The Strengthening Clinical Services project supports all 4 of the Partnership Framework goals: 1): HIV incidence reduced by 35%; 2) reduce morbidity and mortality and provide essential support to PLWH; 3) HR capacity for HIV service delivery is improved and increased; 4) Health systems are strengthened.

The projects main targets are: 100% of facilities offer comprehensive PMTCT services by the end of 2011. 100% of facilities offer HIV care & support by the end of 2013. 90% of facilities offer HIV treatment initiation by the end of 2013. Coverage of activities and services is across all districts of Lesotho, targeting all Basotho in need of HIV prevention, care, and/or treatment services. Project activities are designed to meet 5 goals: 1) High-quality, comprehensive, integrated, client-centered HIV services at health facilities 2) Family-centered HIV services available at all points of contact 3) Universal access to comprehensive PMTCT services 4) Strengthened national health system 5) Up-to-date national policies, protocols, & guidelines

An underlying theme central to activities under SCS is to support the MOHSW and work within existing systems to ensure sustainable programming and local ownership of the projects activities and results. Several of the implementing partners are local organizations and this project works closely other organizations to promote local ownership of project interventions.

The effectiveness of the project is measured by the extent to which the objectives and targets are met at the facility and population levels. The PEPFAR NGIs and other indicators have targets against which actual performance/achievements is compared. The major source of data for the indicators is the service data from the service sites.

The SCS project provides adult HIV care & support services at health facilities and communities in all districts of Lesotho; one of the projects targets is to support 100% of facilities to offer HIV care & support by the end of 2013. Currently we are in 201 HFs. With a client-centered approach, the patient becomes the focus; clinical services are made readily accessible to each client in an integrated approach. When appropriate, patients are referred for appropriate care at their own health center, thereby reducing burden on overcrowded hospitals. SCS uses the m2m program where present, building on their model of pairing mentor mothers with HIV-positive women.

SCS supports providers to offer routine screening and treatment of all pregnant women and families for OIs/STIs. ALAFA clinics provide free STI screening and treatment for all apparel workers. To strengthen the follow-up of HIV-positive workers enrolled in care, all ALAFA patient records are integrated into an electronic database enabling program staff and ALAFA service providers to effectively track patients who have missed their ARV refills, missed clinic visits, or lab evaluations. Lists generated centrally are shared with Adherence Support officers at clinics who track patients within the factories through HIV coordinators and peer educators.

In FY12, LENASO will conduct bi-directional outreach activities to improve adult care & support services at the community level. The strategy includes working with the Community Councils as the gateways to HIV service delivery. Focal Persons (volunteers located in each community councils) link communities with health facilities and promote utilization of health services. This approach reaches men, youth, couples, and others who might not use traditional programs. Strategies like Child Health Days, Sports against AIDS tournaments, public gatherings, and focus groups are conducted to increase uptake of HTC. HIV-positive clients are linked to health facilities for care services. In Year 1 of SCS, coverage for care services was about 80%. Quality of care assessments will be conducted in 2012.

Within PMTCT, Adult, Adolescent and pediatric HIV Clinics, EGPAF will continue to support ICF (TB screening of HIV positive patients) as per national guidelines, ensuring that TB Suspects are adequately assessed and all HIV and coinfected TB patients are referred to the appropriate clinics for ART initiation or initiation of antituberculous regimen respectively. Within textile industries and private clinics, these services will continue to be supported. TB screening within these settings (and potentially HTC settings) and establishment of proper linkages to appropriate treatment are very important to reduce the impact of the TB/ HIV syndemic, and, to reduce the drop off rate between coinfected patients tested for HIV and initiated on ARVs. Based on the national guidelines, all TB unifected HIV patients will be enrolled on IPT, in collaboration with the PEPFAR TB/ HIV prime partner (ICAP). An integrated training program is being developed by both partners to ensure all HCWs in GOL and CHAL facilities receive training, mentoring and supervision in both HIV Care and treatment and TB/ HIV. The SCS project, along with the TB partner ICAP, will also continue to support the integration of all treatment and care registers, following the WHO interlinked register model. Support has been provided for the review of all data collection and monitoring tools and these will be disseminated for use in GOL health facilities in FY2012. EGPAF and Baylor will continue to participate in TB/ HIV TAC meetings, providing TA to the MOHSW and supporting HCW trainings in IPT and IC for pediatrics and PMTCT clients.

At hospitals (total of 17), EGPAF establishes nutrition corners where mothers are counseled on IYCF and children and mothers are screened for malnutrition. Children of unknown status are offered PITC. Baylor trains and mentors the providers at nutrition corners to support HIV-infected and malnourished children. Nutrition corners and nutrition activities such as distribution of micronutrients and IMAM (Out- patient Therapeutic program) are integrated into MCH.

SCS subgrantee Baylor will continue to focus on the provision of PSS for children and adolescents by making PSS clubs available to HIV-positive adolescents and Ariel Clubs/Camps for HIV-positive children, which provide education and social connections for children affected by HIV. Where Baylor is not present at the district-level, EGPAF will establish and support Ariel Clubs which will be handed over to Baylor. Consultative meetings will be held with the MOHSW to inform the process including a needs assessment for psychosocial counseling training for health providers.

Support groups for HIV-infected adolescents (Teen Clubs) were established in Qachas Nek and Leribe SCOEs. The teen clubs have ongoing monthly meetings where education is delivered to adolescents on health related issues and opportunities to share experiences. Additional teen clubs will be established in FY12. A standard curriculum for adolescent support groups is being developed by Baylor for adaptation and use with all Teen Clubs in Lesotho. Baylor physicians, social workers and EID/HTC counselors will participate in Mamohato Camps, in partnership with Sentebale and the Association of Hole in the Wall Camps for psychosocial support and education for HIV-infected children aged 10-18.

Specialist psychology services being provided at Baylors Maseru COE and a Play Therapy and Psychosocial Stimulation program for severely malnourished children will be expanded. A Psychosocial training curriculum for health care providers will be finalized. HCWs will be trained on psychosocial support and screening for psychological disorders.

SCS will engage in developing effective 2 way referrals for EID (DNA PCR) between PMTCT, MNCH settings and national laboratories.

PEPFAR will support implementation of workplace programs in settings where HIV Work Place Policies exist. An example of such a setting in Lesotho where we will support this is in the textile industry. Currently, challenges exist in HIV/ AIDS service provision in textile factories as this is almost fully paid for by ALAFA. EGPAF will work with ALAFA to explore and establish sustainable approaches such as health financing/ stellite clinics to ensure services are available to diagnosed and undiagnosed factory workers and their families.

As a way to advocate for institution of workplace policies in the public sector, PEPFAR will support the establishment of a crèche in the MOHSW to ensure working nursing mothers (and fathers) in the establishment are supported, educated and empowered in proper and exclusive breastfeeding techniques and therefore all women, irrespective of HIV status provide proper nutrition to their babies. This positive example will be evaluated as best practice and scaled up by the MOHSW to other government and public sector in subsequent years (context from PMTCT Acceleration Plan).

EGPAF will continue to support ALAFA's program, expanding PMTCT and HIV care and treatment services to more workers in private textile factories. In addition, EGPAF will build and expand the capacity of its other local partners for USG supported programs, developing an exit strategy from subgrantee status for them by 2015.

TA for MOHSW HSS activities (in HIV/ AIDS policy development, guidelines review and service provision and nutrition activities) will continue to be supported, as required, within the FHD and the DDC.

A Public Private Partnership between PEPFAR, MOHSW and with Johnson and Johnson/ University of Cape Town on Management Development for central and district level managers for PMTCT, HIV Care, HIV Treatment, and other HIV related services (such as laboratory services, SCM, Local Councils) will be supported in FY2012. This intensive 1 year program will be evaluated by partners.

Since launching in Feb. 2010, SCS continued to ensure new facilities were supported to initiate PMTCT services, while focusing on improving quality of services provided in all districts. Between Feb 2010 and Jun 2011, 31 additional sites were aided by SCS to provide PMTCT services, bringing the national total to 203 sites. Targets for FY12 are for 9,536 pregnant women to receive ARVS for PMTCT (2,861 receiving ART). Progress will be measured and reported to PEPFAR quarterly through the standard MOHSW reporting tools, supported by a more in-depth mid-project assessment. In FY12, SCS will build the capacity of health workers by a) supporting MOHSW to roll out the 2nd phase of the national PMTCT trainings; b) supporting the MOHSW in accreditation of new PMTCT sites, especially private facilities; c) ensuring provision of high quality PMTCT services through on-site mentoring and supportive supervision.

To improve retention and adherence, HIV-positive mothers and their infants will receive all HIV services within MCH unit. Thus, providers are able to keep track of the infants health, provide CTX, do DNA/PCR test at 6 weeks, initiate treatment if positive, and continue to monitor both mother and baby up to 18 months post-delivery before referral to their clinics. More activities in FY12 under MTCT and care and treatment for HIV positive mothers and children are detailed under the acceleration plan.

At 19 hospitals, SCS will strengthen nutrition corners where caretakers are counseled on infant feeding and children/mothers are screened for malnutrition. Children of unknown status will receive PITC. In FY12, subrecipient Baylor will continue to train and mentor providers at nutrition corners to support HIV-infected and malnourished children. LENASO, a CBO will mobilize communities to improve ANC attendance and facility deliveries.

SCS's support for MOHSW District Health Information Officers to verify data will be expanded. EGPAF is working on a more structured and formalized way of verifying these data including the use of standard verification tools (to be developed in discussion with the MOHSW in FY12). PMTCT Impact Evaluation, FHDs and National ART Costing will be conducted.

As of Jun 2011, the SCS project was supporting 196 facilities to provide adult ART services in all 10 districts. During FY12, EGPAF will support 10 more facilities to provide ART and to initiate 32,733 adults on ART. The SCS project strengthens ART delivery at facilities, through technical assistance, on-site mentoring, clinical training, support supervision, human resource building, and supporting the national-level policy development process. SCS does not procure medications or implement a parallel system.

Health worker training and capacity building is one of the key activities of SCS and is also one of the strategies of PEPFAR. Skills-based trainings will be conducted for MOHSW staff to equip them with relevant knowledge and skills. These are short (2 -10 days) didactic courses, 1-2 hours onsite training, followed by on-site mentorship and support supervision. The onsite mentorship and supportive supervision aims at enhancing health workers skills, confidence, and competence to ensure that knowledge acquired during didactic training is translated into practical action. At the district level, update training will be provided to health providers who have already received initial trainings. For health providers who are new, comprehensive trainings will be facilitated. SCS will enhance pre-service training of medical students (finalist) in health training institutions through IMAI. This is paramount and cost effective as it will enable the GoL build sustainable local capacity with the skills needed to appropriately manage HIV patients. It is anticipated that through this approach, sustainable services will be assured beyond SCS support.

SCS will improve the capacity for all staff along the health information continuum to be better managers and users of the data they generate by developing SOPs, checklists, and feedback processes. SCS M&E Officers will provide support to District Health Information Officers and the site-level data clerks 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.

The SCS project has contributed to scaling up pediatric HIV treatment, having newly enrolled 783 children in treatment in the first half of FY11 at 172 health facilities across the country. During FY12, SCS plans to enroll an additional 1,012 children in treatment and to scale up the number of facilities that offer pediatric treatment to a total of 188 sites.

To reduce loss to follow-up and improve adherence, HIV-positive mothers and their exposed or positive infants will continue to receive all their HIV services within the setting of the regular MNCH unit (at hospitals). This way, providers will be able to keep track of the infants health, provide 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, HIV-positive children will be referred to the Baylor SCOE.

In FY12, SCS will continue to support trainings for health care workers in pediatric treatment, followed by on-site mentoring and support supervision.

Five EID/HTC counselors were hired to conduct Provider Initiated HIV Testing and Counseling (PITC) at Queen Elizabeth ll, Machabeng, Motebang, Botha Bothe and Mokhotlong Hospitals. A large number of children and caregivers in pediatric wards and outpatients departments were screened for HIV through this program, with over 90% at each site being discharged from the hospital with a known and documented HIV status throughout the reporting period.

SCS District Clinical Coordinators in the districts continually work with the MOHSW District Health Information Officers to verify data submitted by facilities before they are submitted to centrally. EGPAF is working on a more structured and formalized way of verifying these data including the use of standard verification tools (to be developed in discussion with the MOHSW in FY12).