Continuing activity: Replacement Narrative

This activity builds from FY07, when CARE received USG Plus Up funds to resume PMTCT support at

selected sites in 3 rural districts. In FY08 this support will continue, and CARE will expand services using a

district-level model in the 3 established areas.

In-service training activities will include refresher training on PMTCT services for ANC/PMTCT staff, clinical

skills development, updates on pediatric care and infant feeding, and care for HIV infected pregnant

women. Special emphasis will be provided for timely referral for eligible HIV infected pregnant women to

initiate ART, male involvement, and adherence support. Training will also be provided to improve PMTCT

competency in the maternity setting.

The activity, in collaboration with MoH, will continue supporting follow- up training for community health

agents, including traditional birth attendants (TBAs). CARE will link health facilities with community based

organizations. CBOs and TBAs will receive 3 day training twice during the year to equip and support them

provide on-going counseling and carry out home-based follow- up for PMTCT defaulters.

Mother support groups will be developed at supported sites, in collaboration with site staff and local groups.

In addition, CARE will utilize mother support group standardized approaches, as per central level guidance.

Implementation of mother support groups will incorporate the community to promote adherence to PMTCT

services and access to follow up care.

The client referral system between PMTCT and ART will be assessed at supported sites to identify

challenges in improving the referral of clients for ART. MCH, PMTCT and ART staff will be involved in

carrying out the assessment and sharing the findings, to build staff confidence and also to engage them

actively improving the referral system and taking action to ensure smooth flow of clients between PMTCT,

maternal and child health services, and ART treatment.

This activity will also include production and dissemination of selected job aides, in coordination with

partners and the technical working group.

The project in collaboration with the local leadership and coordination with HBC volunteers will select

influential male peer educators and support them to reach out to fellow men at places of socialization to

deliver PMTCT messages to promote care and support for HIV+ women and exposed infants as well fight

HIV related stigma.

The project will facilitate and carryout a focused learning and action intervention with women in maternity

wards, postnatal mothers bringing children to the under five clinic and with MoH staff to identify challenges

with access to treatment from the perspective for clients and providers and work with the USG PMTCT

technical working group to address obstacles faced in order to increase accesses to PMTCT services.

CARE will be an active contributor to the USG PMTCT technical working group, with the aim of addressing

barriers that hinder women from accessing PMTCT services. Reviewing and updating of PMTCT algorithms

will be done with the technical working group.

FY07: The level of knowledge about the risk of a HIV positive mother infecting her child is low, and more so

in rural areas and among poor women and women with no formal education. Utilization of PMTCT services

is observed to be higher in and around provincial capitals, access for women living in remote villages is

limited due to poor infrastructure and long distances to PMTCT sites. CARE Mozambique is proposing to

strengthen MoH PMTCT services at 3 rural district health facilities in Vilankulos, Mabote and Inhassoro

where clinical PMTCT services have recently been initiated but with low capacity to reach women of

reproductive age facing difficulties in accessing HIV/AIDS services, including PMTCT and ART in case of

HIV infection.

Support will include improved and increased access to prophylaxis such as nevirapine for HIV-infected

pregnant women from rural facilities with inadequate health care systems and to-date limited access to HIV

counseling and testing (CT) services. For example in Mabote, the VCT services are located far from the

main health facility where antenatal and other reproductive health services are provided. As staff capacity

and motivation are low, training and on-the-job support will be critical. A comprehensive package of PMTCT

services and interventions will be provided to help uninfected women to stay negative, to lower the risk of

HIV transmission to children from HIV-infected mothers, and to support HIV-infected mothers and babies.

On-the-job training will be provided to nurses and doctors on up-dated PMTCT and pediatric AIDS

treatment protocols, counseling and infant feeding among other topics. The proposed project will create and

strengthen linkages between the PMTCT and ART services to increase access to AZT for pregnant women

and as a result reduce child morbidity and mortality. Moreover HIV-infected mothers are faced by the

burden associated with their own infection, therefore attention will be paid to preserving the health of HIV-

infected mothers after they give birth to ensure the continued survival of their infants. The support to

PMTCT services will include reaching mothers in maternity wards for counseling and testing for those who

missed the opportunity during the antenatal period, and hence increase access to HIV counseling and

testing as well as prophylaxis or treatment when necessary. Health promotion and education on family

planning, breastfeeding and nutrition will be an integral aspect of prevention intervention to be provided to

HIV-infected pregnant women, mothers and their families. Women are often afraid to access CT and ART

because they fear being ostracized by their partners, family and friends. As in Mozambique, HIV-related

stigma is a critical issue, that hinders continued utilization of services, the project will introduce male

participation in PMTCT and counteract stigma by supporting community information campaigns and

increase male support for HIV-infected women in order to reduce drop outs, as well as educate HIV-infected

women from the antenatal to postnatal period to increase adherence among PMTCT clients to treatment

and care. More than 60% of pregnant women in rural areas deliver at home. The project will, in

collaboration with MOH district level staff, identify Traditional Birth Attendants (TBAs), known to provide

antenatal and delivery services to women from the targeted rural areas and will provide basic PMTCT

training and establish referral linkages with PMTCT sites for CT and ART. Beyond reinforcing linkages

between clinical and community interventions, the project will assist Positive Mothers to form support

groups to provide mother-to-mother support, for community level counseling, encourage women to deliver in

health facilities rather than at home, as well as help pregnant HIV-infected women to adhere to PMTCT

Activity Narrative: services.

To improve the diagnosis and management of opportunistic infections, the project will build staff

competencies through in- service training in clinical care of commonly occurring opportunistic infections in

Northern Inhambane. Additional on- the- job skills building will be taking place during monthly case reviews

with support from an external clinician with experience in managing OIs who would be engaged to hold

short clinical seminars based on actual cases as well as providing new clinical information to regularly

update staff. Documentation of the cases reviewed during the clinical seminars will be compiled and used

as reference material in caring for similar cases in future.

The project will facilitate provision of essential supplies and equipment to facilitate service delivery. OI

treatment literacy information materials will be developed /adapted for health care workers to use in

educating clients at both the health facility and community level.

Palliative care will also be provided through home based care activities by working with volunteers and also

supporting the formation and strengthening of community groups providing psychosocial support and for

networking among PLWHAs. HBC volunteers will facilitate discussions with PLWHAs for experience sharing

on how to cope with the challenges of life, fears, how to pursue healthy living and for moral support.

The project will carry out training for HBC volunteers on OI management to equip them with essential

knowledge and enable them to counsel and provide advice to patients. Monthly meetings will be held with

activists (HBC volunteers) to supervise and follow -up HIV+ clients with OIs to appraise whether the

community based case management is responsive to clients needs and as well as for on- site skills building

based on feedback from volunteers concerning challenges they face when caring for clients with OIs.

Adherence Support: Through working with HBC volunteers the project will provide patient education and

counseling to ensure that patients understand the purpose, dosage and frequency of medication

administration, how the patient should respond in the event of rashes, diarrhea, and other complications

and the importance of good adherence.

HIV prevention, nutrition and personal hygiene education will also be provided to reduce the chances of

exposing themselves to infections.

Clients will be encouraged and supported to join groups of PLWHAs for networking and to receive

psychosocial support. Women of reproductive age will receive education about family planning and the

importance of mentioning that they are on OI medication when seeking health care, including family

planning services.

Palliative care project staff working with counselors at treatment sites will discuss with their clients various

options for treatment adherence including home based care. Clients will be supported to link up with HBC

volunteer case managers or other individuals they trust to assist them to continue treatment. HBC

volunteer case managers will support clients on OI treatment directly or indirectly through client treatment

supporters. HBC volunteer case managers will be linked to CBOs and will act as information resources at

the community level. HBC volunteer case managers will provide regular progress updates and will report OI

defaulters or clients facing difficulties to the Palliative care project staff and clinical focal point person for the

project. The project will facilitate discussions with clinical staff to share achievements, challenges and ideas

for improving treatment adherence and care for clients on OI treatment and their families.

To reduce the burden placed on health services, the project will work in coordination with the ART, PMTCT,

TB/HIV and community based counseling and testing interventions. The HIV care project will train HBC

volunteers who are the closest contact persons to families caring for PLWHAs to implement a basic care

package for adults and children who are HIV positive and for children who have been exposed to HIV.

Components of a preventive care package will be agreed upon by the technical work group and include but

not be limited to the following elements:

1. Voluntary counseling and testing services will be offered to family members of people living with HIV in

the home. This would empower people, and particularly couples, to make plans to take special care of

their health after knowing their sero- status. In most cases when one member is HIV-infected, other family

members usually have not had an opportunity to know their HIV status. Expectant couples who have not

received C&T at the PMTCT clinic, or cases where male partners have resisted testing at the health facility,

may especially benefit from community based C&T services in the privacy of their homes. It is anticipated

that this service would also promote better support for women to continue seeking for treatment and

improve gender relations at the household level.

2. Cotrimoxazole prophylaxis has been proven to prevent infections and prolong life in children and adults,

therefore adherence will be promoted at community level.

3. Malaria prevention education and long-lasting insecticide-treated bed nets (LLITN) to prevent malaria will

be promoted and provided to HIV+ pregnant and breastfeeding mothers who did not receive them during

the antenatal period.

4. HBC volunteers will be trained using a protocol developed in collaboration with clinical staff to help them

with basic screening for opportunistic infections and illnesses like tuberculosis, malaria, pneumonia,

diarrhea, for early detection and referral of cases at the community level.

5. HIV positive pregnant women will be encouraged and supported to take HIV exposed infants for health

assessments regularly and HBC volunteers will be trained on growth monitoring and equipped to weigh

infants from HIV+ women during scheduled monthly home visits.

6. The project will promote safe drinking water and provide nutritional education for PLWHAs and their

families.

An M&E plan will be developed to gather essential data to assess and measure progress against

performance based indicators as well as assure the monthly collection and reporting of accurate HBC data

to the appropriate district and provincial health authorities. .

CARE will work with the MoH in Northern Inhambane to implement practices that promote integration of TB

and HIV diagnosis, care and treatment in two districts: Vilankulos and Inhassoro and with limited activities

in a 3rd district, Mabote. The project will introduce TB and HIV integration activities to the technical work

group at each district level health facility. Capacity assessments will be done for all TB clinics at Vilankulos,

Inhassoro and Mabote to identify clinical capacity gaps as well as physical space to actualize the integration

activities for counseling and testing and provide essential supplies and equipment found to be lacking.

TB unit clinical staff or lay counselors will be recruited and trained on HIV Counseling and testing using

MoH curriculum and then they would be facilitated to get essential materials and supplies for example,

Rapid test kits to establish and deliver counseling and testing services at TB health units.

The project will conduct an in-service training for MoH staff to build skills on case management of co-

infected clients to ensure early diagnosis, treatment and care of HIV for TB clients at Vilankulos and

Inhassoro.

Teaching aids for clinical staff will be made available and clinical staff will be facilitated to adapt the

protocols for early diagnosis, treatment and care of HIV for TB clients at 2 targeted sites

The project will enhance MoH staff skills on preventive treatment with Cotrimoxazole (PTC) for reducing the

risk of opportunistic infections in patients with HIV and make it available in the TB health units and support

staff to ensure that Isoniazid treatment for the prevention of TB is offered to healthy HIV patients based on

MoH treatment protocol and TB/HIV integration policy

The project will facilitate knowledge dissemination on TB and HIV correlation at community level in

collaboration with Health care workers, community leaders and HBC Activists. The project will also support

community campaigns and through the media working with a local radio station to further and widely

disseminate messages developed.

To build capacity for continuum of care at the community level, the project will support HBC volunteer

workers with education materials to carry out targeted health education talks to provide information that

would sensitize people on the importance of supporting those diagnosed with TB or suspected cases to

seek for clinical care, HIV C&T services and adhere to clinical care. HIV and TB co-infected clients will

also be provided with regular counseling by HBC volunteers to encourage them to adhere to regimen

prescribed, reduce default rate and clients advised to join support group for social networking for

encouragement and to make connections to available palliative care services in the community.

The project will work with health workers at the clinical sites ensure that routine health education sessions

at TB clinics are held to pre-counsel clients on the relationship of TB to HIV and advantages for early

detection of HIV for TB clients and vice versa and provide IEC materials for further reference while at home.

The project will support and facilitate TB clinical staff to develop a protocol in collaboration HIV Health care

providers in order to establish a standard approach for early detection of TB clients, follow-up of defaulters

and use the protocol to train HBC volunteer activists for field work.

The MoH faces serious shortage of clinical staff and to strengthen the TB clinic teams the project will recruit,

train and deploy and support three lay counselors to be stationed at 2 TB units for C&T services in

Vilankulos and Inhassoro.

The establishment of the first Community-based Counseling and Testing (CCT) services in Mozambique

has been supported by five partner agencies (one international, two national NGO and two FBOs) in four

provinces (Sofala, Zambezia, Gaza and Maputo), since December 2006. This pilot experience has been

testing different models of implementation such as CCT services at non-traditional locations (e.g. churches

and mosques); satellite CT services at fixed locations; CT campaigns at markets and other non-traditional

locations; and home-based (door-to-door) CT services. From December 2006 to July 2007, 6515 people

were counseled; and 6464 people were tested and received results. Considering the new "CT in

Health" (CTH) approach - which entails the introduction of additional services such as hygiene education,

malaria prevention, Sexual and Reproductive Health (SRH) information (especially institutional delivery and

early pregnancy diagnosis), screening and referrals for tuberculosis, sexually transmitted infections and

hypertension - 5679 people received health orientation and screening, through CCT activities. Expansion of

CCT in FY08 will be aimed at replicating the successes of pilot experiences and scaling up access to CCT

to increase opportunities for people to learn their HIV status outside health facility settings.

This activity proposes to expand CCT to Northern Inhambane, a province located in the Northern part of the

Southern region. CARE project staff will work with Inhambane Health Directorates at Provincial and District

levels to enable and support them to launch CCT activities in Vilankulos district, to conduct training

workshops for project and clinical staff on CCT, and to introduce the concept and the approaches used

based on MOH guidelines and experiences from the above-described pilot phase.

Activities will include facilitating development of a community outreach CT schedule in collaboration with

hospital based services and as well as with local leaders to ensure coordination and mobilization of the

population for the CCT services at the selected sites is well organized.

Lay counselors will be recruited using MOH criteria and in coordination with Vilankulos District Directorate

staff and local authorities, and subsequently be trained using the MOH approved CCT curriculum to equip

them with knowledge and skills. After completing the training, lay counselors will be working under the

umbrella of Vilankulos health facilities and linked with Community Based Organizations (CBOs) working in

areas of HIV prevention, care and support that are partnering with CARE development projects. Lay

counselors will work in collaboration with clinical HIV services as well as collaborate with PLHIV groups to

refer clients for further counseling and palliative care provided through community support networks. The

project will promote and support the establishment of HIV post- test clubs to promote positive living and

initiate activities for prevention with positives (PwP).

The project staff will train and carryout monthly meetings to support and supervise work being carried out by

HBC volunteer activists to form and/or strengthen groups of people living with HIV and identify counselors to

champion prevention with positives activities with members of the post test clubs. Life coaches who will help

individual persons living with HIV will be identified to help them develop and sustain prevention plans and

provide support.

The project will support the CCT services by providing equipment and commodities to be used in delivering

the services like disposable supplies, bicycles, furniture, etc. Clinical and laboratory staff from Vilankulos

hospital will be supported to conduct supervision and on-the-job training for lay counselors for quality

assurance of CCT services. Funding will also support reproduction and dissemination of nationally

developed CT IEC materials.

This is a continuing activity from FY07

This activity is linked to Emergency Plan funded treatment activities through and complements treatment

expansion being implemented by other partners who also receive funds from the emergency plan (Columbia

University, Health Alliance International, Vanderbilt University, Elizabeth Glaser Pediatric AIDS Foundation)

.

During FY08, CARE International proposes to work in Inhambane province to continue implementation of

FY07 funded treatment activities that were started in Inhambane province (Vilanculos) as well as expand

and scale- up similar services to two other districts; Inhassoro and Mabote.

Therefore, in addition to continued support to Vilanculos for ART, the funding to CARE International will be

used to undertake the following activities:

1) Continue and initiate in- service and refresher trainings for MOH staff in Vilankulos, Inhassoro and

Mabote on HIV care and treatment, using national guidelines in order to improve clinical skills for provision

of HIV care treatment for adults and children and to strengthen supply chain and inventory systems in

supported districts. This will be through clinical mentoring, exchange visits to facilities already providing

ART and financing the participation of staff to local and national trainings.

2) Support program monitoring and evaluation and reporting in the 3 districts where CARE International will

implement services.

3) Develop links with and train Community Based Organizations and Activists (Home Based Care

volunteers) for follow -up of patients on ART, provision of psycho-social support, and treatment adherence

4) Provide logistical support to enhance laboratory linkages between Vilankulos district hospital and

Inhambane provincial hospital for CD4 count and PCR testing with Maputo central laboratory. Vilankulos

district hospital would coordinate delivery of blood samples and laboratory reports to and from Mabote and

Inhassoro district health facilities.

5) Support the District Health Directorate (DDS) in Vilankulos, Inhassoro and Mabote to enhance linkages

between ART, PMTCT, pediatric services and TB programs to promote better follow up, referrals and

treatment adherence. Working in partnership with the MoH and HBC volunteers linked to Community based

organizations (CBOs), the project will work to address the known barriers to ART services including HIV-

related stigma, lack of support for people living with HIV and AIDS and their families, limited access to

accurate information on HIV and AIDS including treatment literacy, and inadequate information on positive

living and impact mitigation.

6) Provide technical assistance through technical advisor, to the district medical; directors office responsible

for HIV care and treatment in program monitoring including site visits and supervision to ensure expansion

of the ART program and provision of quality treatment services.

CARE will recruit 2 clinical district supervisors, 1 laboratory technical staff and 1 M&E officer to provide

technical support, train and mentor Mozambican staff at the 3 sites and provide assistance to the district

coordinators. Additionally, 6 ART lay counselors will be recruited and, trained using MoH approved

curriculum and deployed to support the 3 ART sites.

Through these activities CARE will support ART for 750 people (including 75 of whom will be children) at 3

sites in the country.