Continuing Activity - Replacement Narrative:

The University of Washington International Training and Education Center on HIV (I-TECH) has been

committed to providing technical assistance to the Ministry of Health in support of their ambitious HIV

program expansion plans, particularly in the areas of pre- and in-service training curricula and design;

training of teachers, facilitators and mentors for course rollout; and outcome and impact evaluations.

In FY07, I-TECH partnered with Columbia University International Center for AIDS Care and Treatment

Program (ICAP) in developing a PMTCT nurse-mentors curriculum and training, and designing rotational

mentoring programs for model centers in Maputo and Nampula. With FY07 budget allocations, I-TECH will

complete a review of linkages between community- and facility-based PMTCT activities, including

mobilization of community health agents (traditional birth attendants, peer educators, PLWH, etc.), with an

additional focus on PMTCT mother support groups. Community-facility linkages and mother support group

activities include review of national and regional materials, development of revised materials (standardized

guides and other tools), technical support for preparing a pilot of revised materials in selected sites, and

draft a framework for expansion of activities.

I-TECH's objectives in 2008 are as follows: (1) Strengthen PMTCT clinical mentoring programs, adapt the

model to clinic-based mentoring at district level, and expand technical support for clinical mentoring

activities to additional USG partners; (2) Strengthen community-based PMTCT initiatives through the

provision of technical assistance to MOH and implementing partners, including the establishment of best

practices, the development of a standardized package of tools and job aids, and the refining of a strategy

for comprehensive roll-out to new sites country-wide; (3) Strengthen mother support group activities in

PMTCT settings, in coordination with USG partners to be determined. Specifically, findings from FY07

activities in reviewing and developing models for support will be leveraged to implement and expand

appropriate models; (4) Provide technical assistance to MOH and NGO partners to ensure adequate and

appropriate integration of PMTCT information into pre-service curricula; (5) Provide technical assistance to

MOH and NGO partners for revision of the in-service training manual used for training PMTCT service

providers, which was developed in 2004 and disseminated in 2005; and (6) Develop prioritized job aids in

coordination with USG and partners.

1. Strengthen PMTCT clinical mentoring programs

The continuation of this activity in 2008 would support MOH in the roll out of the PMTCT clinical mentoring

package in selected sites, as well as providing technical assistance for adaptation of the mentoring package

to accommodate site-based mentoring and supervision at the district level.

Activity 1.1: Provide on-going technical assistance to ICAP, as appropriate, to strengthen the design and

impact of the mentoring program in the model centers, including the development of a plan for the clinical

staff of other partner organizations to participate in mentoring rotations. I-TECH will also collaborate with

other implementing partners to adapt the mentoring model to local contexts. 20 nurse-mentors will be

trained, in addition to 6 trainers from the Elizabeth Glaser Pediatric AIDS Foundation. I-TECH will provide

technical assistance in the adaptation of the mentor curriculum, assist in the training of the mentors, and

assist in the adaptation of evaluation tools.

Activity 1.2: I-TECH will work with implementing organizations to conduct training for 30 district-level

PMTCT supervisors with the aim of fortifying their PMTCT supervisory skills, including the incorporation of

mentoring techniques into their visits. This activity would provide additional on-site support for the nurses

who rotated through the model centers, as well as those who received on-site mentoring.

Activity 1.3: As the mentoring programs evolve, it is likely that the need for new or improved job aids will

become apparent for both the mentors and the newly trained PMTCT providers. I-TECH will develop

prioritized job aids in support of the new information and skills, as recommended by MOH and partner

organizations.

2. Strengthen community-based PMTCT training and mother support activities

Community-based positive mothers / mother-to-mother support groups are recognized as important

instruments for increasing use and adherence to PMTCT services, encouraging early treatment access for

mother/infant pairs, improving linkages between community and clinic based services, tracking defaulters,

and supporting positive mothers and mothers-to-be, both psychosocially and for purposes of medical

adherence including ARV regimens, longitudinal follow-up, facility delivery, and post-partum care for mother

and child. The groups also assist women to resolve issues around infant feeding and provide needed

emotional support for combating stigma in their homes and communities.

The activities under this objective build on I-TECH's ongoing work to review materials, develop a

framework, and pilot materials for improving linkages between facility-based and community-based PMTCT

activities, as well as improving mother support groups that have been poorly organized and insufficiently

equipped to guide activities.

Activity 2.1: I-TECH will provide technical assistance to MOH and implementing partners to establish best

practices and refine the implementing framework developed in 2007 in order to ensure standardized rollout

of high quality support packages. In collaboration with MOH, I-TECH will coordinate and sponsor a

workshop analyzing best practices and lessons learned in the provision of support to HIV positive mothers

and pregnant women. I-TECH will work with the partners and MOH to further develop the framework

developed with FY07 funding, develop guidelines for establishing community based support services, and

develop a model and strategy for rolling out quality positive mother / mother-to-mother support programs to

new sites. Of critical importance is the goal of developing a strong linkage between clinic-based services

and community-based support in order to improve use and access to both PMTCT and treatment services

for mother/infant pairs.

Activity 2.2: As the best practices, support package contents, and the framework evolve, I-TECH will

develop standardized job aids and tools for piloting by the implementing partners with community support

groups.

Activity Narrative:

Activity 2.3: During the roll-out, I-TECH will provide technical assistance to MOH and partners to ensure that

the model is achieving results. Activities may include a small targeted evaluation, and include

recommendations for further adaptation of materials and trainings methodologies.

3. Strengthen PMTCT integration into pre-service curricula

Since 2006, I-TECH has been committed to supporting MOH in their efforts to develop high quality and

standardized pre and in-service training curricula. I-TECH's focus to date has been on the provision of

training of pre-service teaching faculty, and the development of pre and in-service curricula for Tecnicos de

Medicina (TdM) and Maternal and Child Health (MCH) nurses. I-TECH placed a specialist within the MOH

Training Department in 2007 to provide training to MOH staff in curricula review.

I-TECH will work closely with MOH to jointly review and analyze existing and new pre-service curricula for

different health cadres (nurses, physicians, TdM) and make recommendations for strengthening the PMTCT

components, as appropriate.

4. Provide technical assistance to MOH and NGO partners for revision of the in-service training manual

used for training PMTCT service providers

The PMTCT in-service training manual was disseminated by MOH in 2005, based on design and

development in 2004. Since that time, significant revisions in international and national PMTCT policy and

practice have been made, and updates to the training manual have been provided in periodic memos from

MOH. Currently the training manual contains outdated and partial information for PMTCT services, and

there is no single resource document or training manual available to meet the needs to PMTCT service

providers in Mozambique. This activity will build from FY07 efforts by USG partners to develop a CT section

for the PMTCT manual.

I-TECH will provide support to MOH and additional NGO partners in the finalization of the PMTCT in-service

curriculum.

5. I-TECH will integrate PMTCT curricula review activities into its ongoing capacity building program for

Ministry staff.

The combination of described activities will ensure that the relevant issues are addressed at multiple levels,

from the technical training and support for the clinicians providing medical services for pregnant women and

mother/infant pairs, to the strengthening of community groups and agents encouraging adherence to

medical advice and treatment.

The activities are designed to strengthen the linkages between local health services and community-support

interventions, ensuring the flow of correct information to women and providing them with a supportive

environment to combat stigma, make healthy choices, and improve the use of PMTCT services from ANC to

follow up of both mother and infant.

One of the key objectives of the Ministry of Health (MOH) Strategic Plan to Combat STIs, HIV, and AIDS for

2004-2008 is to reduce the impact of HIV/AIDS on health care workers. As a primary means of prevention,

behaviors associated with HIV transmission must be addressed, especially those sexual behaviors that put

individuals at greatest risk of infection. To date, there are few existing activities that support health workers

in dealing with HIV/AIDS risk behaviors and that address issues of abstinence, delay of sexual debut, and

faithfulness to one's partners. The focus of this activity is to promote these behaviors and strengthening the

norms that support them. FY 08 funds are being requested to support the University of Washington through

its partner Global Health Communications (GHC), a partner with experience in the successful development

and evaluation of Behavior Change Communication (BCC) interventions in the African context. Activities

that this partner will support in Mozambique include:

(a) Building on the results of quantitative and qualitative assessments conducted with funding support from

FY06/07, to identify informational and educational gaps that might be quickly and efficiently addressed by

adapting existing A/B materials. Most of these may be print-based, but there may be radio PSAs that can be

identified. Some of these materials may be circulating in parts of Mozambique, but the partner will be

encouraged to identify materials from other countries in the region that may be translated into Portuguese

and other local idioms as well as material from other lusophone countries (e.g., Angola, Brazil, Cabo Verde,

Guinea Bissau) that may be modified to address the Mozambican context;

(b) Creating new A/B informational/educational materials where existing regional or lusophone materials do

not exist;

(c) Developing and piloting behavioral and educational interventions focused on issues of abstinence and

faithfulness;

(d) Evaluating pilot interventions to assess their personal life effectiveness, and;

(e) Training and on-the-job mentoring of MOH staff from human resources, training, health education

departments, and HIV/AIDS/STI program in evaluation of A/B behavior change and educational

interventions.

This activity sheet describes support for two components:

The first component is proposed for funding ($100,000) for the following activities: Health workers in every

country play an important role. In developing countries such as Mozambique, this role takes on an even

greater magnitude as this segment of the population is critical to the entire nation's fight against HIV/AIDS.

For this reason the Mozambican MoH has declared that reducing the impact of HIV/AIDS among health

workers (including support and administrative staff in addition to students currently enrolled in health

institutes) is one of their highest priorities. In addition to A/B-related information, post-exposure prophylaxis

(PEP) and condom use behaviors are very central to prevention within this population. Condom use is an

important tool in prevention in a situation such as Mozambique where health workers are frequently rotated

to positions away from their homes. FY 08 funds are being requested to support the University of

Washington and its partner Global Health Communications (GHC) with experience in the successful

development and evaluation of Behavior Change Communication (BCC) interventions in the African context.

Activities that this partner will support in Mozambique include:

(a) Using the findings of quantitative and qualitative studies to identify informational and educational gaps

that might be quickly and efficiently addressed by identifying existing PEP and condom-use promotional and

educational materials. Many of these may be print-based, but there may be radio PSAs that can be

identified and adapted to the Mozambican context. The partner will be encouraged to identify materials

from other countries in the region that may be translated into Portuguese and other local idioms as well as

materials from other lusophone countries (e.g., Angola, Brazil, Cabo Verde, Guinea Bissau) that may be

modified to address the Mozambican context;

(b) Creating new PEP, condom marketing, and other prevention materials where existing regional or

lusophone materials do not exist;

(c) Designing and facilitating a local stakeholder meeting at which study findings related to issues of

condom use, PEP and other prevention measures will be disseminated. Attendees will be members of the

MoH working group, and NGO/CBO communities working in the area of HIV prevention. Participants will

develop recommendations based on the findings, and identify opportunities for collaboration among

stakeholders;

(d) Developing and piloting C&OP behavioral and educational interventions (including training local

implementing partners), and;

(f) Assisting the MoH in the evaluation of C&OP pilot interventions to assess their effectiveness both in the

workplace as well as in workers' personal lives.

The second component is proposed for funding ($150,000) is: Mozambique's International Rapid

Assessment Response and Evaluation (I-RARE) has been designed to better understand, assess, and

make recommendations for how to respond to rapidly changing sexual risk and drug using patterns that

increase vulnerability to HIV infection among sex workers and drug users in three cities in Mozambique,

Maputo, Beira, and Nacala Porto, Mozambique. The assessment explores the presence of drug and alcohol

use and high risk sexual behavior in sex workers and injection (IDU) and non-injection drug users (NIDU),

including drug use among sex workers, and sexual risk behavior among drug users. The potential for

overlapping risk behaviors, sexual mixing among these populations, and bridging to the general population

exists, and may be contributing to the rapid spread of HIV in the country. The possibility of increased HIV

risk creates the need for targeted prevention programming and improved access to services for these

populations. I-RARE supported through funding from FY06/07 will provide recommendations for introducing

and scaling up sustainable interventions designed to reach sex workers and drug users. Findings will be

analyzed and used in FY08 to develop recommendations for targeted approaches and feasible public health

interventions in these populations. FY08 funds are being requested to support the development,

implementation, and evaluation of prevention activities relating to at risk populations. Activities will include:

(a) Developing and piloting outreach activities for sex workers and drug users, and enhancing the capacity

of NGOs to introduce and or strengthen outreach to sex workers (this may entail adapting processes and

procedures developed in South Africa following the rapid assessment and designed for their FY07 COP

submission).

(d) Facilitating a workshop to adapt an outreach manual focusing on condom promotion and HIV prevention

among sex workers and drug users, with the NGOs/CBOs to ensure that outreach activities are based on

data from the rapid assessment and best practices. The training workshop will include components of the

community-based outreach such as risk reduction counseling. The NGOs will then in turn train potential

outreach workers both from their organizations and other members of local consortia to access hidden

populations and provide risk reduction strategies related to injecting and non-injecting drug use and sexual

practices.

(e) Developing venue-based interventions that deliver HIV prevention information, in particular information,

education, and/or skills based training on sexual risk reduction, especially as related to HIV risk in the

context of drinking alcohol. Distribute condoms in formal and informal drinking venues; refer patrons to

alcohol treatment and/or social services as appropriate. Refer patrons to HIV/AIDS care and treatment, and

provide information on prevention for positives and, specifically, information on the relationship between

alcohol and adherence to ARVs;

(f) Identifying monitoring and evaluation forms previously used in countries such as Vietnam, Thailand and

Kenya will be adapted for use in Mozambique.; and

(g) Facilitating on-going technical assistance in collaboration with to CDC to provide training on how to

monitor and evaluate outreach activities.

According to a WHO working paper (Key Elements in HIV/AIDS Care and Support,2002) major barriers to

implementing the key components of palliative care and treatment often stem from systemic, organizational

or policy shortcomings. These include: Low priority of HIV care within national health budgets; lack of

investments in building infrastructure; insufficient remuneration and support for care professionals; loss of

staff due to high HIV-related mortality and morbidity; shortages of relevant HIV information and HIV training

opportunities; irregular and inadequate supplies of drugs, reagents, and equipment; and lack of essential

drug lists and drug procurement not adapted to needs of people with HIV/AIDS.

USG policy suggests that addressing the needs of the infected-including treatment of sexually transmitted

infections and opportunistic infections-should be a fully integrated component in any care system that

emphasizes patients' quality of life by ensuring symptom control and supportive therapies combined, when

possible, with disease-specific therapies. (Foley, Aulino, & Stjernsward, 2003).

Yet there are many barriers to providing sex workers and drug users with needed diagnosis and treatment

of STIs and other opportunistic infections. These barriers range from serious financial limitations of both the

government and of families to stigma and social barriers associated with HIV/AIDS and the behaviors of

these populations. Since treating STIs and opportunistic infections are a crucial component of every

comprehensive AIDS strategy, results from a qualitative assessment (I-RARE) supported by USG FY06/07

funds, will be used to determine how at-risk or infected sex workers and drug users access to services

providing HIV and STI screening and treatment can be improved.

FY08 funds are being requested to support the University of Washington and its partner Global Health

Communications (GHC) to work with local civil and governmental stakeholders to consider Mozambique's

capacity to provide STI and HIV screening, early diagnosis and treatment to sex workers and drug users.

Activities proposed for support in Mozambique include:

(a) Directing the analysis of I-RARE data to address STI and OI needs among sex workers and drug users;

(b) Supplementing I-RARE findings with other government and NGO/CBO information about referral to, and

access and uptake of, screening and treatment services within Mozambique's sex worker and drug using

populations;

(c) Coordinating a review of successful practices in other countries in the region that have dealt with the

particular challenges specific to

hard-to-reach populations such as sex workers and drug users in creating and sustaining access to STI and

OI testing and treatment; and

(d) Organizing and facilitating a workshop in which Ministry of Health (MOH), other Mozambican

stakeholders and technical assistance from USG and elsewhere develop recommendations, guidance, and

activities that promote the referral, screening and treatment of STIs and OI among sex workers and drug

users.

JHPIEGO: Sub grant to GHC: ; Support for design and piloting of interventions to increase and improve

HIV and STI screening and services for vulnerable populations ($75,000)

The first component is proposed for funding ($50,000) for the following activities: Support development of

materials and interventions targeting health workers to increase Counseling and Testing (CT) uptake and

partners counseling among health workers. One of the key objectives of the Ministry of Health (MoH)

Strategic Plan to Combat STIs, HIV, and AIDS is to reduce the impact of HIV/AIDS on health care workers.

One area that the MoH has singled out for special attention is that of counseling and testing (CT).

Considered a "gateway" behavior, CT and determination of serostatus is prerequisite to many other

behavioral efforts. Mozambique currently offers free counseling and testing services available at 334

locales throughout the country. Although it is presently unknown how many health workers themselves have

undergone testing and counseling, analysis of data gathered as part of a quantitative survey in 2007 will

provide a much clearer picture. According to anecdotal information, the confidentiality of information and

fears of discrimination within one's work environment are concerns of health care workers when considering

whether to access counseling and testing services. These concerns represent barriers to accessing

services, seeking accurate information and examining the risk associated with their personal and

professional behaviors. It is unlikely that HIV risk among health workers can be overcome without

significant changes to attitudes and behaviors. FY06 USG funding has been supporting the development of

an assessment of health workers' current behaviors, attitudes, norms, and knowledge around primary

prevention of HIV and uptake of counseling and testing services, to determine how to better design

interventions promoting structured opportunities for educating and assisting health workers to better deal

with HIV/AIDS in their work and home environment. While the assessments are proceeding, the MoH

human resources, training, health education departments and HIV/AIDS program staff have expressed their

desire and requested assistance for urgent start-up of interventions that will target and support health

workers, facilitating behavior change and improved primary prevention, as well as increased CT and anti-

retroviral treatment (ART) up-take among health workers and their partners.

FY08 funds will be used to support the University of Washington and its partner Global Health

Communications (GHC) to assist the MOH team to identify appropriate methods for facilitating behavior

change among health workers and their partners, develop an action plan for conducting appropriate

interventions to support health workers in reducing risk behaviors, pilot and design interventions, explore

use of community radio to reach rural workers and create an environment conducive and supportive to

changes of health worker behaviors and attitudes. In addition, interventions to reduce barriers to use of CT

and ART services among health workers such as for example mobile units for counseling and testing will be

explored and piloted. Finally, the technical assistance provider will work with teachers and students at MoH

training institutions to design and pilot interventions at pre-service training institutions where young doctors,

technicians and nurses are currently undergoing training. Specifically, activities the partner will support in

Mozambique include:

a) Collaborating in the design and conduct of a "structural review" of workplace counseling and testing

programs in Botswana and Tanzania and possibly other countries in the region that will analyze activities

currently undertaken in those countries with an eye towards how successful elements can be recombined

and applied to the Mozambican context;

(b) Providing technical assistance to MoH in applying quantitative and qualitative assessment findings to the

task of designing behavioral and informational interventions with the aim of increasing CT uptake;

(c) Assisting in the development of behavioral and educational interventions focused on issues CT;

(d) Training local implementing partners and stakeholder in implementing (and subsequently piloting) CT

interventions, and;

(e) Assisting MoH in evaluating CT pilot interventions.

The second component ($75,000) is proposed to support the following activities: Sex work in Mozambique

is driven largely by the lack of employment opportunities, and facilitated by the demand of migrant and

mobile laborers, as well as members of the general population (World Vision, 2005). Young women are at

particular risk; the age of sexual debut in Mozambique is low (15.4 years) and the mean age for women

entering sex work is 17.8, with an age range of 9-28 years (World Vision 2005). Younger women are also at

increased risk for STI and HIV acquisition because of biological changes in the cervix that take place

between puberty and adulthood (Berman and Hein 1999). While the extent of drug use among sex workers

is not known, a 2004 survey reported that 13% (15/111) of female sex workers used drugs, including

cocaine, up from 7.4% in 2002 (World Vision 2005). Another study has documented drug dealers as

frequent clients of sex workers in the Maputo corridor area (Wilson 2001). These factors indicate that the

potential for increasing drug use among sex workers and mixing of sex worker and drug using populations

exists, and may serve to spread HIV further into the general population. In response to this situation,

Mozambique's International Rapid Assessment Response and Evaluation (I-RARE), supported through

USG funding from FY06/07, has been designed to better understand, assess, and make recommendations

for how to respond to rapidly changing sexual risk and drug using patterns that increase vulnerability to HIV

infection among sex workers and drug users in three cities in Mozambique, Maputo, Beira, and Nacala

Porto, Mozambique. One of the foci of this assessment is the identification and description of the range of

available counseling and testing (CT) services for sex workers and drug users as well as the understanding

of the personal, social, and environmental barriers that sex workers and drug users perceive as inhibiting

access to CT services. Service providers' perspectives on CT availability and access are also important,

and this activity is aimed at assisting them in making CT services more desirable and convenient. FY08

funds are being requested to support the University of Washington/GHC to undertake the development,

implementation, and evaluation of prevention activities relating to at risk populations. Activities that this

partner will support in Mozambique include:

(a) Supporting local partner in developing outreach programs and possibly bar and other drinking venues

where alcohol consumption and sexual mixing may present opportunities for targeted CT interventions. In

addition to CT, such interventions may deliver a range of informational and behavioral content. This activity

may also include reviewing models of CT processes and procedures based on the South African rapid

assessment experience;

(b) Training NGO/CBO and government agencies to pilot outreach and intervention activities that connect

sex worker and drug/alcohol-using population to CT; and

(c) Coordinating local stakeholders and CDC technical assistance as they develop monitoring and

evaluation protocols and formats for CT that are consonant with best practices in Africa and elsewhere.

Summary:

I-TECH has been committed to providing technical assistance to the Ministry of Health in support of their

ambitious HIV program expansion plans. ($1,686,000)

In 2008, in partnership with MISAU, I-TECH will establish a training center in one of the MISAU / PEPFAR

focal provinces (Sofala, Zambezia or Nampula, TBD), linked with one of the Ministry's pre-service training

centers. The new training center will offer a range of training support services to the Mozambique and will

establish a link between pre- and in-service trainings.

In COP 08, I-TECH will continue its support to MISAU through the provision of technical assistance and

training to conduct a number of critical HIV-related initiatives, including the rollout of a Pediatric ART course,

country-wide; validation research related to opportunistic infections; and the development of a pre-service

curriculum for TdM, including, for the first time, HIV-related topics in the course.

I-TECH's COP 08 objectives are as follows:

Objective 1: Provide training and support to mid-level health workers in the provision of ART and PMTCT

services

Objective 2: Increase the capacity of mid-level practitioners to provide pediatric ART services

Objective 3: Provide support for OI validation research

Objective 4: Provide technical support to MISAU in the development of the TdM pre-service curriculum

Objective 1: Provide training and support to mid-level health workers in the provision of ART and PMTCT

services. In 08, I-TECH will establish a training center in one of the priority provinces (Sofala, Zambezia or

Nampula) in order to better support a range of training services in the region.

Activity 1.1. In a selected province, work with the training institute, provincial training unit, NGO partners,

clinics and hospitals to establish a training center with a regional focus, which would offer a range of training

services, for example, refresher courses for clinicians; trainings for trainers and mentors on a range of HIV-

related topics; and workshops on curriculum development and training methodology. The center would link

pre-service and in-service activities, and didactic and hands-on training.

Activity 1.2. Provide individualized capacity building assistance to training partners in assessing, planning,

organizing, implementing and evaluating HIV-related training activities through assistance from specialists

based at the center.

Objective 2: Increase the capacity of mid-level practitioners to provide pediatric ART services. In 2008, I-

TECH will assist MISAU in rolling out the pediatric ART in-service course for mid-level providers country-

wide.

Activity 2.1. Revise the pediatric ART curriculum and training materials based on the pilot course evaluation.

Activity 2.2. Plan, coordinate and facilitate the national roll-out of the Pediatric ART training: conduct two

national Training of Facilitators courses for MISAU trainers (2 facilitators per province); facilitate one training

per province (x 11 provinces) with MISAU trainers. Conduct training evaluations; adapt materials as

appropriate.

Objective 3: Provide support for OI validation research through the development of a validation proposal,

and pilot of the OI component of the Basic Course on HIV.

Activity 3.1. Serve a supportive role (TBD) in the implementation of 07 proposal for validation research

related to the opportunistic infection (OI) guidelines.

Objective 4: Provide technical support to MISAU in the development of the TdM pre-service curriculum. In

2008, I-TECH will provide technical assistance to MISAU to support them in the management of the phased

development of the TdM pre-service curriculum, envisioned to be a multi-year project.

Activity 1: I-TECH will assist MISAU's Training Unit and Technical Working Group to lead and manage a

phased approach to expanding the course outline by developing the content of the TdM pre-service course,

first prioritizing prerequisites needed for HIV and related courses. I-TECH will collaborate and/or

subcontract with international or regional training institutions to develop the course content. The amount of

course material able to be developed will depend on depth/complexity of a standard module (TBD).

Funding may include related costs of the working group.

.

This activity sheet also proposes funding ($50,000) for the following activities: The MoH currently provides

its workers with free ARV treatment and, according to the MoH, as of May, 2007 ARVs were available in

146 sites covering all 128 districts of Mozambique (and all ARV service sites are integrated with counseling

and testing services). As with accessing other HIV-related services, however, it is unclear that among HIV-

infected and eligible health workers uptake of, and adherence to, ARVs is at an optimal level and what

could be done to improve this situation. According to anecdotal information, concerns around confidentiality

of information and fears of discrimination within one's work environment are concerns of health care

workers when considering whether to access treatment. These concerns present significant barriers for

health workers to accessing ARVs but it is unlikely that increased access to ARV services can occur without

both a clearer understanding of service-seeking behavior and subsequent efforts to address informational

and behavioral gaps. This understanding will be based on the quantitative and the qualitative health

workers studies currently being undertaken and supported through FY06/07 funds. FY08 funds are being

requested to support the University of Washington and its partner Global Health Communications (GHC)

with experience in the successful development and evaluation of Behavior Change Communication (BCC)

interventions in the African context. Activities that this partner will support in Mozambique include:

(a) Providing technical assistance to MoH in applying quantitative and qualitative assessments to the task of

BCC intervention design with the goals of improving access to ARVs, facilitating uptake of ARV services,

and promoting adherence to ARV regimes;(b) Guiding the development and piloting behavioral and

educational interventions focused on issues of ARV access and adherence; and (c) Assisting MoH in

evaluating pilot interventions relating to ARV access and adherence.

Activity Narrative:

(b) Guiding the development and piloting behavioral and educational interventions focused on issues of

ARV access and adherence; and

(c) Assisting MoH in evaluating pilot interventions relating to ARV access and adherence

Continuing activity:

FY07 COP activity number linked to PHE project : 8802

Title: Targeted Evaluation of ARV Training Course in Mozambique.

Time and money summary: this is a 07 COP activity, expected to be complete in early 2008; original budget

request in 07 COP was $88,000; we now estimate that $100,000 will be expended on the actual evaluation.

No funds are requested in 08 COP for the evaluation, but rather follow-on activities, to include the revision

of the TARV course (see below).

Local Co-investigator: several individuals at the MOH's National Department of Medical Assistance are

involved in this project, headed by Dr. Americo Assan

Project description: CDC and the Mozambican Ministry of Health (MoH) supported a new course to teach

Mozambican mid-level health practicioners (tecnicos de medicina) to prescribe and manage active

anetiretorviral therapy (ART) for HIV patients. The two-week course includes classroom and practical

components. The primary purpose of the evaluation in 2007 is to assess to what extent course graduates

adhere to the guidelines taught in the course once they return to their work sites. Secondary questions are:

Do course guidelines address the clinical questions most commonly encountered by the graduates? Are

the guidelines learned by the graduates consistent with other guidelines currently in force in their work

sites? Are the course graduates' working conditions conducive to guideline adherence? The anticipated

outcome is a series of recommendations for revision or updating of the course curriculum, clinical

guidelines, and/or post-course support and supervision systems. The study design will incorporate

structured observation of course graduates as they attend patients in their usual work sites. The study will

use two instruments, one for HIV-infected patients not yet on HAART and one for patients already on

HAART. The structured observations will be supplemented by brief semi-structured interviews with course

graduates and site supervisors. A convenience sample of course graduates will be generated using training

lists and by consulting with provincial and local health authorities where the course graduates work. We will

aim for a sample of 40-50 graduates and will plan to observe one new HIV patient and one patient already

on HAART for each graduate.

Status of study/progress to date: Protocol was initially presented to MOH in November 2006 and approved

by MOH bioethics committee in early July 2007. CDC Atlanta is in the process of reviewing protocol. The

evaluation scheduled to take place in October-November 2007. Data analysis and reporting should be

completed by January 2008. The follow-on activity to this evaluation is the revision of the ARV course based

on the evaluation results, and the design and implementation of two training of trainer courses to roll it out.

The revision of the course was originally included in COP 07, but will likely be carried into COP08 due to

time constraints.

Lessons Learned: to be included in final report

Information Dissemination Plan: The primary audience for the evaluation results is comprised of the

Mozambican Ministry of Health and the institutional partners currently assisting the Ministry in

implementation of public-sector AIDS-related training and patient-care programs. This audience is internal.

However, should the evaluation yield results that might be of interest to other Ministries of Health or

PEPFAR implementers, we would consider presenting them orally (at professional meetings) and/or in

writing (through peer-reviewed scientific journals), depending on the specific nature of the findings.

Planned FY08 activities: Build the capacity of MOH staff and provide them with technical guidance to adapt

and relaunch the TARV course based on the results of the evaluation. The course will be principally used as

in-service refresher trainings for TdMs, their supervisors, and other mid-level practitioners. Conduct 2 TOTs

for implementing agencies to roll out the course.

Budget Justification for FY08 monies (please use US dollars):

Salaries/fringe benefits: $30,000

Equipment: $0

Supplies: $5,000

Travel: $18,000

Other: $12,000

Total: $65,000.

Deliverables/benchmarks:

• Final report on ARV Training Course in Mozambique

• Discussion around results and implications for national policy and procedures

August08 Reprogramming: Funding increase $140K. Ministry of Health has indicated that they are not

interested in developing this type of training facility as they are seeking investmetn in longer term training of

health care workers versus short term courses. Use of technology for training health care workers and for

support/retention of existing health care workers are being considered. A memorandum of understanding

that includes introuction of distance learning was developed with FIOCRUZ and the Ministry of Health.

What remains unknown is the current state of technology for education within Mozambique, both in

infrastructure and human capacity. This reprogrammed money would be used to inventory distance

learning, assess capacity of existing training institutions, assess attitudes toward use of technology for

health care workers, and recommend potential uses.

I-TECH has been committed to providing technical assistance to the Ministry of Health in support of their

ambitious HIV program expansion plans. In FY06 and 07, I-TECH focused on assisting MISAU to develop

and standardize its pre-service and in-service courses in order to improve the knowledge and skills of the

clinicians serving in the National Health Service. To that end, I-TECH assisted in the development of an in-

service ART ("TARV") course for técnicos de medicina (TdM). I-TECH trained the course facilitators,

evaluated the training and modified the course content, and performed clinical observations of a sample of

TdM who received the in-service ART course. I-TECH also developed and piloted the first pre-service HIV

training materials for TdM, covering the topics of AIDS, TB, OI, malaria and malnutrition in order to better

prepare them for diagnosing and managing HIV-infected cases. In tandem, I-TECH began a series of

trainings for TdM pre-service teachers to assist them in delivering high quality education to their students,

as well as working with implementing partners, supporting them in a range of in-service mentoring and

training courses.

In 08, I-TECH proposes to build on the previous year's work by providing capacity building assistance to

MISAU and implementing partners to develop and roll out effective and consistent pre-service and in-

service training programs. I-TECH's COP 08 objectives are as follows:

Objective 1: Strengthen capacity of the faculty in the pre-service training institutions to deliver high-quality

training in HIV/AIDS and related topics to health workers.

Objective 2: Strengthen the capacity of health care workers to deliver quality HIV care and treatment

through in-service training and mentoring programs.

Objective 3: Provide technical assistance to MISAU and its training institutions to improve and standardize

their national training systems and materials

Activities and Expected Results:

Objective 1: Strengthen capacity of the faculty in the pre-service training institutions to deliver high-quality

training in HIV/AIDS and related topics to health workers.

In 2007, I-TECH conducted initial training of the faculty of the Institutes of Health Sciences who teach TdM

pre-service courses. The results of the trainings indicated that the faculty of the different institutes required

different levels and types of support, and that the teacher skills, knowledge and attitudes varied

considerably. For this reason, I-TECH requests the flexibility in 08 to develop a series of trainings for the

faculty of the training institutes which responds to particular institutional needs, which would be jointly

defined, and which ensures a minimum skill and knowledge level of all TdM teachers.

Activity 1.1: Work closely with the faculty of the 7 institutes that train TdM to develop comprehensive

capacity building programs based on the institutes' individual needs, so that the faculty are skilled in

delivering the current TdM Plano Analitico and new curriculum (including ATOMM) as it evolves over the

next few years. Training would include participatory teaching methodologies, developing student practica,

and the introduction of a variety of innovative and effective methodologies to respond to the operational

realities of the TdM (as documented in the TdM clinical observation study for the TARV course). May

include financing for covering costs associated with conducting courses outside of normal academic year.

Objective 2: Strengthen the capacity of health care workers to deliver quality HIV care and treatment

through in-service training and mentoring programs.

In 2007, I-TECH updated the ART course for in-service TdM based on a country-wide clinical observation,

and developed a mentoring program to ensure on-site support. I-TECH assisted ICAP in developing an in-

service nurse-mentoring program for those involved in PMTCT. I-TECH also developed and piloted the OI

section of the in-service training course "Basic Course on HIV". Based on the best practices of these 07

activities, I-TECH will continue to expand and strengthen the provision of in-service training and mentoring

programs for clinicians in 2008.

Activity 2.1: Subsequent to the 07 activity to revise and pilot the OI portion of the in-service course, "Basic

Course on HIV", adapt the course for 3 cadres of health workers (TdM, medical assistants and referral

nurses), and conduct 3 TOT for implementing agencies to roll it out.

Activity 2.3: Conduct refresher courses for all cadres of health workers, as appropriate, particularly in the

instance of the development of new guidelines, new practices, or for addressing general concerns relating

to clinical practices as identified by MISAU. Estimated 2 five-day trainings in each of the three focal

provinces (Sofala, Zambezia & Nampula) on various HIV-related topics.

Activity 2.4: Building on an 07 clinical mentoring pilot for TdM, provide technical assistance to partner

organizations for designing and developing mentoring of mentors program (MOM) in two sites.

Objective 3: Provide technical assistance to MISAU and its training institutions to improve and standardize

their national training systems and materials.

Building the capacity of MISAU is critical to the sustainability of HIV-related training and support activities,

and is the most effective way in the long term of ensuring standardized, high quality health care services. It

is MISAU's mandate to lead the country in the medical response to HIV, and to ensure that its institutes, as

Activity Narrative: well as all the implementing partners, train health care workers using the same guidelines, standards and

operating principles.

To assist MISAU, I-TECH placed a curriculum specialist in the MISAU training department part time in 07,

whose main function was to train, mentor and technically support MISAU staff in their efforts to develop

standardized training curricula, materials, methodologies, implementation techniques, and evaluations,

whereby ensuring consistent and effective pre-service and in-service trainings. In 08, I-TECH will continue

to provide hands-on assistance to MISAU.

Activity 3.1: Mentor the Training Unit staff in strengthening their skills for developing guidelines, templates,

principles and standards for curriculum development and training design to ensure consistent and effective

programs across their training institutes.

Activity 3.2: Act as lead agency and provide technical assistance to the trainers at MISAU Central Training

Unit, the DPS Training Units, and partner organizations in the support of the roll out of various training

programs. This includes the dissemination of standardized curriculum guidelines and templates, as well as

standards for training methodology, implementation, and evaluations.

Deliverables/benchmarks:

• Pre-service faculty development in HIV/AIDS and related topics

• Standardized template for pre-service educational modules

• In-service training and mentoring programs

• Materials adaptation

• Training of trainers

• Technical assistance to MOH and its training institutions

• Curriculum specialist working part time at the MOH to mentor training department staff

• Establish lead training agency that will provide technical assistance to the trainers at MOH, DPS Training

Units and partner organizations in the roll-out of various training programs