In Mozambique, to date, most prevention interventions target uninfected persons, or persons with unknown HIV status. The goal of such interventions is to prevent individuals from becoming infected and to encourage HIV testing. The content of these primary prevention interventions is generally informational (e.g. how HIV is transmitted, how to reduce transmission risks), motivational (e.g. why it is important to reduce HIV risk), and skills-based (e.g. how to negotiate risk reduction). As anti-retroviral therapy becomes more widely available, directing interventions toward individuals who are living with HIV is increasingly important. More individuals with HIV are living longer, feeling better, and enjoying a renewed interest in life. These improvements in the health and well-being of people living with HIV bring new challenges, including negotiating sex as an HIV-infected individual.

The Twinning Center (TC) is a program of the American International Health Alliance (AIHA). TC activities in Mozambique started in January 2006. With PEPFAR funds, AIHA/TC facilitated the partnership between the School of Nursing, University of California, San Francisco (UCSF) and two sites in Maputo Province (Beluluane and Namaacha), to start implementation of a PwP Demonstration Project aimed at two levels: an intervention for health care settings/medical providers and community workers/clients. After completion of first site assessments in January 2006, 2 sites in Maputo Province were selected for the implementation of the PWP interventions (Namaacha Health Center and Esperanza Voluntary Counseling and Testing (VCT) Center). TC identified suitable US-based partners and started the development of the program in collaboration with the MOH. Also TC established relationships with the U.S. National Evaluation Center, to determine the monitoring and evaluation strategies for this project.

Namaacha Health Center is a MOH facility, supported in part by an International NGO (Medicos de Mondo) and provides the following HIV/AIDS and related services: VCT (one VCT center and 4 peripheral VCT service sites), PMTCT services, diagnosis and treatment of TB, Sexually Transmitted Infections and Opportunistic Infections, and a Home-Based Care program covering the surrounding villages. ARV treatment services were expected to be started soon; physicians had already been trained on provision of ART. Health personnel had identified the need for more consistent and systematic prevention counseling across all types of services and through different health cadres working at different service points (e.g. counselors at VCT, nurses in the antenatal clinic; physicians at the wards etc.). They felt that messages repeated and re-enforced at various points of contact over time with clients would contribute to a change in behavior. They indicated that health care providers would like to learn more about counseling for the HIV-positive person, and were willing and interested to work on this as a team composed of individual providers with complimentary skills. This site has started to engage in the development of clinic/ provider-based PwP intervention. In FY07, the Namaacha site will implement an intervention model that will allow to determine whether and how provider-delivered prevention messages and counseling, incorporated as part of routine HIV clinic care, are feasible and effective in reducing risk HIV transmission rates among clinic patients within the Mozambican context. FY07 scale up activities include conducting a pilot of skills based education and training sessions for staff at Namaacha health center. The goals of the pilot are to introduce the training program; explain the justification for doing prevention with positives; introduce a model for conducting HIV prevention counseling with HIV+ patients in the clinical setting; and to conduct skills building exercises related to opening prevention conversations and risk assessment.

Esperanza VCT Center is a community-based VCT center located in Matola, Maputo Province, supported by a local FBO, ADPP, and receiving assistance from a local private company, Mozal (aluminum factory). The center, using a team approach, employs more than 80 local volunteers and at least 2 international volunteers at all times. This site uses a peer-education approach through the linkages they have developed with the PLWHA groups. Strong linkages had been established between the VCT center and a number of PLWHA groups that had formed at community level.

This site has started to partake in the development of a PwP model that targets HIV-positive individuals (and their families) outside of the clinic setting, e.g. through counselors, peer educators and community-based support groups. Staff and volunteers from this site are involved in the design and implementation of community-based and client-lead PwP interventions. PLWHA participants are developing peer lead prevention

discussion and training sessions around disclosure, adoption of preventive and risk reduction measures, PMTCT, negotiation of safe sex, and other topics identified by the PLWHA group members.

In FY07, plans include the expansion of these interventions from the 2 existing sites in Maputo province to two new sites in the 2007 focus provinces Sofala and Zambezia.

OBJECTIVE A: Health care workers from Namaacha Health Center, Esperanza VCT Center and 2 TBD sites from Sofala and Zambezia have competencies and skills to address the prevention counseling, disclosure of HIV status, partner notification, risk reduction techniques. ACTIVITY 1 Develop training and skills building sessions at the 4 sites. TC through the partnership will conduct trainings for health care workers and community workers in prevention counseling, on disclosure of HIV status, partner notification, and risk reduction techniques at 4 sites. Deliverable: 200 people trained (4 sites x 50 people/each site). OBJECTIVE B: Provide technical and program expertise for translating proven-effective monitoring and evaluation models from domestic PwP programs to proposed settings in Mozambique. ACTIVITY 2 Through a combination of the skills summarized above the proposed collaboration between the UCSF team, CDC Mozambique staff, and partner agency staff (e.g. VCT Beluluane) will support the development of an evaluation plan-by training the staff from the 4 sites, and from the Provincial Health District in evaluation methods, design, implementation of evaluation protocols. Deliverable: evaluation plan and 20 people trained (5 people x 4 sites).

Expected outcomes for proposed PwP activities are: 1) Patient/client level: change in behavior that can transmit HIV to others, increased knowledge of HIV transmission risks and sense of responsibility for preventing HIV transmission, acceptability of HIV PwP programs and services. 2) Provider level: change in provider behavior, comfort and skill to assess contextual and behavioral risk in HIV positive patients and clients and to provide brief prevention messages to HIV positive persons within the context of current services provided (e.g. VCT, antenatal care, initiating ART). 3) Community level: Increase in number of partners who report to the VCT in both community and clinic based programs for HIV testing.

This activity is also linked to Activities 8639 and 8632.

The USG's SI team's primary challenge in collaborating with the Ministry of Health (MoH) on key public health evaluations and routine data analysis is the limited number of trained staff working at a technical level high enough to support these monitoring and evaluation (M&E) activities. Of specific concern is the entire lack of staff with the capacity to support the SI Team's principle strategy: to address issues around the quality of service delivery for HIV care and treatment programs. Additionally, there are no accredited PhD programs in M&E or public health in Mozambique that can help to build this capacity in the future.

Accordingly, with proposed USG FY07 funds, we will support long-term M&E training for one candidate with an M.D. currently working in the MoH's National Institue of Health (INH). The selected candidate, who has been in the MoH for 10 years, will attend an accredited PhD program at a foreign university in health policy, planning and financing. This area of study is directly related to program monitoring and evaluation for quality service delivery improvement. As previously mentioned, there are no in-country opportunities to receive this training at a local university.

To ensure that the MoH and the USG receive maximum benefit from this long-term training, the candidate has agreed that his dissertation will focus on the Cost Effectiveness M&E PHE evaluation described in Activity 8639 and related to Activity 8632. In addition, he will sign a return commitment letter as described in PEPFAR's long term training guidance. We anticipate that the outcomes of the PHE will be more robust with the involvement of this MoH in this capacity.

This activity is linked with activities 8806 and 9212.

American International Health Association (AIHA) administers the Twinning Center. The purpose of the Twinning Center is to strengthen human and organizational capacity among health service organizations. In FY06, three twinning activities were initiated 1) Mozambican nursing association, ANEMO and the Uganda-based African Palliative Care Association (APCA), 2) Catholic University in Beira and University of Pittsburgh, and 3) Prevention with Positives. In FY 07, two of the three partnerships will be funded under OPHS. Prevention with Positives will continue to be supported in FY 07 but under treatment funds along with all the prevention with positives activities.

University of Pittsburgh and Catholic University of Mozambique (This activity is linked with 8806).

Established in January 2006, this is a north-south twinning partnership between two academic institutions: Mozambique Catholic University and University of Pittsburgh. The partnership's overall goal is to increase the availability of quality HIV/AIDS services in the Sofala Province by increasing the numbers of qualified healthcare workers trained in HIV/AIDS and by creating a model clinic that both provides quality HIV/AIDS care and treatment services and serves as a clinical training facility for healthcare professionals. The model clinic will provide in-service training for practicing mid- and lower-level clinicians and provide pre-service training to nursing and allied health students at the Ministry of Health (MoH)-sponsored Instituto de Ciencias de Saude da Beira (ICSB).

FY 07 funds will continue activities started in 2006 to establish organizational structure for Catholic University's HIV/AIDS training center; create and convene center of excellence Advisory Board; define clinical competencies and design practical hands-on training sessions; establish formal relationships with local HIV treatment clinics to serve as sites for the practical component of the training; develop Monitoring and Evaluation (M&E) capacity at UCM for measuring quality and effectiveness of trainings; develop and train faculty on syllabus for each training track, based on MoH guidelines; train ICSB instructors; train in-service healthcare workers based on MoH priorities; train orderlies in universal precautions/infection control. The clinical training facility will be a part of the training collaborative coordinated by I-TECH in the Sofala Province.

APCA/ANEMO (This activity is linked with USAID activity 9212.)

In FY 06, the partnership between APCA (African Palliative Care Association) and ANEMO made good progress toward their main objective which was to strengthen ANEMO's capacity to function as a well structured, sustainable national association to implement a home-based care training program. Besides an initial planning meeting, APCA conducted a 5 day organizational development meeting with ANEMO principals where they developed a new governance structure, developed clear mission and vision for the organization, initiated strategic planning, and developed an operational structure for the Training Unit. Plans for the remainder of the year work plan include convening an annual general meeting where new board members will be selected; a strategic planning meeting; and a membership drive.

In FY 07, based on discussions with ANEMO, the Twinning Center activities will focus on expanding their role as a professional nursing association. The focus will be on developing functions typically found in associations such as policy development, advocacy, offering and developing standards for continuing education, developing standards of care and ethics. With APCA experience as a health care association, they are well-positioned to work with ANEMO on their growth toward a professional association. AED (Academy for Educational Development) will take over the organizational development work for the home based care training activities of ANEMO. These areas include financial guidelines, strengthening their capacity to reach down to their regional members, leadership, advocacy and training/mentoring to strengthen ANEMO's M&E capacity. APCA's strengths lie less in organizational development and more in professional association development while AED possesses strong organizational development capacity with NGOs, CBOs and FBOs. In order to facilitate a smooth transition between APCA and AED, there will be a meeting involving all three organizations and ongoing communication between APCA and AED so that they are not duplicating efforts and identifying areas where they could work

together collaboratively.

Reprogramming October 2007: Added $200,000 to activity. Funding will include support for clinic equipment and furniture.