In EGPAFs care and treatment program, palliative care includes the provision of patient and family centered

care throughout the continuum of illness. Providing a comprehensive care package includes the prevention,

diagnosis and treatment of opportunistic infections, pain management, linkage with home-based care and

other community support services, psychosocial and adherence support for the patients and his/her family.

In addition, it considers nutritional issues as they interact with health status and treatment success for the

patient as well as food insecurity for the whole family as a result of disease.

EGPAF wants to address these components by:

- building capacity in the health facility to prevent, diagnose and treat opportunistic infections and provide

comprehensive chronic HIV care, including the management of pain

- building capacity in the health facility to provide counseling and psychosocial support throughout the

continuum of illness

- collaborating with community-based organizations implementing HIV prevention activities and providing

additional psychosocial support services (individual and family counseling, support groups), home-based

care, nutritional support, and active tracing of patients lost to follow up (subgrants to cover part of these

activities)

- establish linkages with other (international) organizations providing support services to ensure provision of

bednets, clean water supplies, nutritional supplementation where feasible

Capacity building of health staff on palliative HIV care: In the health facilities, EGPAFs Clinical Advisors will

conduct training and on the job mentoring on OI management for health facility staff including physicians,

medical technicians, nurses, laboratory and pharmacy staff. Involvement of DPS and DDS staff in regular

supervision and mentoring will help build their capacity to develop formative supervision skills and provide

staff with necessary technical support. EGPAF will implement the QI and supervision tools that have been

developed during PY04 for the supervision of chronic HIV care.

In so far as some essential drugs for the treatment of OIs have not been available or with long stock

ruptures, EGPAF will procure and manage a buffer stock of essential drugs for the management of OIs.

Counseling and psychosocial support: In the health facilities additional counseling will primarily be provide

by lay counselors and peer educators. In addition, they will also, together with volunteers from CBOs,

provide counseling in the community and in support groups meetings. Training of lay counselors and peer

educators will focus on essential HIV knowledge, HIV care and treatment related knowledge including

treatment preparation, prevention with positives, nutrition, positive living with HIV as well as couple/family

counseling. Lay counselors and peer educators will work within the health facility but provide an important

linkage with the community and community-based services.

Community-based support: since 2006, EGPAF has provided small subgrants to an increasing number of

CBOs. Activities of these CBOs initially focused on HIV education, community mobilization for PMTCT and

psychosocial support for pregnant women in the PMTCT program. Since 2007, activities have expanded to

include community education on ART, treatment literacy, active tracing of HIV exposed infants and linking

them with ART services as well as active tracing of patients on treatment lost to follow up. CBOs have also

established support groups for people on treatment. EGPAF will continue to provide relevant training and

technical assistance to the CBOs, as well as support for coordination and exchange with other CBOs,

monitoring and evaluation and the documentation of lessons learned. In COP08 the number of CBOs with

which EGPAF will have a subgrant will increase. The goal is to have one CBO in the catchment area of

each treatment site to provide these additional support services. In each of the new districts, new CBOs will

be identified through a process of mapping and capacity assessment. In district where no capable

community-based organization exists, EGPAF will work with health facility staff and motivated beneficiaries

to establish support groups for PLHA. In some districts EGPAF has established MOUs with other

organizations providing home-based care, psychosocial support and support for OVC. EGPAF will expand

this and work to increase collaboration with other USG and other partners to increasingly provide a

comprehensive package of services. As EGPAF is not directly providing bednets, safe water supplies and

nutritional support, this support will only be provide through partnerships. Currently this includes the

provision of Plump'Nut to several malnourished infants and children. EGPAF will explore the possibly to

include several malnourished adults in this program as well as explore other possibilities to provide

nutritional support to patients on treatment.

To support both the counseling activities in the health facilities as well as HIV education and counseling

activities implemented by CBOs, EGPAF will reproduce and disseminate existing IEC/BCC materials.

The patient tracking system EGPAF has implemented in each of the care and treatment sites facilitates the

monitoring of quality of care provided to patients in care. As currently many patients enrolled but not yet in

need of treatment are lost to follow up, EGPAF in collaboration with the CBOs will work to recuperate these

patients and ensure that they receive clinical follow up care and are linked with support services.

This activity also relates to activity 8593 and OI logistics systems strengthening described in USAID activity

9136 elsewhere in this document.

The main component of this activity is to provide all HIV patients with a minimum package of quality clinical

care services at EGPAF's 17 ARV treatment sites. Patients will receive access to this minimum package of

care regardless of whether they have initiated ART. Key components of the care package will include:

1) Management of opportunistic infections (OIs) and other acute illnesses: including the prevention,

diagnosis and treatment of common oi as well as provision of cotrimoxazole prophylaxis, pain control,

facilitating the distribution of bed nets to prevent malaria, as well as site level support for the recording and

reporting of opportunistic infections through maintenance of good registers that keep track of a) HIV clinical

stage and prophylactic medicines prescribed, b) OIs diagnosed (TB, CM) c) record of adherence to

medication and clinic reviews d) specific psycho-social issues requiring follow-up and e) eligibility for ART

2) Provision of psychosocial and adherence support through working with community-based groups and

associations and recruitment and training of clinic staff to provide on-going counseling support

Activity Narrative:

3) Assurances of continuity of care services beyond the clinical setting through referral to community-based

organizations that serve the respective health facilities. This may include referral to counseling and testing

as necessary.

4) Continued patient and family education about HIV disease, OIs, appropriate nutrition and HIV prevention

5) Continued monitoring and regular follow-up to determine readiness and eligibility for initiation of ARV

therapy.

To ensure access to all five elements, EGPAF will develop a system for tracking the types of services

offered and delivered. Additionally, clinic nurses, clinical officers/medical technicians and pharmacy staff will

be trained in the provision of standard HIV care services. Training will include adult and pediatric HIV

management and will be provided in coordination with the Ministry of Health.

Through these activities, 13,132 adult and 2,456 children will be provided with clinic-based HIV-related care

services during FY07. Children will be identified for care through linkage with PMTCT services, postnatal

clinics, in- and out-patient child care services as well as child at risk consultation services. At least 22

community based organizations will be engaged to support referral networks and 300 individuals will be

trained in OI management.

Per guidance sent by CDC/GAP, this activity represents approximately 1/12 of the funding originally

allocated to EGPAF for this program area under activity 8595.08. Funding is provided to pay for that activity

from February 23 - April 1, 2009.

Per guidance sent by CDC/GAP, this activity represents approximately 1/12 of the funding originally

allocated to EGPAF for this program area under activity 8594.08. Funding is provided to pay for that activity

from February 23 - April 1, 2009.

Expanding access to tuberculosis treatment, combined with introducing HIV testing and anti-retroviral (ARV)

delivery into TB programs, is essential to ensure the survival of HIV-positive people. Since up to half of

people living with HIV/AIDS (PLWHA) develop tuberculosis, and tuberculosis has an adverse effect on HIV

progression, EGPAF will work to ensure that tuberculosis care and prevention is a priority in its HIV care

and treatment program, and that HIV/AIDS prevention and care will be a priority in the TB program.

Mozambique is ranked 18th for TB incidence (447/100,000 pop./Y) worldwide and faces many serious

constraints in addressing the TB epidemic. TB notification related to case identification (Notification Rate:

168/100,000 pop./Y) and TB management translated into cure, treatment completion and death rates

(124/100,000 pop/Y) remain very poor. Within MOH, coordination between TB and HIV departments,

essential to develop an effective approach to address this associated HIV/TB epidemic (Source: WHO

report 2007).

MOH faces major challenges in improving access to and quality of care for TB and T/HIV co-infected

patients, including a lack of qualified staff, a lack of support to staff through supervision and on the job

training, poor diagnostic capacity, and weak linkages between TB and HIV care and treatment services.With

the expansion of C&TS, the MOH together with partners has worked to improve TB management and to link

and integrate TB and HIV care and treatment services.

During FY08 these funds are requested to implement a range of activities that include: integration of TB and

HIV care and treatment services, and improve the quality of services provided to TB/HIV co-infected

patients. EGPAFs general objectives focusing on improving access to and quality of service, ensuring

access to psychosocial and other support services, building institutional capacity within MOH to manage

the programs and ensuring monitoring and evaluation of services, will consider TB/HIV services as an

integral part of the program. Activities are aimed at 1) preventing HIV infection in TB patients, 2) preventing

occurence of TB disease in HIV patients, 3) providing comprehensive care for co-infected with TB and HIV

Under each of the 5 objectives, EGPAF will support specific activities:

Objective 1: Improve and reinforce care and treatment for adults and children co-infected with TB/HIV

through;

i) Training of staff in the following; TB prevention and case detection in HIV patients, HIV counselling and

testing and clinical management of co-infection, both for adults and children (new sites) ii) continuous

training, supervision and clinical mentoring .iii) Ensure continued implementation of TB screening at all ART

facilities as well as assure for treatment those infected with TB through referral to TB programs iv) Support

to coordination and planning meetings to help establish effective linkages between and integration of TB

and HIV care and treatment services.

EGPAF target is to offer counselling and testing services to 4,571 TB patients, test 3,672 patient and to

enrol 1,836 TB/HIV co-infected patients into C&TS; additionall to ensure treatment of TB for 1,836 HIV

infected patients.

Objective 2: Build capacity of health staff and communities to provide psychosocial, nutritional and

adherence support to PLWHA and their family members and to sensitize the population on TB/HIV/AIDS.

This will be achieved through i) collaboration with CBOs to devlop programs for psychosocial, literacy

promoting and adherenc support activities to reach TB/HIV co-infected patients and improve the linkages

between commuity and health centre services. ii) train and organise sensitization campaigns targetting lay

counsellors, peer educators, community leaders and CBO members to increase community awareness

about the inter-relationships between TB and HIV and where to obtain care and treatment. ii) Provide

counselling training for health staff, lay counsellors, peer educators and CBO volunteers which includes TB

to ensure that TB is addressed within support groups and patients are well educated about TB case

detection.

Objective 3: Build institutional capacity of the MOH to plan, monitor and manage TB services

In addition, activities focusing on increasing DPS and DDS capacity to manage HIV care and treatment

programs that will benefit the TB program will be undertaken. these include, support pharmacy

management in relation to TB drugs and ensure joint supervision of TB/HIV services, implementation of

supervision tools and support DPS & DDS planning and coordination and in TB taskforce meetings and

nationa ART technical meetings provide technical inputs regarding TB/HIV management.

Additionally, EGPAF will within laboratory and clinical space rehabilitations ensure availabilty of a safe

environment for laboratory function and clinical managment of PLWHA with a view of infection control.

Objective 4: Improve monitoring and evaluation systems and implement quality assurance mechanisms to

enhance TB within C&TS

EGPAF support to monitoring and evaluation of HIV care and treatment program will also encompass

TB/HIV treatment services. EGPAF will ensure systematic monitoring of TB screening among HIV patients

within care and ttreatment and antenatal services sites ,as well as monitor HIV screening among TB

patients. The Patient tracking system (PTS) implemented at ART facilities includes a TB component which

facilitates monitoring of TB care provided to HIV patients. The PTS (computer based) will be rolled out to

other sites with implementation of a papaer based system at lower volume care and treatment sites.

EGPAF particpates in the HIVQUAL program whose implementation for the care and treatment program will

address quality of services as it relates to the screening for and management of TB/HIV co-infection in

adults and children.

Per guidance sent by CDC/GAP, this activity represents approximately 1/12 of the funding originally

allocated to EGPAF for this program area under activity 5182.08. Funding is provided to pay for that activity

from February 23 - April 1, 2009.

The Help Expand Anti-Retroviral Therapy for Children and Families Project (project HEART/Mozambique),

is part of a five-country program, that started two years ago and has focused on expanding access to care

and treatment programs in the rural and remote areas of Mozambique, linking care and treatment programs

with existing PMTCT programs.

During the 3rd year of implementation, EGPAF will focus on implementing comprehensive, family-focused

care and treatment programs in 30 sites in 23 districts in 4 provinces of Mozambique:(Moçimboa de Praia,

Montepuez, Mueda, Muidumbe, Nangade, Palma, Pemba,/Cabo Delgado - Angoche, Ilha de Moçambique,

Nacala Velha, Meconta, Mogincual, Mogovolas, Monapo, Mossuril /Nampula - Chibuto, Bilene, Xai Xai,

Mabalane/Gaza - Boane, Marracuene, Moamba, Matutuine/Maputo)

EGPAFs approach is to support the MOH in the implementation of the national HIV/AIDS strategic plan and

initiate and strengthen HIV care and treatment services integrated into existing health services. The first

year focused on increasing human resource capacity to support the program and establish services while

the second year on gradually increasing the number of patients on treatment. The third year of program

implementation will have an increased focus on pediatric treatment, integration and linkages with TB and

HIV programs and other essential services, monitoring and improvement of the quality of services provided

to ensure a more comprehensive package of care for PLHA.

Activities to be implemented relate to 5 main program objectives.

1) Objective 1: Improve and expand care and treatment services for HIV-infected adults including pregnant

women.

To ensure that human capacity to provide quality services are in place, EGPAF will continue supporting the

training of clinical staff (doctors, nurses, tecnicos de medicina), and pharmacy staff, as well as lay

counselors and other staff involved in HIV care and treatment services. This includes pre-service training

of tecnicos de medicina (physician assistants) at the Institute of Health Sciences (Instituto de Sciencias de

Saude) in Nampula province as well as in service and refresher training for all clinical staff. Specific training

includes training on provision of HIV care and ART for pregnant women.

Increased emphasis will be placed and more staff time allocated to regular case reviews and on-going

clinical mentoring of staff in HIV care and treatment. Implementation of supervision tools developed in the

second year will ensure that supervision is standardized and objective.

In addition, EGPAF will collaborate with the Federal University of Rio de Janeiro (FURJ) to support the

mentoring of laboratory staff; one week intensive mentoring at each site will help to improving the quality of

laboratory tests and adherence to SOPs. EGPAF will recruit through a pre-contracting mechanism,

additional health staff including counselors where this is needed.

EGPAF will support the District and Provincial Health Authorities in Gaza, Nampula and Cabo Delgado

provinces to hold HIV and ART coordination meetings with partners and implementing agents to ensure

coordination of activities, exchange experiences between sites and address problems in program

implementation and service quality. Efforts will be made to ensure that case reviews are included as part of

these meetings. EGPAF will provide technical support to facilitate these case reviews.

Objective 2: Improve and expand pediatric care and treatment services for HIV-exposed and infected

infants and children

To further expand access to pediatric treatment and to achieve EGPAFs objective to ensure that 15% of

people on ART are children, EGPAF will support similar activities as for adult treatment but focusing

specifically on pediatric treatment, i.e. (refresher) training of clinical staff at provincial and district levels, on

the job training, supervision and mentoring. Further training on IMCI/HIV/AIDS, early infant diagnosis and

DNA-PCR will be provided.

Through a collaborative relationship with Baylor, EGPAF will provide the opportunity to Mozambican

medical doctors and medical assistants (tecnicos de medicina) for two-week attachments in pediatric HIV

care and treatment, thus receiving much needed hands on training and intensive mentoring. These

attachments with Baylor/BIPAI have been very successful in improving skills to provide pediatric care and

treatment and boosting confidence of clinical staff to initiate infants and children on ART.

To expand access to pediatric treatment in the northern part of the country and increase capacity of

responsible Provincial and District Health Authority (DPS and DDS)staff to manage this program, EGPAF

will second a pediatric HIV/AIDS technical advisor to the DPS in Nampula. This person will work closely with

the pediatric treatment coordinator for the 3 Northern provinces, Dr. Zeferino and support provincial level

pediatric treatment scale up, monitoring and superivion in Nampula, Cabo Delgado and Niassa.

A significant proportion of children on treatment are adolescents. However, the special challenges these

children face in dealing with chronic illness and lifelong treatment, the special needs as they become

sexually active and challenges related to disclosure are currently hardly dealt with in the program. To

address this important gap, EGPAF, in collaboration with the Ministry of Health and other treatment

partners, will work to adapt, test and implement counseling and psychosocial support materials and

activities for adolescents and their families to be implemented within the health facilities and community-

based programs.

Finally EGPAF will work to ensure linkages between existing OVC programs and the care and treatment

program, particularly in Gaza Province. Working through community-based and other organizations with

programs targeting OVC and their families, EGPAF will promote HIV counseling of OVC and ensure their

access to HIV care and treatment programs.

Objective 3: Build capacity of health facilities and community to provide psychosocial, nutritional and

educational support to PLWHA and their family members and to sensitize the population on HIV/AIDS

EGPAF will continue to train lay counselors and increase their role in providing counseling and psychosocial

support for patients enrolled in the care and treatment program. Activities will include developing

subagreements with CBOs to provide community-based education on HIV, PMTCT and treatment literacy;

establish support groups and conducted active tracing of defaulting patients. The number of CBO

subgrantees will increase to ensure that in each district the program is linked with community-based support

activities.

In addition specific activities targetting children and adolescents will be enhanced by providing training,

workshops, continuous technical assistance and the provision of counseling and IEC materials. EGPAF will

organize three-day Children's Camps to enable children to share with peers their experiences and problems

Activity Narrative: related to having to deal with a chronic disease requiring life-long treatment and affecting their lives and

relationships. Children will receive relevant HIV, adherence and positive living education and psychosocial

support through play, discussions, individual and groups counseling.

Objective 4: Build institutional capacity of the MOH to plan, monitor and manage the national ART program

EGPAF will increasingly focus on district level support and technical assistance to DPS to oversee and

manage the care and treatment programs. Involvement of province and district level staff in joint supervision

functions not only as a means to train and mentor site level staff, but also to train MOH supervisors in

formative supervision skills, the use of supervision tools and providing constructive feedback. EGPAF will

provide coordination support and technical assistance to the HIV and ART meetings at provincial and

district level as a forum to ensure coordination of activities, identify and address problems, and provide

technical inputs. EGPAF will also support proper forecasting and management with a focus to the

laboratory and pharmacy departments at provincial and district level.

EGPAF will continue to provide technical assistance at the national level by participation in central level

working groups to develop and update guidelines and training. Our specific focus will be on pediatric care

and treatment (National Pediatric ART Committe) including psychosocial support.

Funding will also be used to implement infrastructure and space improvements (treatment services,

pharmacy, laboratory) at sites where EGPAF plans to implement care and treatment programs.

Objective 5: Improve monitoring and evaluation systems and implement quality assurance mechanisms to

enhance care and treatment services

The implementation of the Patient Tracking system will be expanded to all supported sites; this will be an

important tool to monitor program progress and quality. EGPAF will continue working to support and expand

implementation of QI tools and processes (HIVQual) in the supported sites, ensuring that quality monitoring

becomes routine and staff is capacitated to assess program quality and adequately address problems as

well as document lessons learned. In addition, through district and provincial level support, EGPAF will

contribute to quality improvement within the ditrict that EGPAF supports treatment services by particpating

in supervision and program monitoring jointly with the MOH staff.