFE. This transition will help support health facilities under NDFE to focus on building IP management capacity through providing training, printing and distributing IPPS guidelines, integrating injection safety and waste management practices into all OPD/IPDs in the facilities, and also to procure and distribute standard IP commodities.

Thus, the NDFE will closely work with the Health Unit, the Disease Prevention and Control department of the NDFE, and the IP committees in all health facilities to build their capacity through mentoring of clinical staff and waste handlers, ISS, and providing IP support materials. This support will include assistance with planning for cost effective, appropriate, and environmentally friendly waste management techniques at the facility level. The health facilities will continue to work on ventilation of TB wards and complete the MDR/XDR TB prevention activities. A continuous quality improvement assessment on the injection safety activities will be conducted to identify and close gaps in close collaboration with the IP committees at the health facilities and national TWGs.

In collaboration with UCSD, the NDFE has been implementing HCT activities over the last couple of years. The purpose of this activity in COP 2013 will be to build the managerial and technical capacity of NDFE in order to fully transition the HCT activities in the coming years. NDFE will build its capacity to implement and coordinate the HCT-related activities. The following major activities to be implemented in COP 2013 include:

Providing PITC for all clients accessing services at military health facilities.

Providing HTC for the Uniformed Services and their spouses, as well as for mobile, hard-to-reach communities around military camps.

Establishing routine annual testing services, promoting couples counseling for regular partners of soldiers, and referrals to counseling and care services.

Promoting and providing couples testing for soldiers and their regular partners.

The NDFE has more than 15,000 active and well-organized peer-to-peer HIV/AIDS discussion groups and aims to conclude the existing peer education sessions based on the print serial drama.

In COP 2013 the focus will be on new recruits. The interventions will include:

Providing peer leadership training to 4,000 peer leaders in all NDFE commands to reach 40,000 soldiers and their families.

Promoting the other prevention (OP) component of HIV prevention through peer education, which includes 100% correct and consistent condom use.

Providing all new recruits with intensified one-year peer education based on the MARCH model.

Training on the production of IEC/BCC materials.

The NDFE will produce and distribute military-specific and tailored information education and communication (IEC) and behavior change communication (BCC) materials on OP-focused topics, and will provide information on STI services.

Promotion and distribution of condoms and establishment of condom service outlets.

Reinforcement of the peer group activities with other NDFE HIV/AIDS activities such as NDFE music and sports clubs, radio programs, newsletters, movies or staged dramas, and events like World AIDS Day.

Targeting soldiers who have already been reached with MARCH in the past using various mechanisms such as outreach focusing on consistent and correct condom use.

Onsite training for health care workers on screening, syndromic management of STIs and PITC services.

Promotion and linkage to HTC, STI, PMTCT, and HIV care and treatment services.

Screening and syndromic management of STIs as well as PICT services.

Strengthening its AIDS Resource Centers (ARC) with audio-visual materials and IEC materials on HIV-related topics.

In addition to the activities mentioned above, NDFE will build its capacity to implement STI activities and to implement the following activities:

Ensuring the availability of STI data in all military health facilities.

Promoting PITC for all STI patients, and linkages to care and treatment services for PLHIV.

Scaling up and sustaining STI education focused on risk reduction, screening, and treatment for patients enrolled in HIV/AIDS care and treatment at the hospitals.

Strengthening provision of condoms to patients enrolled in care and treatment and education on how to use them,

Strengthening of STI data recording and reporting systems at all levels and site level data use.

Strengthening integration of STI services into antenatal and PMTCT services.

Providing on-site training, supportive supervision, and mentorship for health providers on STI prevention, diagnosis, and treatment.

Technical assistance to the NDFE will be provided by the University of California at San Diego (UCSD) and the US Department of Defense (DOD) to strengthen the capacity of the NDFE to successfully implement these activities on its own in the long-term.

In COP2013, NDFE will work with the international implementing partner to build its capacity, and will transition PMTCT activities incrementally to strengthen local ownership and ensure sustainability of the program. It will enhance capacity of the regional Defense Health Offices to support transitioning of PMTCT services effectively.

In COP 2013, NDFE will:

Support transitioning of PMTCT services to the NDFE health facilities.

Support rolling out of Option B+ through training and mentoring of health care providers at facilities providing PMTCT services.

Conduct site supportive supervision, use site level performance data, and implement quality improvement approaches to improve retention of HIV positive mother and HEIs in care services.

Strengthen case managers and MSGs to improve retention of HIV+ women and family members in care and treatment services

Support implementation of the updated PMTCT monitoring system in line with the Option B+ strategy.

Support training on safe pregnancy and FP counseling, and promote integration of FP and HIV services.

Support integration of TB screening within the PMTCT program.

Scale-up couples counseling and partner testing, facilitate male friendly services, and establish monitoring systems related to these services.

Provide minor renovation, refurbishment, and repair of ANC, labor and delivery rooms, and maternity wards.

Improve referral systems to ensure continuum of PMTCT care.

Thus far, NDFEs international partner has implemented the MARCH project and contributed to the reduction of HIV/AIDS incidence among members of the military. Through this process, the partner collaborated with JHU-CCP and produced IEC materials. The materials contained information on HIV/AIDS prevention, care and treatment. The IEC materials advise military members on what to do if they become HIV positive, and describe adherence issues that may arise while taking ARV medication. This experience will help NDFE to take over HIV/AIDS treatment activities which are currently being implemented by UCSD. UCSD has provided the necessary technical assistance to the military health facilities. Additionally, the NDFE has received capacity building assistance from UCSD. Since the military health facilities are under the Ministry of Defense, transitioning of HIV/AIDS treatment activities ensures sustainability of the program.

Providing HIV/AIDS treatment activities through the military health system requires strengthening several areas of focus. The major areas of focus are human resource capacity building, referral linkages, mentoring, adherence, laboratory monitoring, and program monitoring and evaluation. UCSD had already helped to establish many of these systems within the military health facilities and will now help to ensure that activities run without interruption during the transition period. In order for a successful transition to take place, NDFE will build capacity in different areas (human resources, technical, administrative, leadership, etc). NDFE will collaborate with Defense University to provide in-service and refresher trainings for health care providers (physicians, health officers, nurses, lab personnel and pharmacy), case managers, and data clerks engaged in treatment activities. The partner will also make sure MDT meetings run smoothly to ensure intra and inter-facility referral linkage. NDFE will recruit additional staff that can provide competent mentoring and supervision to different health and non-health professionals. The partner will build the capacity of the command posts health department in order to strengthen the health system within different levels of the military. Adherence activities will be handled by case managers. The partner will strengthen clinical patient monitoring using CD4 counts, other tests, and WHO staging. To improve program performance overtime, NDFE will undertake regular monitoring and evaluation activities using PEPFAR indicators and targets. NDFE will also collaborate with the MOH to coordinate the implementation of new guideline and directives for HIV/AIDS treatment.

In COP2013, NDFE will build its managerial and technical capacity to manage the pediatric care and treatment program in preparation for a full transition of support by 2015. Moreover, NDFE will gain experience by working with UCSD to:

Provide technical support to national and regional working groups in the area of guideline development, training curricula, and other job aids.

Improve pediatric case-finding and referrals to care and treatment services with strong linkages to PMTCT; strengthen implementation of PITC at the under-5 clinics, pediatric inpatient facilities, TB clinics, and EPI clinics.

Ensure the implementation of family-focused care and family testing in all sites,

Provide trainings for health workers in Uniformed Service facilities on comprehensive pediatric HIV care/ART in collaboration with Defense University.

Promote advocacy to improve the approach of health professionals, and create awareness in the community on the importance and benefit of pediatric ART services.

Improve the quality of service (growth monitoring, TB screening, CPT, determination of infection status) provided for HIV exposed infants in the follow up clinic with on-the-job refresher trainings and regular mentorship, as well as through the provision of job aids to all the facilities.

Focus on regular site level support through clinical mentoring, on-the-job refresher trainings and supportive supervision.

Assess and improve the quality of services for pediatric care and treatment through a standardized QI approach.

Work to establish and strengthen strategies to integrate pediatric HIV services with MNCH and other child survival program interventions.

Identify potential challenges in implementing the program related to the unusual structure of the Uniformed Services and provide solutions.