1. The implementing mechanism's comprehensive goals and objectives under the award reflecting its breadth across technical areas, as appropriate. Through the new five-year Strengthening Clinical Services (SCS) Project, USAID aims to help Lesotho become one of the first countries in Africa to reach 100% coverage of all hospitals and clinics for prevention of mother-to-child transmission services (PMTCT) and HIV care and support services, and 90% facility coverage for the initiation of HIV treatment in adults and children. These are ambitious goals, but ones that we believe are achievable. The five goals of USAID's SCS Project are: •SCS Goal One: Sustained high-level, quality, comprehensive, integrated, client-centered HIV/AIDS care & treatment services •SCS Goal Two: Strengthened & increased rollout of family-centered HIV/AIDS care and treatment services •SCS Goal Three: Universal access to PMTCT including expanded delivery of services •SCS Goal Four: Strengthened national health system in accordance with MOHSW's plan

•SCS Goal Five: MOHSW's policy, protocols & guidelines for care & treatment services reviewed & improved on a regular basis

Overarching themes incorporated in the TBD Partner's approach to the SCS Project will include 1) provision of comprehensive clinical expertise by TBD Partner and its consortium members, 2) a family- focused approach to service delivery, 3) promotion of true local ownership, 4) reliance on strong existing relationships with the MOHSW and DHMTs, and 5) the ability to seamlessly transition from USAID's previous implementation model to the more integrated SCS Project approach.

2. If applicable, how the implementing mechanism is linked to the Partnership Framework goals and benchmarks over the life of its agreement/award In 2009, the Partnership Framework to Support Implementation of the Lesotho National HIV and AIDS Response (2009-14) between the U.S. and Lesotho governments was signed demonstrating a long-term commitment and advancing resources to tackle the epidemic. As the M&E system for the SCS Project is developed, it will involve all project partners under TBD Partner's leadership and be consistent with the Partnership Framework between GOL and USG. SCS will be a leader in achieving the necessary results to reach the goals of the Partnership Framework for all four goals. Specific contributions to each goal are mentioned below (over the 5 year project period).

Goal I: HIV incidence in Lesotho is reduced by 35% by 2014. -100% of health facilities providing ANC (216) will provide both HIV testing and ARVs for PMTCT on site. -43,947 HIV-positive women will receive ARVs for PMTCT prophylaxis. -46,260 HIV-positive pregnant women will be assessed for ART eligibility.

Goal II: To reduce morbidity and mortality and provide essential support to Basotho people living with or affected by HIV and AIDS through expanding access to high quality treatment, care, and OVC services by 2014. -100% of all 216 health facilities in the country will be assisted to provide care and support services. -90% of health facilities (195 of 216) will be assisted to offer ART by 2013. -By the end of the project, 194,400 HIV-positive Basotho will have received a minimum of one clinical HIV service. -95% of infants born to HIV-positive mothers will start CTX prophylaxis within 2 months of birth and will receive an HIV test within 12 months of birth. -87,288 HIV-positive adults will be receiving ART by the end of the project. -90% of HIV-positive patients on ART will be knowon to be alive and on treatment 12 months after initiation.

Goal III: The human resource capacity for HIV service delivery is improved and increased in 3 key areas (retention, training and quality improvement) by 2014. -500 health workers will have completed in-service training each year in HIV/AIDS (for a total of 1,500) -TBD Partner plans to extend its current performance measurement activities in sites using the EZ-QI tool for quality improvement. This will be followed by specific quality improvement (QI) projects based on the outcome of performance measurement activities specific to each site. -Continual on-site mentorship of clinical staff (including lab and pharmacy technicians) helps address problems in service provision and ensures that staff can provide quality services. Through TBD Partner's model of mentorship and supervision at the sites, health providers will gain both competency and confidence in providing HIV services. Through mentoring, health providers learn to fully utilize the skills and knowledge acquired through more formal training channels. Under the previous award, EGPAF has been providing on-site mentorship to 103 sites in the north and this model will continue under the SCS Project with TA provided to all sites in the country by the end of 2011.

Goal IV: Health systems are strengthened in 4 key areas (HMIS, laboratory, organizational capacity, and supply chain) to support the prevention, treatment, care and support goals by 2014. -Please see section 4 below for details of health system strengthening activities under the SCS project and how they will contribute to reaching the goals of the Partnership Framework.

3. The implementing mechanism's geographic coverage and target population(s). The SCS project will be a national project, supporting health facilities in all ten of Lesotho's districts and targeting the entire Basotho population in need of PMTCT or HIV/AIDS services or support, from the health clinics to the communitiies.

4. Please briefly describe the key contributions to health systems strengthening, if appropriate. The TBD Partner team will build on local resources and approaches that have been tested on-the-ground in Lesotho, enhancing the capacity of DHMTs through proven leadership and management approaches. EGPAF will lead the team in strengthening M&E systems and improving data use for decision-making.

-Through improving data quality gathered at the site-level and seconding an M&E Officer to the MOHSW, SCS will promote the use of quality data to base programmatic decisions and to evaluate performance. Data is also made available to communities so that they can prioritize their health care needs and design useful workplans and strategies to address those needs. -SCS will provide management and leadership training to the DHMTs, in collaboration with the Millennium Challenge Account (MCA-L). Targeted activities focused on building the technical and managerial capacity of DHMTs and selected facility management staff, the project's primary local partners, will cut across all program and operational areas. The expected outcome is to empower the DHMTs and to direct,

manage and implement comprehensive HIV services without further external assistance, and to prepare staff for projected changes resulting from decentralization. -Health management information system strengthening & use of data for decision-making. The team will focus on supporting and strengthening the planned decentralization of M&E systems focusing at the district level which will serve as the connection point for data generation (for health centers and hospitals) and the central level. SCS will improve the capacity for all responsible staff along the health information system to be better managers and users of the data they generate. The project's two M&E Officers will provide support to the District Health Information Officers (DHIOs) and the site-level data clerks (where in position) to improve their collection and reporting of complete, accurate and quality data, and their data management and utilization skills, through regular supportive supervision, mentorship, and onsite trainings.

5. A description of the implementing mechanism's cross-cutting programs and key issues: if a cross- cutting attribution is entered or key issue selected it should be described in this narrative.

Cross Cutting Budget Issue 3.A Food and Nutrition: Policy, Tools, and Service Delivery: At hospitals and referral centers, SCS will designate an area to serve as the nutrition corner where mothers are counseled on proper infant feeding practices and children and mothers are screened for malnutrition. SCS will also support providers to offer routine screening and treatment of all pregnant women for OIs and STIs using syndromic management.

Cross Cutting Budget Issue 1. Human Resources for Health: In addition to the clinical training and mentoring discussed above, SCS will further support Human Resources for Health by seconding staff. In ongoing cooperation with MOHSW, the SCS Project will continue to second critical staff to the MOHSW to cover gaps. This will include the existing M&E Officer, counseling trainer, and counseling mentor at the national level. At individual facilities, staff will be seconded where there is immediate need, such as the ART nurse positioned in Mokhotlong. The purpose of these seconded positions is to provide immediately required resources while moving toward absorption into the MOHSW's existing staffing structure.

Cross Cutting Budget Issue 7. Gender: Reducing Violence and Coercion: The SCS Project will employ a crosscutting gender plan to ensure that gender issues are incorporated across all aspect of the project and are in line with the approach of the President's Emergecy Plan for AIDS Relief (PEPFAR) of "gender mainstreaming" or integration of gender into all HIV prevention, care and treatment services. The EGPAF- led team will aim to provide equal opportunities to men and women under project implementation, mitigate inequities between men and women in HIV/AIDS programming, and increase male involvement by employing new strategies and drawing on EGPAF's past experience in Lesotho as well as from other EGPAF and partner-led projects in the southern Africa region.

Key Issue 6. Workplan Programs: Through Apparel Lesotho Alliance to Fight AIDS (ALAFA), SCS will help make workplace care and support groups available in the majority of textile companies throughout Lesotho, as well as HIV treatment. ALAFA will advocate for improved HIV/AIDS programs in the workplace and continue to support PMTCT services for employees in the garment industry, one of the largest private sector employers in Lesotho.

Key Issue 1. Health-Related Wraparound Programs: TBD Partner will implement crosscutting interventions around MNCH and nutrition, ensuring the implementation of a truly integrated service delivery approach and maximizing USAID's resources through cost-share arrangement.

6. The implementing mechanism's strategy to become more cost efficient over time, such as achieving improved economies in procurement, coordinating service delivery with other partners in the public and private sector, and expanding coverage of programs with low marginal costs. Maximizing value to the government is a core principle for the EGPAF-led SCS Project. EGPAF and its partners are proposing a minimum cost-share contribution of 8.73 percent over the life of the project. This leveraging of private resources offers significant benefits to the government through the UNICEF MCH and Nutrition programs, Johnson and Johnson PMTCT partnership, and DFID funded clinical service providers. EGPAF's implementing partners, such as LENASO, also present major cost savings in areas of local and international volunteers, community level contributions, office infrastructure, and partnership contributions.

7. Monitoring and evaluation plans for each activity As a first step toward project implementation, TBD partner will developed a detailed performance monitoring matrix, incorporating PEPFAR Next Generation Indicators (NGIs) as well as additional indicators that will be valuable in measuring attainment of project objectives. In accordance with the principle of one M&E system, the indicators have been carefully selected so that they can be generated through the MOHSW health information system. The project's final M&E strategy will ensure the generation of appropriate data to monitor program performance and assess the effectiveness of program interventions, while continuing to foster integration with the national strategic information system. Its development will involve all project partners under EGPAF's leadership and be consistent with the GOL's National HIV & AIDS M&E Plan (2006-11), while retaining sufficient flexibility to accommodate changes related to Lesotho's on-going decentralization process and the recently-signed partnership framework between GOL and USG. The M&E plan will be based on these principles: • Steady flow of information from service provision points to district and national level coordinating bodies • Comparability of data over time and across different service provision points • High quality data that meet the reporting requirements of GOL and PEPFAR

• Sustainability of the M&E systems

The types of HIV care and support services, location/s of service delivery sites (facility, community, home based) and target audience/s (adolescents, adults, women, MARPs, others). TBD Partner's approach to providing adult HIV care and support at the health center level will be based on the minimum package of care, including: • Integration of care and treatment for women and families within the MCH unit • Provision of CTX prophylaxis for eligible patients, treatment of OI, including prescription of OI prophylaxis for eligible patients, systematic screening for TB during pregnancy • Provision of comprehensive HIV care to infected patients and strengthened linkages to treatment • Support groups and peer mentors • Adherence support for long term CTX prophylaxis, as appropriate

•Coverage in the geographic area and among the target population/s' how it fits with the overall PEPFAR and country strategy. The SCS project goal is to have 100% of Lesotho's health facilities providing HIV care and support in all 10 districts. The target population is every HIV-positive adult in the country.

•Mechanisms to address client retention and referrals, including the use of outreach and bi-directional referral systems. Defaulter tracking will be implemented through use of volunteer site focal persons (under LENASO), members of existing community support networks, who will liaise with the appropriate community health workers to bring defaulting mothers and babies back for treatment.

PSS services for families & communities. The SCS project will build better linkages for PSS with the families and communities seeking services from the health system. Activities in this area will include family support groups, mentor mothers, workplace support groups, male support groups, and care and support for Lesotho's health care providers themselves. LENASO will facilitate PSS activities for adults, ensuring that family support groups are available in all districts and in each community council catchment area, incorporating the current PMTCT partners existing 58 family support groups, and will facilitate learning and support in areas such as stigma reduction, treatment adherence, nutrition, and disclosure. They will also establish mothers-in-law groups and expand male support groups to all districts. The SCS Project will also link with the mothers2mothers (m2m) program where they are present, building on their widely recognized model of pairing mentor mothers with HIV-positive women.

•Linkages between program sites with other HIV care, treatment and prevention sites within jurisdiction and linkages and/or referrals between program sites and non-HIV specific services (at a minimum food support, IGA, RH/FP and PLHIV support groups). The TBD Partner's team will work with the MOHSW to define clear referral systems for partners tested at MCH, for HIV-positive mothers 18 months post delivery (in accordance to national standards). A referral linkage will be developed between MCH units supported by TBD Partner and SCOEs supported by Baylor, a model which will be expanded to all districts.

SCS Project partner LENASO works with community-based organizations to promote adherence to HIV care and treatment within communities. LENASO has helped implement comprehensive family-focused programs at the community level, ensuring that mothers, children and family members living with HIV are beneficiaries of the comprehensive care and treatment package. LENASO will strengthen the development of a network system of community-based support for holistic and integrated services for pediatric and family HIV care and treatment at the community level for this project.

•Methods of program monitoring and evaluation, monitoring the quality of care and support services, and program evaluations and research studies to advance program approaches and/or fill gaps in knowledge

on priority care and support issues. TBD Partner will work with LENASO to make sure that community involvement data are collected in a timely and accurate manner. We will leverage our experience in development and piloting of community involvement indicators to help LENASO set up a strong community-level M&E system.

HIV services provided at every facility. Due to the high prevalence rates in the country, it is impossible and impractical to separate HIV services from general health services or to provide them in separate locations. SCS will ensure that HIV care and treatment will be provided at every single health facility in the country, including the private sector. Because many health centers are staffed by just one or two providers who take care of all the needs of each family member, the SCS Project will strengthen these sites to be able to serve as a "one-stop shop" for families to address their health care needs, including testing, care, and treatment of HIV.

Through training and mentorship, TBD partner will improve service delivery at the site level by building appropriate capacity and providing supportive monitoring opportunities. At the health center level, TBD partner will support and strengthen care and treatment services to HIV-positive individuals, with particular emphasis for pregnant women/mothers, children and other family members. Until recently, treatment for HIV was only available in a limited number of hospitals. TBD partner will work with the MOHSW to expand coverage of ART services to 90% of sites, with a goal of providing treatment services at the health clinic levels where feasible. TBD partner's approach to providing treatment at the health center level will be based on the minimum package of care, including: • Integration of care and treatment for women and families within the MCH unit • Clinical staging and CD4 count on the same day as HIV testing within the MCH, and routine follow-up to initiate treatment in a timely manner • Provision of CTX prophylaxis for eligible patients, treatment of OI, including prescription of OI prophylaxis for eligible patients, systematic screening for TB during pregnancy • Provision of comprehensive HIV care to infected patients and strengthened linkages to treatment • Implementation of comprehensive services to ensure that MCH services are provided on the same day as care and treatment for HIV-infected women and exposed infants. • Nutritional assessment of patients on ART • Support groups for women and their families • Adherence support for long term CTX prophylaxis and ART as appropriate

•What is the partner's target population(s) and coverage with a comprehensive care and treatment package, including ART provision, cotrimoxazole prophylaxis and TB screening? The target population is all HIV-positive adults in need of treatment throughout the country.

•What adherence activities does the partner support? What are the outcomes of these adherence activities? LENASO will facilitate psychosocial activities for adults, ensuring that family support groups are available in all districts and in each community council catchment area, incorporating the current PMTCT partner's existing 58 family support groups, and will facilitate learning and support in areas such as stigma reduction, treatment adherence, nutrition, and disclosure. The SCS Project will also link with the mothers2mothers (m2m) program where they are present, building on their widely recognized model of pairing mentor mothers with HIV-positive women to encourage treatment adherence. We expect that with this intervention, there will be rise in patient retention, reduction in loss to follow up, better clinical outcome.

•What type of training does the partner provide? Training activities may include in-service training, mentorship, and preceptor programs. TBD Partner will strengthen the referral linkages within health facilities, between facilities and the community to access better services. TBD Partner will support the sites with training, onsite clinical mentorship, support supervision, documentation and reporting. In order to strengthen the ability of the districts to provide care and treatment at the health center level, TBD Partner will work to build capacity within the District Health Management Teams (DHMT) through mentoring and targeted technical assistance in preparing HIV strategies and helping them to monitor their interventions.

Clinical training. The TBD Partner team will strengthen training of health care workers by offering initial training to newly recruited or newly placed health care workers and refresher course to all, provide consistent on-site training, supportive supervision and mentoring, as well as assisting health workers to use their site level data for program improvement. SCS will promote an integrated training curriculum based on the request of the MOHSW and in line with the project's goal of ensuring integrated services at all delivery points.

•How does partner track and evaluate clinical outcomes? What are their current clinical outcomes? Clinical outcome will be evaluated based on the survival of patients enrolled into care and treatment. In addition, the clinical progression of HIV positive patients from chronic care to enrollement on HAART and the rate of failure to first line regimen will be evaluated. Currently, effprts have been made to follow up patients who are alive and picking their from health facilities as a means of evaluating clinical outcome.

•The mechanism's target population and contribution to scaling up pediatric participation in treatment programs, including pediatric targets The target population is all HIV-positive infants and children throughout the country. SCS partner Baylor will use its outstanding clinical expertise to provide support for pediatric HIV/AIDS clinical services at hospitals and clinics (including its satellite Centers of Excellence), psychosocial support (PSS) of children and adolescents, and technical assistance (TA) in pediatrics to the entire health system.

The SCS Project will expand support for the new Baylor Satellite Centers of Excellence (SCOEs) in all 10 districts, while advocating with other partners and donors for adequate staffing and promoting task shifting to nurses, expert clients and lay counselors. SCOEs will serve as a specialized care center for children for cases that cannot be managed at the HC level.

Baylor will provide PSS services for children and adolescents in all ten districts making PSS clubs available to HIV-positive adolescents and Ariel clubs/camps for HIV-positive children, which will provide education and social connections for those children affected by HIV.

•Activities that provide drugs, food and other commodities for pediatric clients Nutrition corners will be established in the hospitals to emphasize the importance of correct IYCF practices.

•Activities for supervision, improved quality of care and strengthening of health services To help make pediatric HIV services available to the entire population in need, EGPAF has worked to strengthen the capacity of health care workers at primary-level facilities to provide quality services for prevention, care, and support of infants and young children by providing in-service trainings, clinical mentoring, support supervision and useful job aids and tools to health centers. The SCS Project will support the MOHSW to develop standard operating procedures (SOPs) for integrated, comprehensive HIV/AIDS services. SOPs will include booklets on care of HIV-positive children in a rural setting, care of HIV-exposed infants, and linking to care and treatment.

•Activities promoting integration with routine pediatric care, nutrition services and maternal health services. To enhance identification of HIV-exposed and infected infants and children, the SCS Project will promote PITC at all points of contact within the health system and extending into the community. SCS will spearhead training in pediatric counseling so providers are comfortable discussing HIV testing with

parents to encourage uptake of the test.

•Activities to strengthen laboratory support and diagnostics for pediatric clients. The SCS project will support training of all health care professionals and CHW on appropriate technique to perform DBS throughout the country. Working in collaboration with Clinton foundation and the directorate of laboratory services, EGPAF will support early transfer of blood sample to collection centres. EGPAF will continue to support the electronic distribution of DNA/PCR results in the whole country through 3 G technology in the dfistrict.

•The mechanism's target population and contribution to scaling up pediatric participation in treatment programs, including pediatric targets

The target population is all HIV-positive children, as early initiation of treatment is vital for the survival of HIV-infected children. HIV treatment for children is an essential component of the fourth strategic prong for PMTCT, which has largely been neglected. All TBD Partner-supported sites will be helped to provide the essential PMTCT interventions to HIV-exposed infants and young children. As defined by the WHO, TBD Partner will promote the essential postnatal care interventions for HIV-exposed children, which is:

• Early HIV diagnostic testing and diagnosis of HIV-related conditions, ART for children living with HIV, when indicated and treatment monitoring, counseling on adherence support for caregivers • Diagnosis and management of common childhood infections and conditions and Integrated Management of Childhood Illness (IMCI), diagnosis and management of TB and other opportunistic infections

Keep mother/baby pairs together for treatment in hospital setting. SCS will scale-up this best practice in line with the MOHSW's future plans to integrate PMTCT and early infant initiation on treatment within the MCH units at hospitals and filter clinics. Leveraging the current UNICEF-funded MNCH/PMTCT integration project , SCS will be able to utilize the lessons learned to further increase integration. To reduce loss to follow up and improve adherence, HIV-positive mothers and their exposed or positive infants will receive all their HIV services within the setting of the regular MCH unit (at hospitals). This way, providers will be able to keep track of the infant's health, provide cotrimoxazole (CTX) prophylaxis, perform DNA/PCR testing at six weeks, initiate treatment if positive, and continue to monitor both mother and baby up to 18 months after delivery. At that time, mothers will be referred to the ART center for

continued treatment; HIV-negative children will be referred to the under-five clinic; and HIV-positive children will be referred to the Baylor SCOE.

•Activities that provide drugs, food and other commodities for pediatric clients Nutrition corners to be established in all hospitals will help to identify malnourished children and to refer them for clinical care.

•Activities for supervision, improved quality of care and strengthening of health services Regular site visits by the district team members, along with on-site trainings from the SCS project technical team, allow for mentoring and supportive supervision at all of the TBD Partner-supported sites.

•Activities promoting integration with routine pediatric care, nutrition services and maternal health services. See above-mentioned UNICEF jointly-funded project on integrating PMTCT into MCH services.

•Activities to strengthen laboratory support and diagnostics for pediatric clients. The SCS project will support training of all health care professionals and CHW on appropriate technique to perform DBS throughout the country. Working in collaboration with Clinton foundation and the directorate of laboratory services, EGPAF will support early transfer of blood sample to collection centres. TBD Partnerwill continue to support the electronic distribution of DNA/PCR results in the whole country through 3 G technology in the dfistrict.

1. The mechanism's target population, and cross-cutting system/ activity that contributes to PMTCT scale-up. The target population of the SCS project for PMTCT activities is all pregnant women, postnatal mothers, and breastfeeding mothers in Lesotho.

2. Coverage in the geographic area and/ or among the target population i.e. pregnant women SCS will prioritize making PMTCT services available at each health facility in the country, including those in the private sector. Through our frontloaded implementation plan, we will reach 100% facility coverage by 2011, in line with the MOHSW's goal. This will be possible in concert with the MOHSW's proactive efforts towards task shifting and decentralization of health services.

3. Activities including PMTCT interventions and activities that this partner supports All known HIV-positive women and those who test HIV-positive during pregnancy will be given the complete PMTCT minimum package to take home. The package will be provided at the first contact or on the same visit as when HIV status is determined in line with current national PMTCT guidelines. The TBD partner team will train and mentor providers to initiate all eligible HIV-positive pregnant women on treatment within the antenatal care (ANC) setting in the whole country. The team will also explore use of new point-of-care CD4 machines, particularly in hard to reach areas.

All TBD partner-supported sites will be assisted to implement the complete package of routine quality antenatal and postnatal care for women, regardless of their HIV status. This package, defined by the WHO and international partners, is composed of the following interventions: • Provider-initiated HIV testing and counseling, including women of unknown status at labor and delivery or postpartum, and couple and partner HIV testing and counseling, including support for disclosure • Counseling on maternal nutritional support, iron and folate supplementation, and infant feeding options • Obstetric care (including history taking and physical examination) and birth planning, birth preparedness (including pregnancy and postpartum danger signs), including skilled birth attendants • Health education and information on: prevention and care for HIV and sexually transmitted infections; safer sex practices; pregnancy including antenatal care; birth planning and delivery assistance; malaria prevention; optimal infant feeding; and family planning counseling and related services • Psychosocial support and HIV-related gender-based violence screening • Tetanus vaccination, and screening and management of sexually transmitted infections

In addition to the interventions listed above, the additional package of services for HIV-positive women at each TBD partner-supported site includes: • Additional counseling and support to encourage partner testing, adoption of risk reduction and disclosure • Clinical evaluation, including clinical staging of HIV disease and immunological assessment (CD4 cell count) where available, ART when indicated, and supportive care including adherence support, and TB screening and treatment when indicated; preventive therapy (CTX) when appropriate • Maternal ARV prophylaxis for PMTCT provided during the antepartum and/or intrapartum periods • Additional counseling and support on infant feeding based on knowledge of HIV status, counseling and provision of services as appropriate to prevent unintended pregnancies, advice and support on other prevention interventions, such as safe drinking-water • Supportive care, including adherence support and palliative care and symptom management

TBD Partner will complement the facility-based clinical services for PMTCT with a community initiative that mobilizes a wide variety of individuals and organizations to empower local communities to address

MTCT. Aspects of TBD Partner's community initiative will include: • Utilizing the Gateway Approach to empower community councils to set priorities in the area of PMTCT services, provide technical support for the implementation of the essential service package (ESP) in each of the five TBD Partner-supported districts to encourage community-based planning and implementation. • With the MOHSW, train community health workers, expert patients, and lay counselors to provide specific PMTCT services and support at the health facility and community levels. • Facilitate the establishment of Family Support Groups at each site (or strengthen those that exist) in order to provide counseling and psychosocial support to HIV-positive pregnant women and mothers. • Create men's groups with the communities to address issues related to PMTCT, including encouraging more men to accept HIV testing with their partners. • Provide a community involvement officer in each district who will coordinate community-based HIV activities (including PMTCT), supervised by TBD Partner's Community Involvement Program Officer. • Support local organizations including Mothers to Mothers and the Lesotho Network of People Living with HIV/AIDS (LENEPWHA) to improve their management capabilities and sustainability.

Improved patient tracking & referrals. The child health card has recently been updated to better reflect HIV exposure status and testing, and is being printed with support from UNICEF. The TBD Partner team will support the MOHSW in the rollout of this new card, primarily through training health providers and providing onsite mentorship on the proper use of this card. Defaulter tracking will be implemented through use of volunteer site focal persons (under LENASO), members of existing community support networks, who will liaise with the appropriate community health workers to bring defaulting mothers and babies back for treatment. The TBD Partner team will work with the MOHSW to define clear referral systems for partners tested at MCH, for HIV-positive mothers 18 months post delivery (in accordance to national standards). A referral linkage will be developed between MCH units and SCOEs supported by Baylor, a model which will be expanded to all districts.

Repeated retesting of negative women. In keeping with the PMTCT national guidelines, retesting of negative women will be provided in ANC and maternity wards. Women who test negative in ANC will be counseled around a number of issues, including the importance of staying negative; the association of high maternal viral load (occurring after primary infection) with vertical transmission; and the importance of retesting at subsequent antenatal visits, during labor and breast-feeding so that antiretroviral (ARV) prophylaxis can be started should the mother sero-convert. ALAFA will continue to provide support groups for women who have tested negative, and the SCS Project will look at implementing this intervention in other settings.

4. Activities promoting integration with routine maternal child health/reproductive health services and adult and child care and treatment services. If there are linkages with food and nutrition or associated

funding, please describe here.

Keep mother/baby pairs together for treatment in hospital setting. Based on the current PMTCT program's pilot program in 2009, SCS will scale-up this best practice in line with the MOHSW's future plans to integrate PMTCT and early infant initiation on treatment within the MCH units at hospitals and filter clinics. Leveraging the current UNICEF-funded MNCH/PMTCT integration project which the current PMTCT program is implementing, SCS will be able to utilize the lessons learned to further increase integration. To reduce loss to follow up and improve adherence, HIV-positive mothers and their exposed or positive infants will receive all their HIV services within the setting of the regular MCH unit (at hospitals). This way, providers will be able to keep track of the infant's health, provide cotrimoxazole (CTX) prophylaxis, perform DNA/PCR testing at six weeks, initiate treatment if positive, and continue to monitor both mother and baby up to 18 months after delivery. At that time, mothers will be referred to the ART center for continued treatment; HIV-negative children will be referred to the under-five clinic; and HIV-positive children will be referred to the Baylor SCOE.

Link communities to PMTCT & MNCH health services. LENASO will implement a campaign to encourage mothers to deliver in health facilities. They will encourage TBAs to refer all women for delivery in a timely manner. The TBD Partner team will train all VHWs to refer all women to deliver in health facility. The team will also leverage UNICEF funding to improve living conditions in existing waiting mothers' shelters at health facilities. The SCS Project also aims to establish a consistent and functioning outreach system for women delivering at home. LENASO will establish a linkage between site focal persons and village health workers who know which women in their community are pregnant so that they can be visited after delivery and encouraged to attend postnatal services at the health center. Community-based volunteers will be trained and empowered to do home visits for newborn children, as a strategy to improve the survival of newborn infants within the first four weeks after birth. This is a complementary strategy to facility-based postnatal care in order to improve newborn survival.

Establish nutrition corners and ensure routine screening for OIs & STIs. At hospitals and referral centers, TBD Partner will designate an area to serve as the nutrition corner where mothers are counseled on proper infant feeding practices and children and mothers are screened for malnutrition. SCS will also support providers to offer routine screening and treatment of all pregnant women for OIs and STIs using syndromic management.

TBD partner will follow WHO's complete package of routine quality antenatal and postnatal care for

women, regardless of their HIV status and also provide an additional package of services for HIV-positive

women at each site, which includes TB screening and treatment when indicated. TBD partner will work

with the new TB/HIV partner (ICAP) to achieve this.