This is a continuing activity under COP08. HAI's will continue to foster linkages with the Child at Risk

Consult (CCR) as well as treatment services. The referral system between PMTCT, treatment services,

and the CCR will be the first line of approach, which has broad Governmental support. However, the

program will also explore manners to reinforce testing and treatment linkages with vaccination campaigns,

well baby visits, and weighing stations.

Using COP 07 plus up funds, PSI will map existing PEPFAR and non-PEPFAR partner interventions in

PMTCT and overlay this map with mosquito net distribution data from the President's Malaria Initiative (PMI)

and other donors and partners (Malaria Consortium, Government of Japan, the Global Fund, etc). The

assessment will be a gaps analysis of where present activities under PEPFAR, PMI, and other partners are

taking place and where, geographically and programmatically speaking, more concerted and coordinated

action is needed by the consortia of actors. PEPFAR and PMI will leverage each others' resources with

PMI providing the vast amount of LLINs for distribution to pregnant and lactating mothers. However,

PEPFAR, through PSI, will provide a buffer stock of LLIN for PMTCT partners to ensure that all pregnant

women receive a mosquito net. Finally, PMTCT partners will be crucial partners to PMI for the routine

integration of at least two doses (of the recommended three) of SP.

The program will also partner with WFP to support the nutritional needs of the most vulnerable PMTCT

clients through provision of short-term emergency food support. Please refer to the activity sheet for WFP

for funding levels and targets.

The FY2007 narrative below has not been updated.

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.

Reprogramming August08: HAI will no longer undertake this PHE.

This is a continuing PHE activity under COP08, linked to COP07 activity # 5352.07.

Title: A Targeted Evaluation to Improve Access to Nevirapine (NVP) and Social Support for Mothers and

Infants in PMTCT Programs in Mozambique

Time and Money Summary: Fy08 funding request for $200,000 for a biological component to test cord-

blood and do related follow-up. Once COP08 is approved, protocol will be amended and sent through the

University of Washington's IRB for approval.

Local Co-Investigator: Pablo Montoya, HAI

Project Description:

Study Question: Does an intervention providing social support and home provision of NVP for both

mothers and infants increase the number of mother-child pairs receiving a full course of NVP and/or

antiretroviral treatment for eligible women?

Study Design: This study will be a non-equivalent control group design to test the effectiveness of an

intervention using lay activists to improve adherence to PMTCT services and treatment referrals among

seropositive women identified through HIV testing at the time of their initial prenatal visit. This evaluation

will compare the rates of NVP provision and provision of HAART to HIV-positive mother-baby pairs at

PMTCT sites where the intervention has been implemented (experimental group) to the rates in matched

sites without the intervention (control sites). Up to eight sites in Manica and Sofala (and potentially one

other province) will be chosen for the intervention.

All women testing HIV-positive at these sites during the study period will be included in the experimental

group, including both those who accept participation in the intervention activities and those who refuse. The

intervention sites will be matched with an equal number of non-intervention sites, and all women testing HIV

positive at these sites during the study period will be included in the control group. Matched sites will be in

the same province, have a similar rate of NVP coverage and treatment referral before the intervention, be

similar in volume of patients seen, and have a similar type of catchment area (urban or rural).

Importance of Study: Currently more than 30,000 children per year are infected via mother-to-child

transmission of HIV in Mozambique. The vertical transmission rate from mothers to children is thought to

be as high as 35%. Overall, the risk of HIV transmission from a seropositive mother is 15-30% during

pregnancy, labor and delivery, with an additional 5-20% risk for breastfed children.

Regimens such as single-dose nevirapine for mother and infant, alone or paired with third trimester

zidovudine (AZT), have been employed in resource-poor settings to reduce the risk of MTCT. Single-dose

nevirapine (SD NVP) has been shown to reduce in utero and intrapartum MTCT by at least 50%. These

interventions have most commonly been provided in maternity wards before and after delivery, or given to

women during third trimester prenatal visits for self-administration at home. However, access to PMTCT

regimens remains limited for several reasons.

In settings like those in Mozambique, because most women have few prenatal visits and low rates of

institutional deliveries, barriers to access remain high. Although prenatal care coverage in Mozambique is

high, with an estimated 80% of pregnant women having at least one visit, most women have 3 or fewer total

visits and, outside of urban centers, only about 40% have institutional deliveries.

Several experiences from other countries have shown that that women can successfully administer NVP to

themselves and their babies and achieve lower rates of HIV transmission. One program in Kenya gave NVP

syrup in a foil-wrapped syringe for mothers to take home. In the first half of 2004, the percent of infants

receiving the dose was 45%. The percentage of infants receiving the infant dose steadily increased over

the subsequent 3 months to 87.4% of the HIV exposed infants receiving NVP. These are service delivery

data and not from a controlled research design, but suggest that coverage could significantly improve by

liberalizing the infant dose.

Although current policy in all PMTCT sites is to refer mothers for evaluation and definitive HIV care, many

barriers and constraints conspire to make implementation of this goal difficult. Some PMTCT sites are far

from treatment centers, but even where treatment sites are close by, less than 40% of HIV-positive mothers

make even one visit and less than 5% start HAART before their delivery.

Planned Use of Findings: This targeted evaluation is expected to provide useful and practical information

which will help inform:

• A training curriculum for the training of community-based lay activists to support PMTCT and referral HIV

treatment

• The development of educational tools designed to improve mothers' knowledge of HIV, PMTCT, HAART

adherence, nutritional recommendations, and appropriate follow-up

• Recommendations for the development of a cost-effective lay activist social support model to improve

PMTCT coverage and HAART referral in resource poor-settings

Status of Study: Protocol is pending approval at the University of Washington (HAI affiliated).

Lessons Learned: Research takes longer than anticipated due to long processes of review and

authorization by the Ethics Committee and the Minister of Health.

Information Dissemination Plan: Publicly announced at both provincial and federal levels.

Planned FY08 Activities: HAI will expand the scope of this existing PHE to also gauge the effectiveness of

take-home Nevirapine (NVP). The question which will be addressed is whether women who receive NVP at

28 weeks or after and give birth outside of the formal health system actually take the NVP, administer it

correctly, and whether they bring their children to a health facility for follow-up. To avoid issues of recall

Activity Narrative: bias, the only objective manner to gauge the effectiveness of take-home NVP is to quantify its presence in

cord blood. HAI has two ongoing studies that access women and babies from which this component of the

study can be added. The results of the investigation will assist the USG and MOH in defining take-home

NVP policy for both mothers and babies. An added benefit to this study is that HAI will be able to provide

data which better informs pediatric treatment interventions and directly addresses the issue of loss to follow-

up, enabling better tracking and enrollment of eligible children into treatment and care programs.

Budget Justification for the FY08 Monies:

Field study team $30,000 Includes study coordinator, field supervisors, data collection and data entry

costs.

Consultants $30,000 Includes participation in study design, training of study team, initial

enrollment, supervision visits

and data analysis.

International Travel $15,000 For Technical Advisors/Consultants 2 trips including per-diems.

Training of field staff $15,000 Includes development of materials and reproduction..

Equipment and supplies $8,000 Includes two laptop computers, software, computer

supplies, office supplies and printing.

Clinical supplies $34,000 Testing of samples

Transportation vouchers $2,000 Transportation of samples

Dissemination of results $5,000

Supervision and support costs $25,000 Includes staff time, phone, fuel, and other organizational support

costs related to study.

Indirect costs $36,000 At rate of 18%

GRAND TOTAL $200,000

This is a continuing PHE activity under COP08, linked to COP07 activity # 5352.07.

Health Alliance International and the Elizabeth Glaser Pediatric AIDS Foundation will complete a targeted

evaluation of improved early breastfeeding cessation strategies. The TE will identify replacement feeding

recommendations to help HIV-positive women achieve breastfeeding cessation at six-months. Using data

from formative research, recommendations will be field tested, using recipe trials, cooking demonstrations

and a qualitative consultative research design, to determine feasibility in Mozambique settings. Findings

will be used to develop acceptable, feasible, affordable, sustainable, and safe recommendations, per WHO

guidelines, and to create demonstration sites to teach HIV-positive postnatal women about new feeding

practices.

Title: Improved Strategies for Early Breastfeeding Cessation

Time and Money Summary: All monies absorbed with exception of dissemination activities, which should

take place within the first quarter of FY08.

Local Co-Investigator: Pablo Montoya, HIA and Cathrien Alons, EGPAF

Project Description:

Study Question: What are the best strategies for feeding non-breastfed HIV-exposed infants following

early breastfeeding cessation (EBC) at six months in high-prevalence HIV/AIDS regions of Mozambique?

Study Design: The study involves three overlapping and complementary stages: 1) review of existing

information; 2) assessment of local context for EBC and RF6; and feasibility of developing specific

replacement diets, and 3) evaluation of the initial recommendations for replacement diets to determine their

feasibility, affordability, acceptability, and sustainability in mothers who are given EBC advice. Qualitative

and quantitative methods will be used throughout.

Importance of Study: Prolonged breastfeeding beyond 6 months is responsible for 50-68% of all

postnatal HIV transmission (PNT) if BF is continued for 18 months. Early breastfeeding cessation at 6

months (EBC) is currently recommended for HIV-positive Mozambican mothers who choose to breastfeed

in order to reduce the risk of late PNT. However, health workers report that mothers are having difficulty

implementing this recommendation because prolonged breastfeeding is the cultural norm, traditional

weaning foods are nutritionally inadequate for infants who are not breastfed, and commercial infant formula

is too expensive for the majority of Mozambican families to use daily. Mothers justifiably worry that if they

stop breastfeeding their infants will become sick and malnourished, and health workers have not yet been

equipped to provide advice on this issue.

Planned Use of Findings:

• Recommendations for EBC that are based on field experience and inputs of HIV-affected Mozambican

families

• Recommendations for RF6 that are based on locally available foods, nutritional and cost analysis, and

inputs of HIV-affected Mozambican families

• Recommendations on the feasibility and acceptability of different approaches for providing HIV-positive

mothers with postnatal infant feeding support

Status of Study: Study completed, data analysis in progress

Lessons Learned: Research in Mozambique takes longer than expected due to long processes of review

and authorization by the Ethics Committee and the Minister of Health.

Information Dissemination Plan: Preliminary data has already been presented; however, a larger

dissemination campaign will take place upon completion of the data analysis.

Planned FY08 Activities: HAI, along with other PEPFAR partners, have collected data to explore the best

strategies for feeding non-breastfed HIV-exposed infants following early breastfeeding cessation (EBC) at

six-months in high-prevalence HIV/AIDS regions of Mozambique. Final results should be disseminated

within the next three months.

Budget Justification for FY08: No new money in FY08.

This is a continuing activity under COP08.

HAI will continue to invest in the improvement of the quality of HBC services and community mobilization

activities by strengthening the capacity of community based organizations (CBOs) and other relevant

community structures as well as strengthening individual and social palliative care services and the linkages

between the community and the health system, home-based care activities totalling approximately

$2,000,000 administered through sub-grants to national and international NGOs. By more pro-actively

engaging the community and clinical staff and structures, community participation will be strengthened,

which should improve the linkages within the health system and facilitate the development of prevention

strategies and the promotion of available services at both the community and clinical level. HAI will work

towards strengthening the monitoring and evaluation capacities of the system, as well as improve the

capacity of the program to adapt to the needs of the population. HAI will also expand to a few sites in Tete

province where they will be expanding their treatment activities as well.

Under COP08 the program will create new, and utilize existing, community to clinic and clinic to community

referral systems to ensure that PLWHA are accessing treatment and other necessary services, particularly

food, to improve their health status. WFP, in conjunction with PEPFAR treatment partners including PSI,

will work to improve provision of food and nutrition to PLWHA registered at treatment sites based on clinical

and nutritional assessments. This model helps ensure that individuals are accessing health care and

receiving services along with food supplementation. The standard for determining malnutrition will be based

on adult non-preg/lact women patients with a BMI <18.5 at entry into the program. The food supplement

consists of short-term emergency food support. Please refer to the treatment activity sheet for WFP for

funding levels and targets.

The FY2007 narrative below has not been updated.

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

Activity Narrative: 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.

This is a continuing activity under COP08.

HAI will work with the Provincial and District Health Directors, exapnding activities into the Tete Province, to

improve the functional integration of TB/HIV services through ongoing onsite training for TB diagnostic and

treatment staff and joint supervision visits to sites, especially those situated in the periphery. HAI will

undertake trainings to address quality control of smear microscopy and promote the de-centralization of

smear fixation. Increasing laboratory and x-ray capacity for TB diagnosis is crucial in improving TB/HIV

services; both of which HAI will actively pursue. Finally, HAI will work with community-based partners to

expand DOTS services to the community.

The activity narrative below from FY2007 has not been updated.

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.

Reprogramming August08: Funding decrease $150,000. Funds reprogrammed to support Mission RFA

funded across 3 SOs to ensure an integrated package of services, leveraging each SO's strengths.

This is a continuing activity under COP08.

HAI will increase the number of counseling and testing sites, both mobile and fixed sites, to a total of 93

sites in order to increase the number of people being tested. HAI will become increasingly involved in

social mobilization to not only increase the number of people who test but also to strengthen the link to

treatment as well as avoiding missed opportunities for care. HAI will continue to integrate cousneling and

testing into the components of the integrated health netwrok system and strengthen the monitoring and

evaluation system. To better ensure access to comprehensive services HAI will continue to use moments

within pre and post-test counseling to appropriately refer HIV positive clients to other health services of

importance such as family planning, MCH, TB, etc. HIV-negative clients are also referred but more active

referral mechanisms are either being developed or are already in place for those who are HIV-positive.

The activity narrative below from FY2007 has not been updated.

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 is a PHE activity under COP08, linked to COP07 activity # 5229.07.

Within the currently existing Day Hospitals providing HIV care in Sofala and Manica provinces, HAI,

together with the Ministry of Health and the University of Washington, will develop, implement, and examine

the effects of interventions aimed to improve adherence to care and treatment for patients on HAART.

Interventions will be developed that are sustainable and practical within the context of HIV care in

Mozambique, and will focus on patient and health system factors that are likely to influence adherence

rates. Findings will be applicable to other treatment sites in Mozambique and in other countries expanding

HIV care in resource-poor settings.

Title: A Targeted Evaluation to Improve Adherence to HIV Care and Treatment for Patients on HAART in

Central Mozambique

Time and Money Summary: Study is in year two and should be completed in FY08, using FY07 funds for

completion.

Local Co-Investigator: Pablo Montoya, HAI

Project Description:

Study Question: What are the best practical and sustainable interventions that improve adherence to HIV

care and treatment in Mozambique the context of the Ministry of Health's current human resource and

capital constraints?

Study Design: A quasi-experimental time-series design study to test the effectiveness of two different

interventions aimed at improving adherence to care and treatment among patients on HAART. There will

be a health system intervention consisting of the creation of a full-time "HAART monitoring team" and a

community-based intervention consisting of strengthening and formalizing the involvement of community-

based PLWHA groups in monitoring patients on HAART.

Importance of Study: Adherence, defined by the WHO as "the extent to which a person's behavior -

taking medication, following a diet, and/or executing lifestyle changes - corresponds with agreed

recommendations from a health care provider," is important for patients to achieve the maximum benefits

from health care interventions aimed at chronic illnesses such as HIV/AIDS. Adherence is particularly

important for HIV-positive patients taking highly active antiretroviral treatment (HAART), since poor

adherence to medications can lead to higher rates of treatment failure (as measured by viral suppression,

CD4 count rise, and clinical response) and resistance. Broadly construed, adherence for patients on

HAART relates to their adherence to treatment (i.e., taking medications such as HAART) as well as their

adherence to care (i.e., coming to follow-up appointments, performing appropriate laboratory monitoring).

Assuring optimal adherence to both care and treatment is necessary to ensure that patients are not only

taking their medications correctly, but also being monitored for side effects and treatment failure so that

their medications can be adjusted appropriately.

Planned Use of Findings: This targeted evaluation will help to develop, implement, and evaluate two

additional adherence strategies aimed at improving factors identified as potentially limiting the adherence of

patients on HAART at the Beira and Chimoio Day Hospitals.

Status of Study: The protocols have been approved by the Ministry of Health and are currently pending

approval of the IRB at the University of Washington.

Lessons Learned: Research in Mozambique takes longer than anticipated due to the long process of review

and authorization by the Ethics Committee and the Minister of Health.

Information Dissemination Plan: The results of these analyses will be disseminated at the local, national,

and international levels, and will immediately assist with the implementation of interventions to improve

adherence and quality of care at other programs and sites involved in expanding access to HAART in

resource-poor settings.

Planned FY08 Activities: The study will be completed during the year and results immediately released.

Budget Justification for FY08: No new FY08 funds.

This is a continuing activity under COP08.

Health Alliance International will expand its reach within the 23 districts of Sofala and Manica provinces and

begin to provide district-level support in the province of Tete this year. COP 08 is the year in which it is

widely expected for the HAI model to hit its stride and provide the quantity of patients and the quality of

services for which it has been working its way towards over the last several years. HAI will continue to

strive to improve the capacity of the health system for those already infected with HIV and upgrade the

laboratory testing capacity and the quality of services the laboratory offers a s means to support the referral

system of samples and results. HAI's longstanding commitment to fully integrate HIV/AIDS services into a

cohesive health network, provides support along the continuum of care and strengthen the capacity of

provincial and district directorates of health to manage the HIV program will continue under COP08. In

addition, HAI will provide approximately $500,000 in support of a scholarship program for laboratory

technicians, pharmacists, medical technicians, as well as MCH and general nurses, eight classes in all,

totaling approximately 240 students. Students will be chosen from districts, offered pre-service training, and

returned to their district to work for at least two years in repayment of their scholarship; whilst waiting to be

absorbed into the MOH system, HAI will provide salary support. HAI will also construct six facilities

(2,500,000), twenty staff houses (800,000) and repair and renovate 18 service outlets (1,580,000). Finally,

HAI will continue to work with a number of wrap-arounds including developing sustainable strategies to

guarantee food security for PLWHA, the provision of SP to pregnant women, and collaborative work with

PMI in the distribution of bed nets as well as TB-CAP to more effectively integrate tuberculosis and HIV care

and treatment. Like other partners HAI will continue to foster linkages with the Child at Risk Consult (CCR)

as well as treatment services. The referral system between PMTCT, treatment services, and the CCR will

be the first line of approach, which has broad Governmental support. However, HAI is already exploring

ways to reinforce testing and treatment linkages with vaccination campaigns, well baby visits, and weighing

stations.

The activity narrative below from FY2007 has not been updated.

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.