Per July 2007 reprogramming; Health Alliance International will need less money than anticipated given previous re-programming. This re-programming request should not affect the achievement of their targets.

Plus-up change: With plus up funds, HAI will expand PMTCT interventions to five new sites, three in Sofala (a focus province) and two in Manica. The new sites are expected to be smaller in nature than most sites as HAI is already working in the most high-yield sites. This site expansion is exciting as it will test HAI's model of care. To that end, HAI will also create a comprehensive care model for HIV/AIDS. The model will include tie-ins from the President's Malaria Initiative, cross-training of family planning/reproductive health and PMTCT nurses, and nutritional support and micro-nutrient supplementation. Further, HAI will explore how they might further link this new model to the Child at Risk consult to ensure better and more complete follow-up of infected children. HAI will also build into the model the bridging mechanism between clinic and home-based care including palliative care, social support, and possibly income generation activities. Finally, HAI will hire a PMTCT technical advisor for the province of Sofala to assist the DPS in improving the quality and quantity of PMTCT services within the province, especially in sites that receive no direct NGO support. HAI will support the provincial PMTCT advisor with funds to assist in supervisory visits, petrol, and communications.

This activity is related to other HAI activities in care CT 9113 and treatment HTXS 8799. In FY07, HAI will support a comprehensive package of PMTCT services in 117 sites: 52 existing sites, and 65 new sites within the highly HIV-infected Beira Corridor in Manica and Sofala provinces. Populations receiving services at antenatal sites in the Beira Corridor are among the most-at-risk populations in Mozambique. At some antenatal centers where HAI's USG-supported integrated PMTCT, family planning, and neonatal services are provided, HIV infection rates among young pregnant women are 30-43%. HAI's PMTCT services are specially designed to bring both men and women into counseling prior to the birth of an infant, so that HIV serostatus is determined and other care and treatment needs can begin to be addressed even prior to delivery. An increasing number of pregnant women are continuing ARV treatment after delivery, thus linking HAI's PMTCT activities with HAI activities in HIV/AIDS care and treatment. In FY06, HAI's capacity for CD4 testing has increased facilitating the entry of more eligible pregnant women and new mothers into treatment. Emphasis on getting eligible mothers into treatment will continue in FY07. HAI works with community groups, community leaders, CBO and FBO in linkages with care and treatment, and to form support groups for people living with HIV/AIDS, positive pregnant women and mothers groups. Working with these groups as well as high quality services and well trained providers help reduce stigma and discrimination in the community. These interventions are helping others in the community see that people living with HIV can continue to live productive lives.

Additionally, the MOH has set ambitious targets for provision of bednets and IPT for ANC, and PMTCT will benefit from this program. However, it will take some time for the malaria initiative to get up and running, and for bednets and IPT to flow to all parts of the country. HAI should plan for a 3-6 month supply of bednets and IPT to assure that the minimum package of PMTCT includes these malaria interventions.

Per 07/07 reporgramming; Health Alliance International will reach an additional 5,000 people with home-based health care services and train an additional 90 activists to provide care within communities. The additional resources will also allow HAI more staff to properly oversee home-based care activities as well as provide increased oversight through joint supervision with the Provincial Delegate of Health and strategically improve the quality of care clients receive from HAI's partners.

This activity is related to HVCT 9113, HVTB 9128, HBHC 9131, MTCT 9140,HTXS 9164, HTXD 9160, and HLAB 9253.

In addition to HAI's provision of treatment activities, HAI also supports the provision of palliative care through HBC services through 10 local CBOs and clinical services HIV positive patients, who are officially registered at day hospitals. All patients on ART are assigned to a community based care volunteer for follow-up and referral.

In FY07, HAI will continue to provide technical support and sub-grants to fifteen national CBOs delivering palliative care in home-based care setting in 15 districts. This will be expanded to 41 organizations linked to 47 ARV treatment sites. These sub-partners offer logistical support and care to HIV+ clients who have been referred through the "day hospital" clinical services or through other health services. This is a continuation of services started in FY2004-FY2006 and includes an expansion to reach a total of 12,800 persons with home-based palliative care. Additional home-based care volunteers will be trained by MOH-accredited trainers. They will work hand-in-hand with clinical service providers and conduct follow-up visits to clients on ART to support adherence and provide palliative care. The trained volunteers will encourage and set up community-level safety net programs for PLWHA as need. Clinical HIV services supported by HAI will serve an estimated 63,000 seropositive patients presenting with OIs and/or STIs.

HAI will continue the expansion of capacity building for community-based groups. Training for 120 people from home-based care organizations will be provided in the areas of institutional capacity building, monitoring and evaluation, and quality assurance (linked with HBHC 9131). In addition, HAI will take advantage of their extensive network of CBOs, and will work with over 100 organizations to increase mobilization efforts for stigma reduction, prevention, care and treatment. These activities will improve HIV information available in the communities and reinforce the network of HIV services.

Under COP07, mechanisms will be put in place to improve linkages to clinics. Although, NGOs were encouraged to liaise with local clinics, many volunteers were comfortable working at the community level only. In FY07, volunteers will be required to work along with clinics in caring for PLWHA on ART, with TB patients, patients with OIs, STIs and other conditions. At least 50% of all HBC clients will need to have a clinic record. Treatment adherence also will be supported by a related USG activity to ensure TB and HIV patients are taking their medicines and not experiencing any overt reactions. In addition, volunteers will be trained to further recognize probable diseases and to refer clients to the clinic for proper follow-up. Coupons for transport or use of bicycle ambulances will be used to ensure clients attendance. Further training will be held to ensure that HBC supervisors, and volunteers have the necessary skills to handle these new activities.

HAI will also increase interventions that improve health workers skills and ability for diagnosis, prevention, and treatment of opportunistic infections amongst patients seen at HAI supported treatment facilities including HBC programs through: 1)Training of health staff in the diagnosis and clinical management of important OIs including cryptococcal meningitis, Oesophageal candidisis and Pneumocystis pneumonia (PCP); 2) Provision of cotrimoxazole prophylaxis to stage 3 and 4 HIV patients including those diagnosed with TB and HIV; 3) Development and implementation of registers and monitoring tools that keep track of OIs being treated at treatment facilities; 4) Referral of HIV infected patients to HBC programs for continuing care; and 5) Follow up of patients regularly for CD4 monitoring and clinical staging to assess when eligible to initiate ART.

HAI will be funded to support the MOH procurement system by maintaining a buffer stock of OI medicines to avoid complete stock-out of these commodities. As a result of this

activity, 240 clinical staff will be trained in OI management, supervision and maintenance of simple pharmacy management systems.

General Information about HBC in Mozambique: Home-based Palliative Care is heavily regulated by MOH policy, guidelines and directives. USG has supported the MOH Home-Based Palliative Care program since 2004 and will continue with the same basic program structure including continued attempts of strengthening quality of services to chronically ill clients affected by HIV/AIDS. In FY02, the MOH developed standards for home based care and a training curriculum which includes a practicum session. Trainers/supervisors receive this 12 day training and are then certified as trainers during their first 12 day training of volunteers. A Master Trainer monitors this first training and provides advice and assistance to improve the trainers' skills and certifies the trainer when skill level is at an approved level. All volunteers that work in HBC must have this initial 12 training by a certified trainer and will also receive up-dated training on a regular basis. The first certified Master Trainers were MOH personnel. Then ANEMO, a professional nursing association, trained a cadre of 7 Master Trainers who are now training Certified Trainers, most of whom are NGO staff who provide HBC services in the community. In the next two years, ANEMO will train and supervise 84 accredited trainers who will train 7,200 volunteers, creating the capacity to reach over 72,000 PLWHA.

In addition, the MOH designed 4 levels of "kits" one of which is used by volunteers to provide direct services to ill clients, one is left with the family to care for the ill family member, one is used by the assigned nurse which holds cotrimoxazole and paracetamol and the 4th kit contains opiates for pain management which only can be prescribed by trained doctors. The kits are an expensive, but necessary in Mozambique where even basic items, such as soap, plastic sheets, ointment, and gentian violet are not found in homes. USG has costed the kits and regular replacement of items at $90 per person per year; NGOs are responsible for initial purchased of the kits and the replacement of items once they are used up except for the prescription medicine, which is filled at the clinics for the nurses' kits. An additional $38 per client per year is provided to implementing NGOs to fund all other activities in HBC, e.g. staff, training, transport, office costs, etc.

MOH also developed monitoring and evaluation tools that include a pictorial form for use by all volunteers, many of whom are illiterate. Information is sent monthly to the district coordinator to collate and send to provincial health departments who then send them on to the MOH. This system allows for monthly information to be accessible for program and funding decisions.

07/07; HAI will utilize these funds to add the cotrimaxazol purchased for tuberculosis and HIV-infected clients.

This activity is related to activities HXTS 9164; HBHC 9133; MTCT 9140; HVCT 9113.

Identifying clients co-infected with TB and HIV is a crucial aspect of the integrated network for HIV services in Mozambique. During FY05 and FY06, HAI, working with Sofala and Manica DPSs and the National TB-Control Program, developed and applied a successful algorithm to expand HIV testing to TB sites and strengthen referral of co-infected TB-HIV clients identified through TB clinics. Clients were referred to appropriate HIV care and treatment services which has help to bring to the forefront the importance of TB/HIV at the national level.

During COP06, several TB sites started gradually providing of ARV treatment under the coordination and supervision of clinicians authorized to prescribe ARVs. During the above mentioned period HAI also worked to strengthen the diagnosis of TB in HIV infected patients. During FY06, the TB reference laboratory in Beira was created and five sites were equipped with portable X-ray machines, activities that improved the capacity to diagnose TB in the region. Also during FY06, a major part of the activity focused on training physicians, nurses, and counselors at existing TB clinics to apply the new algorithm in their clinical practice.

During COP07, HAI will continue to support HIV testing at all TB program sites in a total of 23 districts (Manica and Sofala combined), the provision of ARV treatment directly in the TB program in 25 TB sites, the systematic application of protocols for TB diagnosis in the HIV positive patients (including the expansion of the X-ray services to 7 more sites), the strengthening of the TB laboratory in Beira, and the provision of prophylactic isoniazide.

HAI will also strengthen the collaboration between clinic and community-based palliative care for treatment of adherence of TB and ARVs. Since HAI manages both the clinic and HBC activities, there has been close collaboration in the past. However, with new procedures to link TB and HIV, additional training will be given to the HBC volunteers so that they can assist their HBC clients to adhere to treatment drugs and determine if there is some reaction to the treatment regime.

Expected results will be 4,000 people tested for HIV in TB sites, provision of cotrimoxazole to 2,520 patients, provision of ARVs to 1,411 patients in TB sites and improved infrastructure. The programmatic result of this activity will be expanded and improved care services and strengthened integration of TB and HIV care and treatment.

In addidtion, HAI will participate in a new activity, which will be initiated during FY07 and addresses the need for a more collaborative processes between clinic based and community based palliative care, especially in relationship to treatment adherence for TB and ARV. This activity links with Palliative home-based care partner activities with CARE, FHI, FDC, HAI, WR and WV and with Columbia University in the development of treatment adherence materials.

This activity will make improvements in the areas of collaboration and communication with NGO partners that are working in both clinic and community sites. Small amounts of funding will be provided to five partners who offer palliative care under the home-based care (HBC) model. HBC volunteers and their supervisors will receive training on treatment adherence for ARV and TB. Columbia University will develop training materials for ARV adherence under a separate USG supported activity and provide hands-on training to HBC volunteers so that they can assist their HBC clients to adhere to treatment drugs and determine if there is some reaction to the treatment regime. In addition, collaboration will occur with the MOH's TB program to ensure that HBC volunteers are correctly trained concerning the DOTS model and the MOH's vision for improving case detection and treatment success rates.

This activity is related to : MTCT 9140; HBHC 9133; HVTB 9128; HTXS 9164 and HTXD 9160 .

HAI will continue to strengthen sub-partners in Manica and Sofala provinces to achieve greater community reach and to mobilize community members to learn their HIV status by participating in HIV CT in 77 sites, 19 of which will be new during COP07, and testing approximately 90,000 people, 45% of which will be women. Since many of these new sites will be satellites, HAI will train 15 new counselors and include a refresher training for 75 existing counselors. In addition, HAI will train 240 health workers in "ATS".

With COP06 resources, HAI expanded to 32 CT sites, including services in 5 "youth friendly" health centers and in training of new counselors and refresher training of existing counselors and the referrals communities. All of these CT sites provide referrals to other HIV/AIDS services within the integrated HIV/AIDS networks. HAI will strengthen the quality and impact of CT through by strengthening the link with HCB groups and PLWHA associations. Each CT site is linked to ongoing HIV clinical services, where clinical and home care. Psychosocial support for PLWHA is provided through post-test clubs, mother-to-mother support groups, home-based care, and PLWHA associations. Stigma reduction is central to the work of the community-based sub-partners. End-stage clients who are not currently benefiting from palliative care at HIV treatment and care facilities are referred to home-based palliative care providers who support both the patient and the family. The integration of CT services with facility- and community-based care ensures effective referrals and better outcomes for clients. HAI will train clinical staff in at least 240 health staff to do "C&T in health" as part of their routine activities in the context of the implementation of the MOH policy of integration of services. HAI's emphasis on provision of a continuum of care and treatment is fundamental to its approach to CT. Community mobilization is also an integral part of our activities to encourage people to go for testing and treatment, when necessary. These mobilization activities include HIV education on prevention, stigma reduction, and the importance of testing and treatment.

This activity is related to HTXS 9164.

HAI will be funded to support the MOH procurement by maintaining a buffer stock of ART medicines to avoid complete stock-out. See HTXS 9164 narrative further description.

This activity is linked to HBHC 9133, HVTB 9128, and HTXS 8806.

Health Alliance International implements HIV care and treatment activities in Mozambique in Manica and Sofala provinces. This is a continuing activity and is linked to palliative care and TB/HIV activities being implemented by HAI and its sub-grantees. These activities are described elsewhere in this document.

There are four main component to this activity, the first one being support to human resources development. HAI will provide technical and financial support pre and in-service training and mentorship of medical technicians, nurses, doctors, pharmacists and other health staff focusing on HIV care and treatment. This will be through use of existing training materials that have been developed by the MOH with donor and other partner support. Through this activity, HAI will contribute to the training of 216 health personnel in existing 18 sites; 240 trained in additional 30 sites; and 90 medical technicians, nurses, laboratory technicians and pharmacists.

The second component is infrastructure development that will involve, repair (11sites) renovation (11 sites) and construction (7) of health facilities for the provision of ART services. Included in this component is the construction of 2 health centres including two staff houses per health facility for Sofala province as part of the Emergency Plan's focus on this high HIV burden province. Equipment and supplies such as computers and furniture will be procured and placed in the new sites. In total HAI plans to open 30 new treatment sites, most of which are small satellite sites surrounding larger day hospitals in Sofala and Manica Province at a cost of $550,000. This is addition to the 18 current sites. This support will result in 12, 500 receiving ART including 1250 children.

The third component of this activity is to provide quality supervision and support through mentorship of staff, improvement of the M&E system at site and provincial level by supporting staff training and procurement of computer equipment; in addition to provision of technical assistance and participation in regular planning and program monitoring meetings with the provincial Health Directors office. Maintain ongoing activities in 18 ART treatment sites and open an additional 30 treatment sites through provision of basic equipment and training (rehabilitation in 11 sites in addition to expansion of outpatient department, construction of new health centres and housing for staff.

The last component is to maintain and develop community linkages working with Community based organisations to strengthen adherence support at a cost of $380,000 and disseminate IEC materials related to HIV care and treatment.

Sofala Province is a focus province for emergency plan activities in FY07. HAI will implement the following as part of this focus activity: construct two health centres and 4 staff houses to improve staff retention, collaborate with ITECH and the catholic university in the same province, to provide pre-service training for 90 medical technicians, nurses and pharmacists and recruit technical advisors to work in the Provincial Health authority to support ART program implementation.

Reprogramming October 2007 - This activity will allow HAI to expand treatment adherence activities in Manica through its sub-grantee Africare. HAI will be able to expand mobilization efforts for stigma reduction, prevention, care and treatment and ensure that Africare volunteers continue to work closely with clinics in caring for PLWHA. At least half of the new Africare HBC clients will need to have a clinic record. The additional funding will allow HAI, through Africare, to reach an additonal 800 individuals with adherence and tracing as well as increase the geographic penetration of Africare, specifically, Africare will strengthen its portfolio in Manica and Gondola district.

This activity is related to HTXS 9164 and HTXD 9160.

This activity is linked to treatment activities being implemented by HAI in Sofala and Manica provinces and aims to support ART programs being implemented in these two provinces through strengthening the laboratory network to improve patient monitoring. In coordination with the MOH and the provincial health authority of Sofala and Manica provinces, HAI will support the upgrade of 4 existing sysmex haematology analysers for CD4 count testing.

The expected output of this activity is 30 lab staff trained; 4 haematology analysers upgraded to perform 36,000 tests annually.