PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
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.
Activity Narrative: 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
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
New/Continuing Activity: Continuing Activity
Continuing Activity: 15999
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
15999 15999.08 U.S. Agency for Health Alliance 7278 3629.08 USAID-Health $0
International International Alliance
Development International-
GHAI-Local
Table 3.3.01:
April09 Reprogramming: Increased $2,327,879.
This is a continuing activity under COP09.
ACTIVITY UNCHANGED FROM FY2008
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.
Continuing Activity: 15865
15865 5352.08 U.S. Agency for Health Alliance 7278 3629.08 USAID-Health $3,782,361
9140 5352.07 U.S. Agency for Health Alliance 5041 3629.07 USAID-Health $2,851,875
5352 5352.06 U.S. Agency for Health Alliance 3629 3629.06 $1,495,000
International International
Development
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
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.
Continuing Activity: 16397
16397 16397.08 U.S. Agency for Health Alliance 7278 3629.08 USAID-Health $0
Program Budget Code: 02 - HVAB Sexual Prevention: AB
Total Planned Funding for Program Budget Code: $13,235,078
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
With a general prevalence rate of 16%, Mozambique is one of the few countries in Africa where available data does not suggest a
decline in incidence. Experts describe Mozambique's generalized epidemic as three regional epidemics due to substantial
heterogeneity of prevalence and epidemiological risk factors within the country. The Northern region has high prevalence of male
circumcision (90%) and the lowest prevalence (9%), despite risky behaviors such as high prevalence of multiple and concurrent
partnerships (MCP), high reported sex with commercial sex workers, low condom use, and the nation's lowest age of sexual
debut. The Southern region has the highest level of prevalence (21%), high levels of reported MCP that is often associated with
beliefs about masculinity, and negative attitudes toward condom use. With the exception of Inhambane, which has a male
circumcision rate of 89%, prevalence is increasing in the Southern region and is one of the few places in Africa where HIV
continues to do so. The Central Region has the oldest epidemic, in part, due to war, movement to and from Zimbabwe (which has
had very high HIV prevalence), and low prevalence of male circumcision (less than 20% in Sofala, Manica and Tete). With the
exception of Zambezia, recent surveillance shows prevalence is stable and or declining in the Central region.
These regional data are validated/supplemented by new evidence from the recent Mozambique data triangulation workshops,
modes of transmission study and the 2006 SADC Southern African epidemiological analysis that indicate the key driver of
Mozambique's HIV/AIDS epidemic is the pervasive practice of MCP. In Mozambique, this practice primarily involves HIV
transmission among the general population's consenting adults who are usually over the age of 25.
Furthermore, the I-RARE study conducted in late 2007 identified high risk behaviors and locations where drug use and sex work
occur within Maputo, Beira, and Nacala Porto. Preliminary findings indicate sex workers in Maputo use condoms infrequently, with
use encouraged by requiring a higher price paid by clients. Sex workers report dual consumption of alcohol and drugs to facilitate
sexual encounters. Drug users report injection and non-injection drug use, and consumption of crack cocaine and heroin
increasing in Maputo. Injection drug users report sharing needles despite awareness of HIV risk, often because clean needles are
difficult to obtain.
In light of the above, particularly the increases in prevalence in the Southern Region, stakeholders in Mozambique are reviewing
and re-thinking prevention efforts. The Government of Mozambique is leading this effort and it has constituted a high level
Prevention Reference Group to develop an action plan to refocus prevention efforts in order to reverse this trend. The PEPFAR
team was instrumental in the formation of the Prevention Reference Group and has played a critical leadership role. It is
anticipated that the action plan will be completed by December 2008 following consultations in each province.
In FY09, USG will shift additional resources into Prevention in response to both the epidemiologic realities and the priorities of the
Government of Mozambique. The new USG approach which will roll-out a new set of innovative, highly targeted evidenced based
prevention programs in the most epidemiologically significant, highest prevalence regions of the country. These include: 1) a
highly targeted mass media and behavior change plan which targets the MCP contact pattern and leverages local media funding
and technical expertise; 2) intensified mobilization of communities in epidemiologically significant provinces and within those
regions at hot-spots with selected target groups amongst the MARPS which includes commercial sex workers and their clients,
male and female prisoners, migrant workers and de-miners, refugees fleeing the on-going crisis in Zimbabwe, and the highly
mobile truckers who move through and work in high prevalence corridors, military, police and border guards; 3) HIV positive
prevention programs in the highest prevalence regions; 4) build Mozambican capacity to plan, implement, and evaluate STP
programs; 5) public/private prevention education partnerships in selected multinational and large local workplaces and 6) "know
your epidemic" studies including a Behavioral Surveillance Survey (BSS) and an assessment of alcohol abuse in rural areas. The
approach represents a departure from the USG's previous prevention strategy of general awareness for in and out of school
youth, product specific social marketing without mention of multiple partners and education programs targeting high transmitter
populations in lower prevalence provinces throughout the country and timely conclusion of South to South collaboration with
Brazilian experts.
A new Media Prevention RFA in FY09 will support print, television, Portuguese language and local language radio stations,
information and education. The mass media program will be carried out on the national level in Portuguese and in six provinces
which fall into the highest HIV prevalence corridors (Maputo, Gaza, Sofala, Zambezia, Nampula and Niassa). Subcontracts or
grants will be awarded to local media entities to improve communications within the provinces.
A new "Communities and Corridors" RFA will reinforce the mass media ‘air war' messaging with a ‘ground war' to geographically
target community mobilization and behavior change communications (BCC) in "hot spots" corridors and the highest prevalence
regions (Maputo and Gaza provinces and the Beira and Nacala corridors). This new activity will support long-term, well-
organized, aggressive community based approaches to promote partner reduction in the highest prevalence regions and corridors
noted above. Building an army of committed HIV prevention leaders, and providers is quintessential to breaking down
misinformation and dangerous practices and building risk perception and self efficacy. Within hot spot regions, MARPs will be a
key target and will include sex workers and their clients, prisoners, and the highly mobile population including refugees and
truckers.
The military and other uniformed services will be reached through Department of Defense (DOD) programming and are an
important and necessary complement to this program. Male and female condom social marketing will deliver life saving products
in places where MARPS congregate. The program will ensure wide availability of condoms through large and small commercial
outlets and non-traditional outlets, interpersonal communications for risk reduction, mass media messages, and design,
production, and distribution of print materials for health workers and targeted high-risk populations. CSM distribution will focus on
increasing coverage in outlets frequented by MARPs.
Condom demand and use is among the lowest in the region. Fifty nine million condoms were ordered for CY09, but due to lack of
uptake, there is a considerable pipeline. USAID historically procured 100% of public sector condoms in addition to funding a large
portion of national condom social marketing (CSM) programs for male and female condoms. USG will reduce funding for condoms
in FY 09 after analysis of the large condom pipeline, and agreement with other donors (including UNFPA, the Dutch Embassy and
the donor basket fund.) that they will increase funding for condom procurement.
C&OP funded MARP interventions focus on promotion of condom use and service uptake among commercial sex workers and
clients, uniformed services, health care workers and PLWHA, families and positive prevention. Funds are earmarked for
populations employed or displaced by private businesses such as Vale do Rio Doce, a Mining company set to extract one of the
continent's largest coal reserves in Tete province and the Gorongosa National Park/Carr Foundation in the Beira Corridor. Peer
education and alternative income generation for sex workers, IEC, films and short debates in discotheques and other ‘hot spots'
target CSWs and clients. DOD continues IPC, IEC and CT directed at military personnel at the national level, and at policemen in
all provinces, except Tete and Niassa. Non-USG partners (Medicos Do Mundo and Comunidade de Santo Egidio) provide CT
and ART for prison populations in Maputo City and Province, a MARP currently receiving minimal USG support.
The majority of implementing partners will receive split, AB and C&OP funding for STP services. AB funds support BCC activities
for behavior change and healthier norms and attitudes, as well as life-skills programs in schools, communities, and FBO settings.
Sports-centered community outreach programs target youth will be linked to the 2010 World Cup. Programs targeting non-OVC
10-14 year olds focus on delay of sexual initiation but also provide information on the protective factors of partner reduction for
sexually active individuals.
Counseling and Follow-up Prevention services for HIV Positive and Negative Clients. A cadre of HIV counselors at HIV treatment
sites and outreach teams will be trained to provide support and prevention advice to HIV positive and negative clients. These
counselors will supply condoms to clients that are sexually active and encourage testing by their partners.
Public/Private Partnerships for Prevention Services. A select number of partnerships with large companies who employ over 100
staff will be launched to introduce and improve employee HIV prevention programs. Companies such as Chiquita Banana in
Nampula, and a new large mine extracting company have expressed interest in a PEPFAR partnership. Companies would be
expected to contribute their own resources to carry out employee services such as counseling and testing targeted towards
characteristics of their specific populations.
The USG is collaborating with other donors and partners through the newly established MCP Working Group to ensure consistent,
targeted messages for MCP-focused behavior change following the BCC priority of the Minister. The Public Affairs Office
continues to provide grants for community radio in local languages, further reinforcing these key messages.
Gender: Men, especially those who are older, more affluent and educated, constitute an epidemiologically key population for HIV
transmission. In FY08, the majority of continuing PEPFAR STP partners received capacity building to mainstream gender and
increase male engagement in their and their sub-partners' activities. Continuing STP activities targeted at engaging men in the
general population include the Peace Corps HIV,Gender and Leadership activity for male students, and male targeted activities in
school, workplace and faith-based settings. The majority of all new activities have specific programs targeting men, including
workplace, bar-based activities and activities for uniformed services and MARPs. New MCP activities addressing men combat
"macho" attitudes about MCP and include programs linking partner reduction to responsible paternity amongst men.
Continuing and new activities address reduction of transactional and cross-generational sex, and sexual coercion and violence
against women and children. The second year of the Vulnerable Girls Initiative activity provides employability skills for girls and
women 15-24. In response to USG and MEASURE/Evaluation recommendations, all three Track 1 ABY partners now incorporate
"B" focused curricula for adults addressing transactional sex and sexual abuse.
The USG team will continue programs begun in FY08 to address alcohol abuse including an assessment of alcohol abuse in rural
settings; urban, bar-based interventions linked to male responsibility activities through Communities & Corridors Prevention and
Family Matters; and alcohol and prevention programs for Uniformed Services through DOD.
STP activities addressing OVC-specific vulnerabilities and risks will continue, including access to employability-skills programs for
older or head of household OVCs. Community-based CT will be integrated into community prevention programs under the
Communities & Corridors Prevention activity. Existing activities will continue referrals to community and clinic-based care and
treatment services while new activities will establish a MOU with facilities for active and mutual referrals. In FY09, expansion of
Positive Prevention (PP) activities in Maputo, Sofala and Zambezia Provinces will scale up PP ToT, provision of PP toolkits
(training materials, job aids, IEC materials) and link to USG funded community based organizations providing care to people living
with HIV/AIDS. Capacity building of health care workers to mitigate their risk will be increased.
Voluntary family planning (FP) wrap around programs include PP services. USAID's Health Team will use PEPFAR infrastructure
to integrate non-PEPFAR USG-funded national FP programs into PMTCT, VCT, and treatment program areas. Integration
activities include the provision of commodities, communication materials, and reproductive health and family planning training.
A TBD policy partner will work with the Ministry of Education and Culture (MINEC) to advocate the establishment and enforcement
of national policies addressing school-based sexual abuse, in particular sex for grades, and women's legal rights. System
strengthening and capacity building for Mozambican CBOs in prevention implementation, M&E, management and supervision are
the focus of the AED Capable Partners Program. Small grants to CBOs through Embassy Quick Impact Grants, PAO Small
Grants and PC Volunteer Activities Support and Training grants will also continue to support new local partners. Continued
behavioral studies and assessments will provide policy-level recommendations to increase service access for MARPS, such as
CSW, migrant laborers, refugees, and internally displaced persons. Coordination of prevention and communication activities
remains a barrier for organizations implementing prevention programs in Mozambique. The PEPFAR Team has allocated funds to
support human resources in both the CNCS and the IEC Department of the MOH.
Lack of male circumcision continues to be an outstanding challenge and programmatic gap. Current policies do not allow MC as
the GoM's severe constraints on capacity for surgical care (infrastructure and personnel) leaves the MoH concerned about
resource-shifting to a disease-specific intervention. Should there be a change in national MC policy with a corresponding addition
of STP funding, MC-focused BCC and mass media activities could support services under Biomedical Prevention for this evidence
-based intervention.
Table 3.3.02:
April09 Reprogramming: Increased $100,000.
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.
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
Activity Narrative: treated at treatment facilities; 4) Referral of HIV infected patients to HBC programs for continuing care; and
5) Follow up of patients regularly for CD4 monitoring and clinical staging to assess when eligible to initiate
ART.
HAI will be funded to support the MOH procurement system by maintaining a buffer stock of OI medicines to
avoid complete stock-out of these commodities. As a result of this activity, 240 clinical staff will be trained in
OI management, supervision and maintenance of simple pharmacy management systems.
General Information about HBC in Mozambique:
Home-based Palliative Care is heavily regulated by MOH policy, guidelines and directives. USG has
supported the MOH Home-Based Palliative Care program since 2004 and will continue with the same basic
program structure including continued attempts of strengthening quality of services to chronically ill clients
affected by HIV/AIDS. In FY02, the MOH developed standards for home based care and a training
curriculum which includes a practicum session. Trainers/supervisors receive this 12 day training and are
then certified as trainers during their first 12 day training of volunteers. A Master Trainer monitors this first
training and provides advice and assistance to improve the trainers' skills and certifies the trainer when skill
level is at an approved level. All volunteers that work in HBC must have this initial 12 training by a certified
trainer and will also receive up-dated training on a regular basis. The first certified Master Trainers were
MOH personnel. Then ANEMO, a professional nursing association, trained a cadre of 7 Master Trainers
who are now training Certified Trainers, most of whom are NGO staff who provide HBC services in the
community. In the next two years, ANEMO will train and supervise 84 accredited trainers who will train
7,200 volunteers, creating the capacity to reach over 72,000 PLWHA.
In addition, the MOH designed 4 levels of "kits" one of which is used by volunteers to provide direct services
to ill clients, one is left with the family to care for the ill family member, one is used by the assigned nurse
which holds cotrimoxazole and paracetamol and the 4th kit contains opiates for pain management which
only can be prescribed by trained doctors. The kits are an expensive, but necessary in Mozambique where
even basic items, such as soap, plastic sheets, ointment, and gentian violet are not found in homes. USG
has costed the kits and regular replacement of items at $90 per person per year; NGOs are responsible for
initial purchased of the kits and the replacement of items once they are used up except for the prescription
medicine, which is filled at the clinics for the nurses' kits. An additional $38 per client per year is provided to
implementing NGOs to fund all other activities in HBC, e.g. staff, training, transport, office costs, etc.
MOH also developed monitoring and evaluation tools that include a pictorial form for use by all volunteers,
many of whom are illiterate. Information is sent monthly to the district coordinator to collate and send to
provincial health departments who then send them on to the MOH. This system allows for monthly
information to be accessible for program and funding decisions.
Continuing Activity: 15866
15866 5146.08 U.S. Agency for Health Alliance 7278 3629.08 USAID-Health $3,150,000
9133 5146.07 U.S. Agency for Health Alliance 5041 3629.07 USAID-Health $1,399,816
5146 5146.06 U.S. Agency for Health Alliance 3629 3629.06 $1,070,000
Table 3.3.08:
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.
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
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.
Continuing Activity: 16355
16355 16355.08 U.S. Agency for Health Alliance 7278 3629.08 USAID-Health $0
Table 3.3.09:
April09 Reprogramming: Increased $4,403,185.
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.
Continuing Activity: 15869
15869 5229.08 U.S. Agency for Health Alliance 7278 3629.08 USAID-Health $18,311,184
9164 5229.07 U.S. Agency for Health Alliance 5041 3629.07 USAID-Health $9,714,320
5229 5229.06 U.S. Agency for Health Alliance 3629 3629.06 $2,750,000
April09 Reprogramming: Increased $125,659.
Table 3.3.10:
April09 Reprogramming: Increased $916,380.
Table 3.3.11:
April09 Reprogramming: Increased $381,131.
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.
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.
Continuing Activity: 15867
15867 6442.08 U.S. Agency for Health Alliance 7278 3629.08 USAID-Health $1,473,748
9128 6442.07 U.S. Agency for Health Alliance 5041 3629.07 USAID-Health $365,625
6442 6442.06 U.S. Agency for Health Alliance 3629 3629.06 $300,000
Table 3.3.12:
April09 Reprogramming: Increased $249,146.
This is a continuing activity for COP09 funded at zero dollars. 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.
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.
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.
Continuing Activity: 15868
15868 5235.08 U.S. Agency for Health Alliance 7278 3629.08 USAID-Health $2,750,000
9113 5235.07 U.S. Agency for Health Alliance 5041 3629.07 USAID-Health $1,541,447
5235 5235.06 U.S. Agency for Health Alliance 3629 3629.06 $700,000
Table 3.3.14:
THIS IS A NEW ACTIVITY UNDER FY 09.
With this new activity HAI will be able to provide support in Manica, Sofala and Tete Provinces, in the
following areas:
The laboratory Technical Advisors based at the partner will be responsible for overseeing the laboratory
component of the Care and Treatment Program within the partners' supported sites and supporting
partner's staff in providing supervision of laboratory services within the program. In addition, s/he will
function as a counterpart for the Provincial Laboratory Technical Advisors based in DPS of each province.
The Laboratory Advisor will liaise and coordinate activities related to laboratory services with NGO's and
partners assisting the MOH in laboratory issues such as Clinton Foundation, SCMS, and APHL. The
Laboratory Advisor will identify weaknesses in laboratory processes, procedures, and logistics, propose
adequate strategies for improvement, and contribute to a plan towards building capacities at national,
provincial and district levels. S/he will give specific attention to realities and problems emanating from field
level, communicate needs and priorities identified and channel solutions to adequate forum and authorities.
The work of the laboratory advisor shall be integrated with on-going or new MOH national and provincial
laboratory activities and policies. S/he shall also respond to priorities identified by the partner team(s) or
other direct implementers in these Provinces. Overall, the Partner Laboratory Technical Advisor will
improve laboratory services as a crucial component of quality care in the provinces supported by the
Partner.
This will complement the Partner funding of Provincial Laboratory Advisors to support the organization and
provision of high quality clinical laboratory services through technical assistance to the Direcção Provincial
de Saude (DPS). The Provincial Laboratory advisors will work directly with the Section Chief of the
Provincial Laboratory to improve the quality and coordination of laboratory services in the entire province.
Specific activities include: assistance in planning and implementation of laboratory activities; technical
assistance and supervision to laboratory personnel at district and provincial levels; development of SOPs
and routine work flow, systems for patient registration, increasing access to testing, and reduction in turn
around time for test results, and develop a program for equipment maintenance.
New/Continuing Activity: New Activity
Continuing Activity:
Program Budget Code: 17 - HVSI Strategic Information
Total Planned Funding for Program Budget Code: $5,894,673
The PEPFAR Team has developed a comprehensive strategic information (SI) package to ensure that the SI Team, USG
partners, and the Government of Mozambique (GOM) have access to and utilize quality data to describe the HIV/AIDS epidemic,
monitor the multi-sectoral response, and inform policy and program decision making.
Key SI challenges for Mozambique are:
1) Inadequate human resource capacity in SI within the GOM
2) Inadequate human resources in SI within USG and implementing partners
3) Inadequate standardization and harmonization of M&E systems, and
4) Weak systems for analysis and use of SI data for planning.
The PEPFAR Mozambique SI portfolio is managed by the SI Interagency Technical Working Group (TWG). The SI TWG serves
as the primary coordinating body for SI-related activities, including target setting and program reporting. The SI TWG is
represented on all other TWGs and provides direct SI assistance to these groups.
USG SI Staffing:
The Senior SI Coordinator (CDC) and the HIV/AIDS Program Officer (USAID) serve as co-chairs for the TWG. The Sr. SI
Coordinator also serves as the SI liaison with OGAC. The Senior M&E Specialist (CDC) coordinates M&E activities related to
PEPFAR program reporting and MOH M&E systems. A Community M&E Advisor (USAID) joined the USG team in November
2008 to focus on M&E of community-based HIV services. An Associate Director for Science (CDC) serves as Public Health
Evaluations (PHE) liaison and manages issues related to PHE implementation, human subjects review, and CDC agency
clearance. A PEPFAR Reporting Specialist (Interagency) manages data collection and reporting to OGAC including COP targets,
APR/SAPR data, and reprogramming.
PEPFAR Mozambique continues to face challenges in recruitment of SI staff due to a lack of qualified personnel at the local level,
a lack of Portuguese language skills among U.S. public health professionals, and significant constraints on using third-country
nationals and contractors due to labor regulations in Mozambique. USG is continuing its efforts to fill vacant positions but in the
short-term remains dependent on TDY assistance for many areas within SI.
SI Staffing in the Public Sector:
Ultimately, Mozambique needs to implement creative solutions for building a cadre of Mozambican public health professionals
with adequate SI skills. Increasing local SI capacity is a priority for USG in FY09. National M&E systems, including MOH, the
National AIDS Council (NAC), and other key line ministries remain weak and severely understaffed. There is currently no
epidemiologist counterpart at MOH in HIV/AIDS surveillance and most M&E counterparts in MOH HIV programs are staff funded
through partners and seconded to MOH. Currently, two partner-funded staff are seconded to play vital roles within MOH's
Department of Health Information. Additionally, MOH has requested USG support through COP09 to secure an M&E Advisor to
ensure adequate M&E and reporting systems are in place related to Global Fund grants. At the request of MOH, USG will place
Provincial M&E technical advisors (Mozambican) in all 11 provinces to assist with M&E issues. Until the human resource capacity
improves at MOH, there will be significant needs for technical assistance at every level of the health system.
SI Budget:
The budget for activities funded in the SI program area totals $5,894,673; because of the cross-cutting nature of SI, SI activities
funded in other program areas (with the SI secondary-budget code used in Mozambique) total $4,618,892; therefore SI
constitutes $10,513,565 (6.8%) of the total program
Table 3.3.17:
This is a new activity under COP09.
This is a new activity in that it is organized as its own separate activity, but is a continuation of the
subactivity listed as Activity 8639.08 in COP 08 (Provincial M&E Officers).
Ministry of Health has placed increasing focus on strengthening human and technical resources at the
provincial level to improve the coordination and delivery of services in the province. In FY08, Ministry of
Health developed a standard set of technical advisor positions to be placed at the Provincial level; these
four positions included advisors in Clinical Care, Laboratory, Pharmacy, and Monitoring and Evaluation.
USG was asked to assist with the funding and recruitment of these positions at the provincial level. The
primary partner responsible for providing technical assistance in the area of clinical services in a province
will also be responsible for the recruitment and support of the four technical advisor positions, including this
Monitoring and Evaluation Technical Advisor position.
The M&E Provincial Advisor will provide support in the coordination of routine activities related to monitoring
and evaluation at the Provincial Directorate of Health, giving priority to endemic diseases, including HIV.
This advisor will help to reinforce and support the implementation of the decentralization of HIV services
including related data collection systems. S/he will provide leadership in the supervision and management
of data to ensure the quality of data at the district and site level, help to strengthen the flow of data to the
district, provincial, and central levels. Additionally this person will support the Provincial Directorate of
Health in the analysis and dissemination of data (for example, to the site level, Ministry of Health, and
partners.) This person will sit within the Provincial Department of Planning and Cooperation at the
Provincial Directorate of Health.
The Partner will be asked to place three (3) M&E Advisors in Manica, Sofala and Tete Provinces as part of
its overall support to clinical services in these Provinces.
This is a new activity.
This activity will contribute to strengthening health systems at the site, district and provincial levels with the
goal of developing more sustainable health care systems in Manica, Sofala and Tete Provinces.
The Ministry of Health and the USG are committed to building the technical capacity of Mozambican staff at
all levels to effectively manage high-quality, integrated HIV services. The partner will second one Clinical,
one Pharmacy and one Lab advisor to three Provincial Health Directorate (DPS). These technical support
personnel will directly support their colleagues within the Provincial and District Health Directorates to
ensure the quality of HIV service delivery and the integration of these services within the primary health
system through clinical mentoring; joint planning, supervision & monitoring; and formal & on-the-job training.
In addition to focusing on technical capacity building, the partner will strengthen the institutional capacity of
its MOH partners in the areas of monitoring & evaluation and the management of commodities, human
resources and finances. In addition, partner will assist the District Health Directorates (DDS) with district
level planning for decentralization purposes. HAI will coordinate with the DDS, other PEPFAR-funded
partners and other donor in the districts to build an annual operational plan in such a way as to promote
convergence of all activities in a given district in support of the government of Mozambique's goals and
objectives.
The PEPFAR program has already made a considerable contribution to infrastructure development in
Mozambique. By July 2008 it had supported the renovation or construction, and equipment, of fifteen
laboratories, forty-eight health centers and maternity units, twenty-five hospital consulting rooms, three staff
houses, and twenty-three administrative offices. In addition, thirty-four transportable pre-fabricated
laboratories and diagnostic facilities had been deployed and equipped. A further fifteen houses, seven
maternity units, five health centers and one rural hospital are scheduled for completion by the fall of 2009.
This work was implemented through PEPFAR's Clinical Treatment and Laboratory Partners. COP09 will, for
the first time, treat infrastructure development as a discrete rather than embedded program area, with
appropriate budgetary provision, and a program structure designed to improve the speed, quality and cost-
effectiveness of implementation. Two new mechanisms will be employed: Direct Contracting (see "RFP for
Infrastructure - contracts direct - training centers, warehouses."), and Centrally Managed (see" RFP for
Infrastructure construction - contract health centers, housing, labs, etc."). These arrangements will relieve
PEPFAR's Clinical Treatment and Laboratory Partners of much of the burden of managing activities
somewhat removed from their primary fields of excellence. However there may still be cases where it is
more efficient and appropriate for these Partners to organize minor building repairs and improvements
locally rather than through the centrally managed mechanism. This activity provides discretionary funding
for the partner working in Niassa Province to carry out minor repairs and improvements in support of its core
activities.
Given the urgent need for increasing the number of health care workers at all levels, PEPFAR funds will be
used to pay for course fees associated with attending a pre-service institution. The goal of this activity is to
both increase the production of health care workers and lessen the numbers who drop out due to financial
constraints. HAI will manage a fund for each province to support long term training such as scholarships for
health care workers in such areas as public health, administration, management or epidemiology.
Gap year funding is a means for assuring employment for newly graduated health staff at Ministry of Health
facilities. New graduates will be hired using PEPFAR funds at Ministry of Health salaries and placed at
government health facilities while their recruitment process into the National Health Service is processed.
This typically takes anywhere from 6-12 months. PEPFAR funds for salary support will cease once the
graduate becomes an employee of the National Health Service. It is expected that this gap year funding
will retain graduates at their work while the national health services and other ministries finalize their
recruitment process to transition these new health workers to public servants integrated in the national
health services.
Table 3.3.18:
