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: 2007 2008 2009
SUMMARY
Vanderbilt University / Friends in Global Health (FGH) has been supporting HIV care and treatment in 6
rural districts of Zambezia Province with ongoing plans to scale-up to a total of 24 clinical sites throughout
these 6 districts. FGH support has included direct support to the HIV care and treatment programs with
clinicians; This approach has allowed us to provide one-on-one supervision, clinical mentoring, and
technical assistance to programmatic areas and to focus on our other activities which include training,
logistical support, community development, infrastructure development, monitoring and evaluation, technical
assistance to provincial level MOH (DPS) in Zambezia, provincial human capacity development, and
information technology development. In FY2009, FGH will be expanding its support activities to 6 more
rural districts of Zambezia Province for a total of 12 districts.
Through partner relocation which will be taking place in FY09, FGH will assume support responsibilities for
all facility-based HIV services including HIV care and treatment, PMTCT and counseling and testing in the
districts it supports. This will allow for improved coordination and integration of services offered within the
health units as well as a budgetary scale down of the costs to support these services as a result of economy
of scale. FGH will assume and continue PMTCT services in those sites currently being supported by other
USG PMTCT partners (17 sites) and based on the DPS Zambezia plan for PMTCT roll-out will expand
services to 19 other sites not currently being supported by another USG partner.
ACTIVITIES
(1) Assume responsibility for 17 PMTCT sites and training activities currently supported by other USG
partners. (Estimated budget: $750,000)
These sites will include 11 district headquarters and 6 rural peripheral health units. FGH will support the
provision of a comprehensive package of services integrated with the routine MCH system and the HIV care
and treatment program, with focus on increasing the number of pregnant women who receive appropriate
counseling, testing, and their test results. Once an HIV+ pregnant women is identified she will be staged
clinically, within the MCH setting at the time of diagnosis; staged immunologically with CD4 count; initiated
on cotrimoxazole (CTX) prophylaxis; provided with an appropriate ARV regimen for PMTCT according to
national standards; and offered participation in a psychosocial support group for mothers. Male and family
(including mother in law) involvement in PMTCT/MCH services will be encouraged through invitations and
psychosocial support activities. Wherever possible, malaria prevention interventions (such as distribution of
bed nets) will be integrated into the PMTCT approach in coordination with PMI. Promotion of dual
protection among HIV+ women will continue, and provider-initiated testing and counseling (PITC) will be
implemented within FP services.
HIV+ pregnant women will be integrated into the existing FGH supported adherence network to support
followup for both mother and child, medication adherence including CTX prophylaxis, encouragement for
facility-based birth and appropriate post birth referral, treatment. FGH proposes to focus on the MOH-
approved PMTCT regimen which includes AZT; the target is 70% uptake of ARV prophylaxis among HIV+
pregnant women in FY09. Among all women receiving ARV prophylaxis, at least 20% will be intiated on
ART.
Exposed infants will received an appropriate ARV regimen for PMTCT according to national guidelines,
CTX prophylaxis, and support for best infant feeding practices for reduction of MTCT as described below.
Early infant diagnosis will continue to scale up in FY09.
Due to FGH´s already existing infrastructure for HIV care and treatment, additional costs for support to the
PMTCT program including training/clinical mentoring of health care workers, integration of patients into the
existing medical record and monitoring and evaluation systems, logistical support, and health center
infrastructure support will be kept at a minimum. This will include the salary support for one local MCH
nurse and supervisory staff as well as contribute to the purchase of supplies needed such as PMTCT
registries, hemoglobin meters, and health education materials. FGH will also continue to support routine
syphilis testing and treatment when needed.
HIV+ pregnant women will also receive nutritional assessment and be offered micronutrient
supplementation and nutritional counseling which will focus on the mother´s nutritional needs as well as the
importance of exclusive breastfeeding and rapid weaning for the child. In support of best feeding practices
for reduction of MTCT, FGH currently supports educational cooking demonstrations for mothers waiting to
have their children seen in the CCR (child at risk clinic) and will expand these courses to include mothers
waiting to be seen in the PMTCT clinic. In addition, based on preliminary data collected by FGH in its HIV
Care and Treatment program, approximately 10% of HIV+ patients are severely malnourished. For those
women determined eligible (BMI adjusted for gestational age or MUAC), FGH is proposing to provide
targeted food support, using Fortified Blended Foods, Ready to Use Therapeutic Foods, and/or Corn Soya
Blends, for HIV+ pregnant and lactating women based on the "Food by Prescription" model.
(2) Expansion of support for PMTCT based on the DPS Zambezia plan for PMTCT roll-out to include 19
other sites not currently supported by another USG partner. (Estimated budget: $930,000)
This will include 1 district headquarter (Chinde) and 18 peripheral health units. These sites correspond to
the DPS PMTCT roll-out plan and the existing FGH expansion plan for HIV Care and Treatment.
Programmatic activities and support will be the same as mentioned above. Some funds will be allocated to
address energy and water needs, as well as medical equipment (including gas or solar powered
refrigerators to keep stocks of HIV rapid tests, vaccinations and medications for the PMTCT program).
For both activities (1) and (2), the model of support will begin to transition in FY09 to provide more district-
level capacity building, including coordinated supervision with DPS teams, and less site-specific support.
(3) Training and integration of Traditional Birth Attendants (TBAs) to support facility-based delivery and
follow up. (Estimated budget: $90,000)
As part of the existing FGH adherence network, FGH will target the integration of TBAs into facility-based
services in each district. FGH proposes supporting the creation of associations of TBA´s and providing
them with training related to HIV, PMTCT, to encourage them to support facility-based deliveries. As these
associations develop and strengthen FGH will help the creation of a referral system between the health
units and the TBA´s and vice versa. FGH estimates it will train approximately 20 TBA´s per district at a cost
of $10,000 per training.
Activity Narrative: (4) Health information system support for PMTCT at district level. (Estimated budget: $30,000)
FGH is currently undertaking a roll-out of an OpenSource medical record system in the health units in which
it supports HIV Care and Treatment which will help integration of services, improve patient tracking, improve
monitoring and evaluation activities, improve implementation of HIVQUAL and will be used for all reporting
requirements for PEPFAR and MISAU. As a result, FGH´s PMTCT activities will easily be incorporated into
this system at a minimal cost per health unit. FGH estimates an initial start up cost of $1000 per site.
New/Continuing Activity: Continuing Activity
Continuing Activity: 15778
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
15778 15778.08 HHS/Centers for Vanderbilt 6415 6127.08 CDC-Vanderbilt $490,200
Disease Control & University CoAg
Prevention
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Malaria (PMI)
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $450,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $25,000
and Service Delivery
Food and Nutrition: Commodities
Estimated amount of funding that is planned for Food and Nutrition: Commodities $100,000
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
Summary and Background:
To date FGH has been supporting HIV Care and Treatment in 6 rural districts of Zambezia Province with
ongoing plans to scale-up care and treatment to a total of 24 clinical sites throughout these 6 districts. FGH
support has included direct support to the HIV Care and Treatment programs with ex-patriot clinicians which
live and work in the above districts. This approach has allowed us to provide one-on-one supervision,
clinical mentoring, and technical assistance to programmatic areas and to focus our other activities which
include training, logistical support, community development, infrastructure development, monitoring and
evaluation, technical assistance to DPS Zambezia, provincial human capacity development and information
technology development.
Through partner re-allocation which will be taking place in FY2009, FGH will assume support
responsibilities for 3 districts previously supported by another USG PEPFAR partner and 3 districts NOT
previously supported by another USG PEPFAR partner. As well, FGH will assume support activities for all
facility-based HIV services including HIV Care and Treatment, PMTCT and Counseling and Testing in the
of scale. In coordination with DPS Zambezia, provincially approved plans for roll-out of HIV Care services
include FGH expansion of services to 2 sites in each of the new districts for a total of 36 sites in all districts
supported by FGH. These sites will initially be satellite sites, 6 of which are expected to progress to fixed
sites by the end of calendar year 2009.
Program Area: Minimum Package of Services Offered for HIV Care and Support
Activity 1: FGH will ensure a minimum package of services for patients in follow-up in the HIV care and
support programs in the 36 sites supported by FGH. This will include direct on the job training and clinical
mentoring by FGH clinicians living and working in the districts to ensure appropriate high quality clinical and
nutritional assessments, laboratory follow-up, and prophylaxis for OI´s. National health workers will also
receive clinical mentoring for appropriate diagnosis and medical management of opportunistic infections as
well as mentoring for appropriate pain management and follow-up.
As well, technical assistance will be provided for overall program organization to ensure strengthened
linkages with other facility and community based services such as the TB program and HBC services. FGH
will provide support for counseling services for medication adherence, psychosocial support and
bereavement counseling. FGH counseling support will focus on increasing partner testing, identifying
discordant couples, and prevention and educational activities to empower partners to diminish their risk of
HIV infection.
Estimated budget: (no extra cost. Included as part of other activities)
Program Area: Human Capacity Development and Training related to OI
Activity 1: FGH will continue to work with the DPS-Zambezia to finance Provincial level trainings on the
management and diagnosis of OI. In FY09, FGH proposes to support 2 provincial level trainings for
Doctors, Tecnicos de Medicina, Nurses and other mid-level technicians. The cost of each training is
estimated at $26,000 and approximately 90 persons will be trained.
Estimated budget: $52,000.00
Program Area: System Strengthening Activities
Activity 1: System strengthening activities continue with the MoH and MMAS in support of Integrated Care
and Support sites for piloting of standardized community psychosocial support materials. This also provides
additional support to the Palliative Care Action Plan related to changing attitudes and policies for greater
access to essential medications including more varied opiate formulations and improved training materials
at all levels.
Estimated budget: $95,259.00
Program Area: Monitoring and Evaluation
Activity 1: FGH will continue to integrate all HIV related services into its electronic database for improved
management and follow-up, including those patients in HIV care and treatment receiving prophylaxis with co
-trimoxazole. As well, FGH will provide equipment and technical assistance to the district level (NEPs) to
ensure that district health centers have the capacity to improve OI surveillance and epidemiologic reporting.
This system will be integrated between FGH and the DPS-Zambezia at both a district and Provincial level.
Estimated budget: $12,000.00 ($1000 per district)
Program Area: Nutritional Assessment
Activity 1: As a part of the comprehensive package of services offered to HIV+ patients identified as
severely malnourished, FGH will support the implementation of an integrated food and nutritional support
program. This service will begin with a nutritional status assessment of all patients who test HIV+ in FGH
supported sites. This service will be offered and implemented for all patients entering the various HIV
clinical services (Care and treatment, Pediatrics and PMTCT). FGH will provide training to an average of 20
health care workers per district on nutritional health activities and support the salary of an additional mid-
level Clinical Officer in every district. FGH currently supports educational cooking demonstrations for
mothers waiting to have their children seen in the CCR (child at risk clinic) and will expand these courses to
include mothers waiting to be seen in the PMTCT clinic, as well as patients waiting to be seen in the HIV
care and treatment clinics.
Estimated budget: $0.00 (please see FGH Adult Care and Treatment AND PMTCT Activity Sheet)
Activity Narrative: Program Area: Integrated Supervisions:
Activity 1: FGH will work in concert with DPS-Zambezia to coordinate DPS supervisions at the district level
with regards to all HIV Care and Treatment services including ART, OI, Pediatric ART, PMTCT, CT, and TB
services. FGH will support the logistics and per diems to perform one supervision per month ($500 per
supervision) and include peripheral health units which have expanded to include HIV Care and Treatment.
Estimated Budget: $6,000.00
Program Area: HIV/STI activities
Activity 1: HIV-positive individuals who are co-infected with sexually transmitted infections (STI) are at high
risk of transmitting not only STI, but also HIV to their sexual partners. An important aspect of prevention of
HIV transmission among positives is to rapidly inform the partners of dually infected patients of their
possible exposure so they can seek and receive appropriate STI and HIV diagnosis and treatment. As part
of an assessment of the burden of STI among HIV-infected individuals conducted in Mozambique in 2007-
2008, 498 patients were enrolled and given cards to give to their partners to invite the partners for STI and
HIV counseling and testing (a method used in Mozambique STI clinics in the past). Only 13 of their
partners sought care at the specified health facility, but since the 2007 assessment was not designed to
evaluate this component it is unclear if the patients sought care elsewhere or the intervention was not
effective. Counseling has also been used by providers to encourage patients diagnosed with STI to bring
their partners in, but it is unclear how effective this method is in Mozambique. Vanderbilt has been
supporting DPS Zambezia in a case finding initiative, in which health workers contact the partners of
patients with HIV, but it is not understood how effective this is in bringing partners in to health facilities. This
activity will measure the effectiveness of these partner notification strategies through the number of partners
seeking HIV testing, number of partners seeking syphilis testing, and number of partners treated with STI
medications. The findings of this activity will be used to inform the program on how to better reach out to
partners at high risk of HIV and STI.
Estimated budget: $100,000.00
Program Area: VIA/Cryotherapy for the early diagnosis and prevention of cervical cancer
Activity 1: FGH will support the roll-out of and implementation of services for VIA/Cryotherapy for cervical
cancer prevention in accordance with MISAU plans for expansion. In year one, initial plans will be to
support services in two rural district health units (Namacura and Inhassunge) as well as the Provincial
Hospital serving as reference center for more difficult and advanced cases. Visual Inspection with Acetic
Acid (VIA) is a simple, proven method for the early diagnosis of pre-cancerous cervical cells appropriate for
the limited resource environment of Zambezia Province. FGH support will include training and recruitment
of health workers, purchase of equipment and commodities, and transport of high risk patients to referral
center.
Estimated budget: $50,000.00
Total Budget Estimate: $315,259.00
Reprogramming August08: Funding increase $200,000. Additional activities around Caring for Carers will
be added to the Vanderbilt's activities. In a plan developed through dialogue with the Ministry of Health, this
could involve an exchange experience with Brazil who have developed an accessible "Community Therapy"
model of support to caregivers, as well as the development and piloting of a caring for caregivers training
module, establishing functional support groups for caregivers, training organizational staff on how to provide
training and support for caregivers, and reinforcing links between community organizations and clinical
facilities.
Friends in Global Health - FGH (Vanderbilt University) activities for Palliative Care: Basic health care and
support, including direct implementation activities in Zambézia Province and systems strengthening at the
Central, Provincial and District levels.
Implementation activities in Zambezia Province:
Vanderbilt U./Friends in Global Health is currently providing adult and pediatric HIV care and ART treatment
services in 4 districts in Zambézia Province (Alto Molocue, Ile, Namacurra, Inhassunge), with expansion
planned in 2 more districts (Gile, Lugela). Treatment site expansion will continue to support on-going work
in 7 currently supported sites (Alto Molocue, Nauela, Ile, Mogulama, Namacurra, Macuze, Inhassunge)
within 4 districts and expand to include 4 sites in each district (24 sites in 6 districts) plus the addition of 4
mobile clinics total in 4 districts. This district-wide expansion will result in a total of 28 points of service in the
six districts supported by FGH/VU.
• Support implementation and maintenance of information system to monitor HIV-related palliative care
activities
• Support project data collection by the National AIDS Council (CNCS) for accurate and updated mapping of
NGO activities
• Support SDSAS (District Health and Social Service Department) to coordinate HBC activities in each
district
• Designate and support a focal point in each FGH-supported health facility to coordinate with health
(including HBC), social, legal, and other services available to PLWHA
• Support the formation and functioning of PLWHA groups
• Support ANSA (Food Security and Nutrition Association) to train PLWHA and their families on best
nutritional practices using locally available products
• Support coordination with WFP and UNICEF in distribution of nutritional supplements for eligible PLWHA
including children
• Support Medical Service Corporation International (MSCI) and/or local community organization to start
HBC and HIV-related palliative care services in localities where such services are not yet available
Activity Narrative: • Support the implementation of a minimum package of services provincially, to include the distribution of
ITBN (Insecticide Treated Bednets) in coordination with PMI and the distribution of certeza
• Support pilot activities in two districts for PLWHA transportation systems to reach points of service
Targets:
As a result of these activities, the following targets will be achieved:
Number of service outlets providing HIV-related palliative care: 28*
Number of individuals provided with HIV-related palliative care: 6250*
Number of individuals trained to coordinate HIV-related palliative care based in Health Facilities: 56
* (clinical + community based)
Systems Strengthening activities:
VU/FGH will provide technical support to the MOH, MMAS, and CNCS in systems strengthening
(coordination and referral systems, materials development, M&E, supervision tools, policy development,
etc), including support of the National Mozambican Women's Organization (OMM) for their care, support
and training activities. Activities include:
• OMM - Care, support and Training Center in Gaza Province
• Twinning support with South African multi-service centers and the OMM in: changing cultural norms,
gender-based violence, economic support (income generating activities such as soap making and others)
• Support MOH in the development and revision of HBC materials and ensure the incorporation of palliative
care concepts in the new Community Health Worker materials
• Provide MOH with technical support on Palliative care and Food policy
• Provide initial and ongoing technical support to MMAS in the development of psycho-social support and
other materials related to the implementation of Integrated Care and support systems
• Provide support to MMAS for supervision, M&E, and QA of HIV-related social support activities
• Develop an M&E framework for an Urban HBC model to measure quality and inform policy development in
this area
• Provide technical support to CNCS to develop a plan to strengthen coordination with the MOH in the
selection of HBC/OVC proposals to roll-out with ART
• Support the development and implementation of standard tools for mapping health and social services
including HBC, legal services, and other services available to PLWHA
To implement these HIV-related palliative care and HBC activities, VU/FGH will recruit the following
technical staff:
• Palliative Care/HBC Technical Advisor
• Palliative Care/HBC Coordinator
• Integrated Care and Support Supervisor
Continuing Activity: 13214
13214 12265.08 HHS/Centers for Vanderbilt 6415 6127.08 CDC-Vanderbilt $894,920
12265 12265.07 HHS/Centers for Vanderbilt 6127 6127.07 $915,000
Disease Control & University
Estimated amount of funding that is planned for Human Capacity Development $100,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $30,000
Estimated amount of funding that is planned for Education $60,000
Table 3.3.08:
April09 Reprogramming: Increased $149,176.
This is a continuing activity from FY08 and the narrative replaces the FY08 narrative; it is linked to
Vanderbilt University's activities that are funded through the system strenghthing, PMTCT, pediatrics care
and support, laboratory and infrastructure, and strategic information activities funded in FY09.
ongoing plans to scale-up care and treatment to a total of 24 official ART clinical sites tin 12 districts. In
addition, vanderbilt supports 12 outreach sites. FGH support has included direct support to the HIV Care
and Treatment programs with clinicians who live and work in the above districts. This approach has allowed
us to provide one-on-one supervision, clinical mentoring, and technical assistance to programmatic areas
and to focus other activities which include training, logistical support, community development, infrastructure
development, monitoring and evaluation, technical assistance to DPS Zambezia, provincial human capacity
development and information technology development.
The Mozambique PEPFAR team's partner rationalisation process will result in FGH assuming support
previously supported by another USG PEPFAR partner. As well FGH will assume support activities for all
of scale. In coordination with DPS Zambezia approved plans for roll-out of HIV Care and Treatment
services, FGH will expand services to include 2 sites in each of the new districts for a total of 36 sites in all
districts supported by FGH (24 ART sites and 12 otreach sites).
Program Area: Continue HIV Care and Treatment activities in 6 districts of Zambezia
Activity 1: The first activity will be to continue to support a comprehensive HIV Care and Treatment program
in each of the original 6 districts FGH supports. FGH is currently underway with expansion of HIV care and
treatment services to a total of 4 sites in each of its original 6 districts ( 6 ART sites plus 18 satellite sites).
FGH clinicians based and working in the districts provide ongoing oganizational management and
supervision of HIV clinical services as well as act as a focal point for all FGH related support activities
including logistics, human resources, community outreach, monitoring and evaluation and information
technology. As the first phase of implementing programs is now well developed in the main district health
units of each district, FGH will transition its focus to include:1) Rapidly expanding services to those
peripheral health units it supports. Expansion of services has already begun in peripheral health units but
have been limited in their functioning as a "satellite clinic" of the district sede. This is mainly due to lack of
appropriate infrastructure conditions and lack of human resources. FGH rehabilitation plans have already
been implemented and renovations should be completed or started in the very near future. FGH will
continue to support the salaries of a portionof the national health workers and continue to recruit sufficient
national health workers for the peripheral health units to function independently 2) Elevating quality of
services. FGH will continue its program of clinical mentorship targeting all health workers supporting the
HIV clinical services as well partner with I-Tech to implements its MISAU approved clinical mentoring
program for Tecnicos de Medicina. Due to the partner re-location plans, FGH will focus on efficiency and
strengthening of linkages between various services such as TB, PMTCT, CT, and Pediatrics. Funding is
included for 1 Provincial Technical advisor (clinical advisor) for the DPS in Zambezia province.
Estimated budget: $1,320,000.00
Program area: Begin to support HIV Care and treatment activities in 6 districts in zambezia
Activity 1: FGH will assume support responsibilities in 3 districts previously supported by another USG
PEPFAR partner using the same model as described above. Transition plans are currently being discussed
and should be implemented early in the year 2009. In the first year FGH will support a comprehensive HIV
Care and Treatment program in the main district capital and one peripheral health unit per district (total 6
sites).
stimate budget. $330,000.00
Activity 2: FGH will begin supporting two districts which were not previosuly supported by a USG PEPFAR
partner but which did have support from another international NGO (CIC) to scale-up ART services. FGH
will support the work of this NGO through a subcontract providing them funds to continue their services as
well as integrate services offered by FGH to ensure a comprehensive package of HIV care and treatment
services. As with the above model FGH in partnership with CIC will support two sites in each of these
districts (total 4 sites).
Estimated budget: $268,000.00
Activity 3: FGH will initiate its comprehensive package of HIV care and treatment services in one new
district not previously supported by any USG PEPFAR partner (Chinde) and expand services as above to
include two sites in the district (total 2 sites)
Estimated budget: $135,357.00
Program Area: Strengthen referral, linkages and follow -up activities between the ARV services and
PMTCT, TB, and STI services to create a comprehensive package of clinical services.
Activity 1: Continue to expand and support the FGH created electronic medical record system that will be
established in collaboration with MISAU and the DPS based on an open source platform, being developed
in Zambia and other countries. This will allow individual medical records to be available to selected primary
care clinics, including those with maternities and ANC services, TB screening and care, and general STI,
Activity Narrative: malaria and other co-infections relevant for prevention or care of HIV patients. This linkage will facilitate
patient follow - up and improve quality of care.
Activity 2: This activity will be to continue to reinforce and strengthen activities related to patient adherence
to medication and appointments. FGH currently is supporting peer educator programs in its existing sites
and will expand this program to all future FGH supported sites. This program consists of 6 peer educators
per site (216 total) recruited from local PLWHA groups to participate in case finding, home based visits, and
health center educational activities. Using peer educators in this manner FGH has been able to be more
proactive in relation to patient case finding and provide a home based visit to patients which targets the first
month after initiation of treatment to engage the patient in the system before they are lost to follow-up. Peer
educators will be given a monthly stipend, bicycles, and 3 annual trainings
Estimated budget: $250,000.00
Activity 3: FGH will establish a case management system in each district by contracting one national
Psychologist/Anthropologist/Social scientist per district ($15,000/yr) to reinforce FGH community outreach
activities aimed at improving adherence and treatment literacy at the district level. This person will become
a focal point for all patients entering treatment to ensure coordination and access to all HIV related services
offered in the district such as nutritional support, home based care, transportation support etc. This person
will coordinate services within the health unit related to linkages with other clinical services and coordinate
those activities of the social assistants and peer educators to ensure an efficient and functioning home
based visit and busca activa program, thus diminishing time patients are lost to follow-up and easily
incorporating them back into the system if lost. Costs include $180,000 in salary support, $60,000 in
trainings, and $5000 per district for equipment, supplies, and logistical costs to run the program)
Estimated budget: $300,000.00
Program Area: Expansion of HIVQUAL quality measurement and improvement system
Activity 1: FGH will continue to provide assistance and support for the implementation of HIVQUAL in all
sites supported by FGH.
Estimated budget: $24,000.00
Program Area: Creation of and support to Groups/Associations of PLWHA´s for purpose of social support
and economic strengthening
Activity 1: Through Community Outreach activities FGH is currently assisting with the creation of
associations of persons living with HIV/AIDS (PLWHA) in each of the districts it supports to provide social
support and the opportunity as a group to develop economic strengthening microfinance activities. FGH
supports these activities through trainings and assistance with legalization/organization. These training also
include increasing knowledge and assistance related to inheritance laws.
Estimated budget: $360,000.00
Program Area: Integrated Food and Nutritional Support
severely malnurished, FGH will support the implementation of an integrated food and nutritional support
level Tecnico de Nutrição in every district. FGH currently supports educational cooking demonstrations for
include mothers waiting to be seen in the PMTCT clinic.
Estimated budget: $0.00 (please see FGH PMTCT Activity Sheet)
Activity 2: The second activity will be the implementation of a targeted food support program for HIV+
patients based on the "Food by Prescription" model. Based on preliminary data collected by FGH in its HIV
Care and Treatment program, approximately 10% of HIV+ patients are severely malnourished with a BMI <
16kg/m2 and will be eligible for targeted food support. For those patients determined eligible, FGH is
proposing to provide targeted food support using Fortified Blended Foods (FBF), Ready to Use Therapeutic
Foods (RUTF), and/or Corn Soya Blends (CSB) (depending on availability in country) for a minimum of
1300 Kcal per day (approximately 50% of the energy requirement for symptomatic HIV-infected adults).
Based on results from Kenya, after 4-6 months patients no longer required targeted food support due to an
elevation in their BMI. We estimate that 10% of our HIV+ patients will equal approximately 750 adults and
that purchase of food commodities will cost approximately $1.00 per day per patient or $120.00 per patient
for a 4 month period.
Estimated budget: $90,000
Activity 3: To support the above mentioned Food by Prescription Program we estimate upfront starting costs
in year one to create the capacity in province to support the logistics of this program. This program will
require support of a supply chain system for procurement, shipping and distribution into the province and
districts as well as increased warehousing capacity at the district level. Included in this estimate is the
salary of a dedicated position related to food logistics.
Program Area: Integration and Support for Peace Corps Volunteers
Activity 1: FGH currently supports housing and project activites for four Peace Corps Volunteers. These
four volunteers will be entering their second year in FY09. As well, this year FGH will be assigned 3 new
PCV´s. FGH will continue to provide guidance and support for these 7 volunteers in projects thats directly
Activity Narrative: support HIV Care and Treatment programs. FGH will continue to support their housing needs and average
$5000 per volunteer for program activites.
Estimated Budget: $50,000.00
Continuing Activity: 13215
13215 12270.08 HHS/Centers for Vanderbilt 6415 6127.08 CDC-Vanderbilt $7,022,000
12270 12270.07 HHS/Centers for Vanderbilt 6127 6127.07 $195,000
* TB
Estimated amount of funding that is planned for Human Capacity Development $1,800,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $90,000
Estimated amount of funding that is planned for Economic Strengthening $360,000
Estimated amount of funding that is planned for Education $600,000
Table 3.3.09:
Prior to November 2007, pediatric HIV care and treatment was limited in Zambezia Province due to lack of
trained personnel, lack of diagnostic options for HIV in children less than 18 months of age, poor
coordination of supply chain mangement with regards to infant ART formulations, and poorly coordinated
services amongst DPS and USG partners supporting PMTCT and pediatric care. With the roll-out plans for
EID, priorities shifted within the province to focus on increasing the number of children in pediatric care and
treatment. In collaboration with DPS and all USG partners providing treatment support and PMTCT, FGH
led the development of a provincial pediatric working group to evaluate weakness´ in the program and
recommendations for moving forward. A series of trainings were implemented to strengthen the linkages
between PMTCT and CCR clinics, provide updates to health care workers on pediatric mangement in
general and flow of patients through the various services, and trainings of health care workers on PCR and
pediatric ART. Currently in the sites FGH supports, direct salary support has been given to provide a
dedicated nurse specifically for the CCR clinic followed by direct clinical mentoring and supervision from
FGH clinicians living and working in the sites. FGH has provided technical assistance and resources for the
organization of these clinics by improving dedicated space and appropriate medical equipment for pediatric
care, incorporation of the CCR registries into an electronic database which is shared with DPS to facilitate
national and provincial data collection, strengthened linkages between PMTCT and the CCR clinic for both
mother and child by focusing on the first month post delivery for home based visits to assist with education
for appropriately taking medicines, reminders of upcoming appointments, and education regarding exclusive
breast feeding and weening practices. PCR is currently offered in every district of Zambezia province,
however the system is still weak due to logistical issues of sample transport and an overburdened national
laboratory for sample processing. Currently, results are averaging 8-10 weeks for return to the site. In the
upcoming months, FGH has plans to support a interprovincial transport system of DBS for PCR to diminish
logistical transport time and this month a new PCR machine in Nampula province will begin processing
samples from Zambezia which will hopefully decrease turn around time of sample results.
Program Area: Support the organization and infrastructure to CCR clinics in 12 districts supported by FGH
FGH will continue to support the CCR clinics in each FGH supported district to provide a minimum package
of services in all sites. This includes temporary salary (will become MoH responsability) support for a
dedicated national nurse to staff and run the CCR clinic. Using FGH´s already established network of
clinicians which live and work in the districts, FGH will continue to provide direct clinical mentoring to health
workers staffing the CCR clinic to provide on the job training and ensure a high quality of care which is
delivered. These clinicians will also provide technical assistance for program management which will
ensure appropriate referrals are made from all pediatric entry points into the health center (PMTCT, healthy
child, pediatric triage, and inpatient, etc) and oversee the testing of children in the sites based on the
MISAU directed "opt-out" strategy. Follow-up services for children in the CCR clinic will include appropriate
clinical assessments, nutritional evaluations, monitoring of growth and development,management of OIs
and appropriate testing for HIV using PCR or rapid tests depending on the age of the child. Mothers will
receive nutritional education regarding exclusive breastfeeding and safe weaning after 6 months where
applicable. All children followed in the CCR will receive co-trimoxazole prophylaxis per MISAU protocols.
FGH will continue to provide technical assistance for staff in the CCR clinic to provide on-site nutritional
education for mothers. Children identified with nutritional deficiencies will be appropriately referred for a
more thorough nutritional assessment and linked with MISAU programs for provisions of targeted food
support such as "Plumpy Nut".
Using FGH´s Social Assistants in the community, FGH will strengthen linkages with CBO programs working
with OVC´s to coordinate activities including HIV counseling and testing and referrals if necessary into care
and treatment.
Efforts will also be done to asure provision of ITN, safe water and food support, through linkages with
community based organizations and other PEPFAR partners.
Peer educators will provide psychosocial support, counseling on medication adherence, and reminders of
appointments for both mother and child.
For monitoring and evaluation:
FGH will continue to link these patients into its electronic database to ensure appropriate follow-up and
monitoring of clinical status. These data will be integrated with DPS- Zambezia databases to ensure quality
and efficiency of data collected. Using these data, FGH will be able to rapidly identify children who have
missed appointments or are lost-to-follow-up and refer quickly to the pre-established FGH system for busca-
activa (active search). As well FGH will proactively seek to keep children in care by integrating all children
born into the PMTCT program into it´s peer educator referral system. This system focuses on the first
month following birth and ensures at least one home visit by a peer educator during this month.
Estimated budget: $97,151.00
* Child Survival Activities
* Family Planning
* Safe Motherhood
Estimated amount of funding that is planned for Human Capacity Development $97,151
Table 3.3.10:
April09 Reprogramming: Increased $12,459.
To date, FGH has been supporting HIV Care and Treatment in 6 rural districts of Zambezia Province with
support has included direct support to the HIV Care and Treatment programs with experienced clinicians
who live and work in the above districts. This approach has allowed us to provide one-on-one supervision,
In FY2009, FGH will be expanding its support activities to 6 more rural districts of Zambezia Province for a
total of 12 districts.
Through partner re-location which will be taking place in FY2009, FGH will assume support responsibilities
for all facility-based HIV services including HIV Care and Treatment, Pediatric HIV care and treatment,
PMTCT and Counseling and Testing in the districts it supports. This will allow for improved coordination
and integration of services offered within the health units as well as a budgetary scale down of the costs to
support these services as a result of economy of scale.
National Level Support
• FGH provides technical assitance to the national Pediatric care and treatment program by participating in
the technical working group meetings for Early Infant Diagnosis and pediatric treatment. FGH currently has
pediatricians employed and working in Zambezia province.
Provincial and/or District Level Support
• At the provincial level FGH, provides direct support to the national roll-out of PCR for early infant diagnosis
through support of trainings for provincial health workers on aspects of pediatric care, PCR, and technical
assistance to the provincial and district laboratories in relation to logistics and management of sample
collection and transport. Currently, FGH is exploring ways to improve provincial transport of DPS for PCR
through outsourcing tranportation services to international courier services to diminish length of time for
receiving results. In accordance with MOH guidelines for the training of national health workers on Pediatric
ART, FGH has provided direct financial support for provincial level trainings and post-training clinical
mentoring at a facility level to ensure a high quality of service delivery.
Program Area: Continue Pediatric HIV treatment activities in 6 districts of Zambezia (24 sites)
Activity 1: FGH currently supports pediatric HIV treatment in 6 districts with ongoing plans to expand these
services to a total of four sites per district by August 2009. Currently, 12 sites in these 6 districts offer
pediatric ART and this will expand to a total of 24 sites in these districts over the next year.
Prior to November 2007, pediatric HIV care and treatment services were very limited in Zambezia Province
due to lack of trained personnel, lack of diagnostic options for HIV in children less than 18 months of age,
poor coordination of supply chain mangement with regards to infant ART formulations, and poorly
coordinated services amongst DPS and USG partners supporting PMTCT and pediatric care. With the roll-
out plans for EID, priorities shifted within the province to focus on increasing the number of children in
pediatric care and treatment. In collaboration with DPS and all USG partners providing treatment support
and PMTCT, FGH led the development of a provincial pediatric working group to evaluate weaknesess in
the program and recommendations for moving forward. A series of trainings were implemented to
strengthen the linkages between PMTCT and CCR clinics, provide updates to health care workers on
pediatric mangement in general and flow of patients through the various services, and trainings of health
care workers on PCR and pediatric ART.
FGH will provide technical assistance and resources for the organization of Pediatric HIV treatment clinics
by improving dedicated space and appropriate medical equipment for pediatric care, strengthened linkages
between PMTCT and the CCR clinic for both mother and child by focusing on the first month post delivery
for home-based visits to assist with education for appropriately taking medicines, reminders of upcoming
appointments, and education regarding exclusive breast feeding and weaning practices.
To increase access to pediatric treatment, FGH will building the capacity of health staff to provide pediatric
treatment, ensuring provider initiated counseling and testing at each entry point for children to enhance the
identification of infants and children in need of ART and improving linkages between PMTCT and Care &
Treatment services.
FGH will support formal trainings in various areas including, EID, PITC, pediatric ART, pediatric counseling
and adherence support, counseling on nutrition and HIV and screening and treatment of malnutrition,
including the use of "ready for use therapeutic feed" (RUTF). FGH will also provide on the job training and
mentoring for national health workers trained in pediatric ART with regards to appropriate clinical staging,
diagnosis of OI´s and appropriate management.
FGH will continue to provide counseling services for both children and their caregivers to provide
psychosocial support, medication adherence education, and appropriate referrals to other health center
services. Partnerships will be established with local CBOs to continue provision of psychosocial services
for patients in care and on ART, including active tracing of defaulting patients .
For ART program monitoring FGH will incorporate pediatric patients on ART into an electronic database
which is shared with DPS to facilitate national and provincial data collectionn and evaluation.
Estimated budget $240,000.00
Activity Narrative: Program area: Begin to support Pediatric HIV treatment activities in 6 districts in Zambezia not previously
supported by FGH (12 sites)
Activity 1: In FY09 FGH will be expanding and/or assuming responsibity for services in 6 more districts with
plans to support services in 12 sites total in these districts. The same model of care as previously
described will be implemented in these districts as well.
Estimated Budget: $120,000.00
This will bring to a total 36 sites which FGH is supporting for pediatric HIV care and treatment in Zambezia
province
Program Area: Support the implementation of laboratory transport system for Early Infant Diagnosis
Activity 1: In an attempt to strengthen and diminish turn around time for results of DPS PCR for EID, FGH
will support the implementation of a provincial wide laboratory transport system utilizing private courrier
services. This system will provide district level to provincial level transport of samples which will then
integrate into the National PCR roll-out system for transport between the Province and central laboratories
responsible for sample processing.
Program area: Human capacity development and training in Pediatric Treatment
Activity 1: Recognizing that one of the bottle necks in the rapid scale-up of pediatric HIV treatment is a lack
of health care workers trained and comfortable in all levels of pediatric HIV care and treatment, FGH will
continue to support provincial level trainings in relation to Pediatric ART and OI´s (50 persons trained). As
well, FGH will contiue to support smaller district level continuing education trainings on Pediatric ART and
OI´s (240 persons trained)
Program area: Direct Observed Therapy for Pediatric ART targeting the first 2 weeks of therapy
Activity 1: Recognizing that current MISAU regimens for pediatric ART depend on a Nevirapine based first
line therapy and the difficulties of administration experienced by our patient population associated with use
of four syrup formulations during this time period (including co-trimoxazole), FGH will create a system for
DOT based on the experiences and successes of the DOT-C programs for TB. Incorporated into the FGH
Peer Educator program, FGH will identify a team of Peer Educators in each district dedicated specifically to
the Pediatric DOT program which will perform home visits to provide continuous reinforcement and
education regarding the administration of pediatric formulations accurately. This team of Peer Educators
will be trained on the proper administration of pediatric syrup formulations and how to identify serious side
effects of ART formulations for quick referral back to the health center. After the first 2 week period, children
will continue to be followed in the pediatric HIV treatment clinic as previously described.
Estimated budget: $120,000.00
Total Budget Estimate: $680,000.00
Program Budget Code: 12 - HVTB Care: TB/HIV
Total Planned Funding for Program Budget Code: $3,668,470
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
In the 2007 Global TB Report (WHO, 2008), Mozambique is considered among high burden countries with an estimated incidence
of 443 cases/100,000 population. In 2007, the Mozambique National Program reported 38,999 TB cases, with 47% of TB cases
reported as HIV infected. In the 1980s Mozambique adopted the DOTS Strategy through technical assistance from the
International Union Against TB and Lung Disease (IUATLD) and has reported 100% DOTS coverage since 2000. However, health
infrastructure is extremely limited in Mozambique and only an estimated 40% of the population has access to DOTS services
(defined as a health facility within 10km of a patient's residence). TB case detection was 37% in 2006; well below the global
target of 70%. For the 2005 cohort, treatment outcomes remained inadequate, with 79% successful treatment completion rate
(global target 85%). Case finding relies on smear microscopy, but laboratory infrastructure for TB diagnosis is limited throughout
the country. At present, there is only one national laboratory capable of performing mycobacterial culture and first-line drug
susceptibility testing. Second-line drug (SLD) testing, when performed, must be sent to South Africa or other international
reference facilities.
Key donors to the national TB control program include the USG and the Global Fund. Mozambique was awarded $14.2 million for
TB in the Global Fund Round 2. As of September 2008, $8.8 million has been disbursed. In 2007 the country applied for the
Round 7 funds and a total amount of $6.7 million was approved (with a 5-year total of $21 million). The National Tuberculosis
Program (NTP) mission is to improve quality of services and interventions in the primary health care system through early case
detection and adequate treatment of patients. Furthermore, the country's National Tuberculosis Strategic Plan 2008-2012 aims at
reducing the country's burden of TB in line with the Millennium Development Goals.
Mozambique has one of the highest documented rates of multidrug-resistant TB (MDR) in Africa (WHO/IUATLD Drug Resistance
Surveillance). A national survey in 1998-1999 found that 3.4% of new patients had MDR TB and that drug resistance (isoniazid
and streptomycin) was higher among HIV-infected TB patients. In February 2007, the NTP initiated a new national drug resistance
survey in collaboration with the supra-national reference laboratory in Milan and the World Health Organization and USG.
The final results have not been released yet. National data (2007 National report) showed that at the end of 2007, out of a total of
155 MDR-TB registered patients: 123 (79%) were in treatment, 6 (3.8%) were cured, 12 (7.7%) abandoned treatment and 14 (9%)
died. A survey of resistance to SLDs is planned.
Since Mozambique has a more recent (and still growing) HIV epidemic, it is estimated that the proportion of TB patients who are
HIV-infected will continue to rise. The National TB Program (NTP) recognizes the importance of expanding TB/HIV services in
Mozambique and progress in implementing these activities has been improving. The MOH endorses routine HIV testing to all TB
patients using a provider-initiated model, provision of cotrimoxazole at TB clinics to all HIV-infected TB patients, including referrals
for ART services and screening HIV+ patients for TB in all care settings: VCT, home-based care, and health facilities providing
HIV treatment. To date, TB/HIV policies, training materials, and new reporting formats have been developed and implemented
countywide. According to NTP data from 2007, 68% of all reported TB cases received an HIV test in 2007 and among those who
were coinfected, 93% received cotrimoxazole and almost 33% received ART. Data from HIV programs showed fewer results with
only 3,039 HIV-infected TB suspects reported and 676 persons having received IPT in 2007.
The National Strategic Plan for TB (2008-2012) was finalized in July 2007 with USG support and focuses on increasing the
detection rate, strengthening the laboratory network, improving case-management and patient support, tackling the emerging
MDR/XDR problem and further expanding TB/HIV collaborative activities as well as implementing a quality monitoring and
evaluation system allowing impact measurement of program activities. An important component of the plan is aimed at extending
and strengthening the DOTS strategy. In order to improve the case detection rate, the plan focuses on increasing the suspicion of
TB among health workers working in the different components of the health care system.
USG efforts are consistent with the MOH Strategic Plan and WHO TB/HIV Framework which highlights the need for integrated
programming, decreasing the burden of TB among PLWHA and increasing the HIV care available for TB patients. USG agencies
collaborate with the National TB Program, international donors and other key partners. The emphasis of USG support is to
provide HIV counseling and testing to all TB patients, to ensure that all TB-HIV+ patients are offered cotrimoxazole, and referral to
other HIV-related services, including ART, and to link all HIV-infected persons in care to TB diagnosis and DOTS therapy.
Beginning in FY08, greater emphasis will be placed on promoting the 3 I's (intensified TB case finding, isoniazid preventive
therapy and infection control) and involving HIV programs in the TB/HIV response.
In FY08, USG funds (through PEPFAR and USAID TB-CAP resources) were used to provide technical assistance to MOH in the
following areas: to continue and expand the activities initiated in 2006-7 namely: strengthening HIV counseling and testing in TB
patients through support to the MOH CT component to expand the "CT in Health" (CTH, which has replaced the VCT model in
Mozambique), training of counselors/health providers, reproduction of guidelines, manuals and IEC materials, reviewing and
integrating CT in pre-service curricula, TB screening for HIV-infected patients, infection control in health settings, and
strengthening of referral mechanisms, supporting monitoring and evaluation of TB/HIV activities through assistance in the proper
use of new recording and reporting formats, support for the implementation of Electronic TB Registration ensuring its integration in
the National Health Information system and assessment of MDR-TB registration. Mozambique successfully applied to the Green
Light Committee with USG support.
The USG funds were used to provide assistance at the national level and for all PEPFAR USG-funded clinical partners
(Columbia/ICAP, CARE International, HAI, EGPAF, Vanderbilt University, and FHI) to provide a minimum package of TB/HIV
services. This includes strengthening linkages with community organizations in TB case finding and improved linkages to TB
care. USG efforts in FY 2008 were concentrated in the northern region, in the three focus provinces of the country (Zambezia,
Sofala and Nampula) where the TB case detection rate is low. This included close collaboration with the Provincial Health
Directorates. Treatment partners working in these provinces (HAI in Sofala, Columbia and Vanderbilt University in Zambezia and
Columbia and EGPAF in Nampula) worked to scale up TB/HIV activities, and to develop innovative best practices, including ART
roll out in TB clinical settings, Isoniazid Preventive Therapy (IPT) and improved diagnosis of smear-negative TB. Additionally, a
TB/HIV person was hired to work closely with the provincial directorate in Zambezia. Through JHPIEGO, support was provided at
the national level, to plan and conduct a rapid assessment of TB transmission Risk and Infection Control Compliance and plan the
implementation of infection control in health care settings. A national training of trainers in infection control is planned for
December 2008.
The PEPFAR program in Mozambique is working with its partners and the Ministry of Health to support HIV/TB program
integration, service delivery and training that includes components addressing the specific needs of children. The USG works with
both the HIV unit within the MOH and the National TB Program in a collaborative effort together with other donors.
As part of its plans for FY09 the USG and its implementing partners will conduct an assessment on "Contact Tracing Practices in
TB Programs in Mozambique" at selected sites in two provinces. Early data from this assessment will serve to inform further
program strengthening activities for FY09. Another assessment proposed for FY09 would identify current practices for TB
diagnosis in children and evaluate if HIV testing and cotrimoxazole prophylaxis are routinely offered to the pediatric population
served at TB clinics.
Simple job aids to support further implementation of cotrimoxazole prophylaxis such as easy-to-use pocket sized guidelines and
dosing charts for adults and children are greatly needed. The national TB program, as one of the principal implementers of
cotrimoxazole prophylaxis, with USG support, will work in collaboration with the HIV program at the MOH, to develop these
materials. There are plans to explore how best to support TB/HIV screening, diagnosis and treatment for OVC. Efforts to improve
TB and TB/HIV literacy among persons living with HIV/AIDS, through partnering with Brazilian NGOs, are also planned.
In addition, FY09 activities that will be supported with USG funds (PEPFAR and increased USAID TB CAP, doubled to $2.6
million) will be (1) strengthening TB/HIV collaborative activities with more emphasis on the 3 I's (Intensified case finding, Isoniazid
prophylaxis and Infection Control), (2) contact tracing, (3) implementing activities to target high risk groups (prisoners,
refugees/internally displaced persons).
The USG meets regularly with its TB implementing partners to coordinate planning, oversee program implementation and ensure
rational use of resources related to TB/HIV interagency activities. Additionally, USG is represented on the National TB/HIV Task
Force, MDR-TB, M&E and infection control subgroups, and in the recently created Pediatric TB Working Group in Mozambique.
Table 3.3.12:
Continuing Activity:
All PEPFAR clinical partners will support core TB/HIV collaborative activities in accordance with the WHO
Interim Policy (2004) in all districts and facilities that are supported for other clinical activities. This includes
(1) active participation in TB/HIV coordinating mechanisms at national, provincial, and local level, supporting
MOH TB/HIV planning and supervisory activities, and assisting with TB/HIV monitoring and evaluation
activities. In addition, clinical partners assist national TB programs with activities to reduce the burden of
TB in HIV-infected persons under their care through comprehensive and routine TB screening, isoniazid
preventive therapy (IPT) for those without symptoms or contraindications, and facility-level infection control
measures. Finally, all clinical partners support activities by the TB program to reduce the burden of HIV
through provider-initiated counseling and testing (PICT) for all TB patients (including children),
cotrimoxazole preventive therapy (CPT) (provided in TB clinics) for all TB patients, and referrals or on-site
provision of ART to coinfected patients. In accordance with new WHO guidance and with experience in
Mozambique that some activities (e.g. HIV-testing, CPT and ART) have advanced faster than others, all
partners will be encouraged to strengthen activities related to the 3 I's: intensified TB case finding, IPT, and
infection control. This includes support for routine (and WHO and NTP-recommended) contact tracing.
Partner-specific activities are described below.
ongoing plans to scale-up care and treatment to a total of 24 clinical sites in 12 districts. FGH support has
included direct support to the HIV Care and Treatment programs with clinicians which live and work in the
above districts. This approach has allowed us to provide one-on-one supervision, clinical mentoring, and
technical assistance to programmatic areas and to focus our other activities which include training, logistical
support, community development, infrastructure development, monitoring and evaluation, technical
assistance to DPS Zambezia, provincial human capacity development and information technology
development.
for 3 districts previously supported by another USG PEPFAR partner and 3 districts NOT previously
supported by another USG PEPFAR partner. As well, FGH will assume support activities for all facility-
based HIV services including HIV Care and Treatment, PMTCT, and Counseling and Testing in the districts
it supports. This will allow for improved coordination and integration of services offered within the health
units as well as a budgetary scale down to support these services as a result of economies of scale. In
coordination with DPS Zambezia approved plans for roll-out of HIV Care and Treatment services, FGH will
expand services to include 2 sites in each of the new districts for a total of 36 sites in all districts supported
by FGH (24 ART sites plus 18 out-reach sites)
NTLCP in Zambezia: The provincial TB and leprosy program has experienced a number of challenges over
the last years. These include high turnover of staff with changes in supervisors at both provincial and district
levels - the majority of district supervisors have only been in post since 2004. This turnover is has affected
the peripheral health level workers. Nurses from health centers and posts are not well trained in TB and not
involved in the expansion of the DOTS strategy. Because of the high turnover at the district level and due to
transportation difficulties, the health staff and the community volunteers at the sites receive very little follow
up, supervision and support and have consequently lost motivation. There is insufficient TB diagnostic
capacity due to a serious shortage of trained laboratory technicians and laboratory infrastructure - most
districts with one lab.
In 2007 less than half of the scheduled supervisory visits from the Province to the Districts were realized; it
is unfortunate given these visits have been confirmed to be an important way of motivating and refreshing
district supervisors and health staff in general. Important conclusions of these supervisions are that District
Supervisors are not properly managing the program, the patients, and the registers due to lack of training
and attention; that the collaboration with peripheral health staff is not regular; that contacts are not screened
as should be (and as a consequence, pediatric detection rate is stagnating around 7%); and, that TB/ HIV
collaborative activities are weak (TPC and TPI not properly managed and registered).
Program Area: Strengthening TB/HIV services in health facilities
Activity 1: FGH will continue to support strengthening of TB/HIV services in the health facilities it supports.
Using clinicians which live and work in the districts, FGH will provide direct on-the-job-training and clinical
mentoring for health staff of both the HIV Care and Treatment programs and the TB programs to ensure
appropriate clinical diagnosis, management and follow-up. FGH will provide technical assistance with
regards to program organization to ensure a strong referral system between the two programs. FGH will
continue activities which support universal testing for HIV of all patients seen in the TB clinics and universal
screening for TB of all patients seen in the HIV care and treatment program.
Activity 2: FGH will provide technical assistance and clinical mentoring to ensure appropriate follow-up for
all HIV+ patients who are eligible for INH prophylaxis.
Activity 3: FGH will support the implementation of TB infection control activities within the health facility
including early diagnosis, prompt separation or isolation of infectious TB patients, early initiation of TB
treatment according to MISAU guidelines, and improved documentation of TB status and treatment regimen
of HIV+ patients in HIV care and treatment programs. FGH will provide on-the-job-training to health workers
regarding appropriate infection control measures and implementation within the health facility (in wards,
waiting areas, laboratory, pharmacy, emergency and X-Ray departments). Patients and health care
workers will be sensitized on the importance of the infection control in order to reduce the risk of
transmission of TB in health facilities.
Estimated budget: $120,000
Program Area: Subcontract with LEPRA to continue support of TB programs in communities
Activity Narrative: Activity 1: In 2008, FGH entered into a subcontract agreement with LEPRA with the goal of improving the
response and quality of the health services at district level. The intervention aims at expanding LEPRA´s
presence in the Province and strengthening the linkages between the health facility and the community by
increasing community awareness, access to care, adherence support, referral system and monitoring of the
activities.
The objectives of the primary subcontract are to 1) improve the skills of national staff and the quality of
services involved in TB control in ten districts, 2) strengthen the management and equipment of the NTCP
and its regular supervision, and 3) improve the implementation of TB/ HIV collaborative activities to improve
intensified case finding. LEPRA proposes to accomplish this objective by 1) strengthening the NTCP
through training, equipment and transportation resources, 2) training of health staff at peripheral level, 3)
strengthening and systematization of the supervision and monitoring processes, and 4) sensitization
activities through radio messages and IEC material.
As a follow-up to this activity, FY09 funds are allow for the continuation of this subcontract collaboration to
continue the work of LEPRA in Zambezia Province. This work will include the following:
1) Training of volunteers on basic TB information (general information, modes of transmission, diagnosis,
treatment, impact of HIV, importance counseling and testing and referral system for proper care and
treatment).
2) Support the increase of the case detection rate by looking for people in the community with cough for
more than 3 weeks.
3) Strengthen the collaboration between health facility and community for treatment adherence for TB and
HIV.
4) Strengthen the linkages with other organization providing safe water, food, and impregnated bed nets.
5) Expansion of the Institutional DOTS through the health staff and CB DOTS through volunteers.
6) Training of Traditional Healers in TB and DOTS (identification of patients suspected of having TB, referral
to health facilities and adherence support for both TB and HIV treatment).
7) Involvement of community radios and of drama groups to implement sensitization activities in the rural
areas.
8) Strengthen the M&E keeping proper recording of the activities, reporting to the appropriate level and
conducting supportive supervisions.
Estimated budget: $174,672
Total Budget: $ 294,672
Continuing Activity: 15777
15777 15777.08 HHS/Centers for Vanderbilt 6415 6127.08 CDC-Vanderbilt $450,000
Estimated amount of funding that is planned for Human Capacity Development $150,000
This is a new activity.
support has included direct support to the HIV Care and Treatment programs with clinicians who live and
work in the above districts. This approach has allowed us to provide one-on-one supervision, clinical
mentoring, and technical assistance to programmatic areas and to focus our other activities which include
training, logistical support, community development, infrastructure development, monitoring and evaluation,
technical assistance to DPS Zambezia, provincial human capacity development and information technology
for all facility-based HIV services including HIV Care and Treatment, PMTCT and Counseling and Testing in
the districts it supports. This will allow for improved coordination and integration of services offered within
the health units as well as a budgetary scale down of the costs to support these services as a result of
economy of scale. FGH will assume and continue CT services in those sites currently being supported by
other USG CT partners (7 sites) and based on the DPS Zambezia plans for CT expansion will expand
services to 29 other sites not currently being supported by another USG partner.
Program Area: Assume support responsibilities for Counseling and Testing Units (UATS) in FGH supported
districts that were previously supported by other USG partners (7).
Activity 1: The first activity will be to assume responsibility for and continuity of care for Counseling and
Testing Units (UATS) in the 7 main district health centers that were previously supported by other USG
partners. Transition plans are currently being developed in collaboration with our partners to ensure a
smooth transition without loss of service quality. Conforming to MISAU national directives, FGH will support
a comprehensive package of services within the UATS. Pre and post test HIV counseling and testing will
be offered ensuring general information about HIV, as well as an individualized approach to risk reduction
education. Test results will be offered to the patient immediately and appropriate follow-up determined
depending on result. UATS services will also include general health education focusing on those illnesses
highly endemic in Mozambique such as TB, malaria, and sexually transmitted infections; hygiene practices
such as clean water, safe cooking methods, and personal hygiene; and nutritional education. FGH will
provide salary support ($8000/yr) for one counselor per UATS and ensure they receive proper training on
counseling and testing techniques with ongoing clinical mentoring to ensure a high level of and sustained
quality of services. FGH will provide technical assistance with regards to patient referrals amongst the
various health center services and utilize pre-existing resources to ensure the patients who have received
counseling and testing also are appropriately referred for follow-up. As well, FGH will provide technical
assistance to ensure appropriate supply chain management of needed commodities and tests by helping
coordinate the national SCMS with provincial and district distribution systems. FGH will ensure the
appropriate purchase and creation of educational materials for all services offered in the UATS ($2000/unit).
Estimated budget: $86,400.00
districts that were NOT previously supported by other USG partners (5).
Activity 1: The second activity will be to replicate the above services in the 5 main district health centers not
previously supported by another USG partner. It is anticipated that additional resources wil be needed to
bring these UATS up to USG standards.
Program Area: Support Provider Initiated Counseling and Testing (PICT) for HIV within other services of the
health center.
Activity 1: Currently all FGH supported sites provide "Opt out" PICT with the goal of offering HIV
counseling and testing to all women entering antenatal clinics and the maternity, TB programs, and both
adult and pediatric in-patient wards. FGH clinicians provide clinical mentoring and technical assistance to
local health workers with regards to implementation, future planning of needed commodities, and
appropriate referral of patients post testing. Due to already existing infrastructure and organization of
programs in relation to the establishment of the HIV Care and Treatment programs, no additional funds are
required to support this service. This strategy will be incorporated into all sites in the future that FGH
provides support.
Estimated budget: $0.00
Program Area: Health information system support for CT at district level
Activity 1: FGH is currently undertaking a roll-out of an OpenSource medical record system in the health
units in which it supports HIV care and treatment which will help integration of services, improve patient
tracking, improve monitoring and evaluation activities, improve implementation of HIVQUAL and will be
used for all reporting requirements for PEPFAR and MISAU. This will not be a parallel system but will
support the national rollout. As a result, FGH´s CT activities will easily be incorporated into this system at a
minimal cost per health unit. FGH estimates an initial start up cost of $1000 per site.
Estimated budget: $36,000.00
Program Area: Human Capacity Development
Activity Narrative: Activity 1: FGH will facilitate and/or support provincial level trainings of health workers on the following
themes: Counseling and Testing and Counseling and Adherence. Target audiences include those health
workers that work in the UATS as well as all health workers involved in provider initiated counseling and
testing. It is estimated that approximately 60 health workers will be trained.
Total Budget Estimate: $256,000.00
New/Continuing Activity: New Activity
Estimated amount of funding that is planned for Human Capacity Development $50,000
Estimated amount of funding that is planned for Education $50,000
Table 3.3.14:
THIS IS A NEW ACTIVITY
Position 1:
Title: Provincial Lab Advisor to DPS-Zambezia
Local: Zambezia Province
The MOH has requested that USG Partners support 4 technical advisor positions within the Provincial
Directorate for Health Offices (DPS) in each of the 11 Provinces. One of these technical advisors is a
Laboratory Technical Advisor. As lead Clinical Partner in Zambezia Province, Vanderbilt will support salary
and benefits for the Zambezia Provincial lab technical advisor. The Provincial Lab Technical Advisor will
report directly to the DPS and will oversee laboratory activities across the Province. The Provincial level
Lab Tech Advisor will create a link between the central level Laboratory Section and the Province to
facilitate communication and information flow and to implement policies and practices established by central
level MOH. The Advisor will work with implementing partners, DPS, and other donors to strengthen
laboratory commodity logistics, quality assurance, monitoring and evaluation of lab services, and human
capacity development.
Position 2:
Title: Lab Advisor for Treatment Partner
The laboratory Technical Advisor based at the Vanderbilt National Office level will be responsible for
overseeing the laboratory component of the PMTCT and Care and Treatment Program within Vanderbilt
supported districts and supporting Vanderbilt staff in providing supervision of laboratory services within the
program. In addition, (s)he will function as a counterpart for the Laboratory Technical Advisor based in DPS
of Zambezia.
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 Vanderbilt team or
other direct implementers in the Province. Overall, the Venderbilt Laboratory Technical Advisor will improve
laboratory services as a crucial component of quality care in the supported province.
Estimated Budget: $170,000.00 ($85,000 per position)
Estimated amount of funding that is planned for Human Capacity Development $85,000
Table 3.3.16:
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 4993.08 in COP 08.
This is related to the following activities in COP 09:
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 cooridnation 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.
Vanderbilt University has been asked to place 1 M&E Advisor in Zambezia Province as part of their overall
support to clinical services in these Provinces.
Estimated amount of funding that is planned for Human Capacity Development $43,037
Table 3.3.17:
April09 Reprogramming: Increased $278,681.
supported by another USG PEPFAR partner. As well FGH will assume support activities for all facility-
based HIV services including HIV Care and Treatment, PMTCT and Counseling and Testing in the districts
units as well as a budgetary scale down of the costs to support these services as a result of economy of
scale. In coordination with DPS Zambezia approved plans for roll-out of HIV Care and Treatment services,
FGH will expand services to include 2 sites in each of the new districts for a total of 36 sites in all districts
supported by FGH.
Program Area: Clinical/Pharmacy Advisor to DPS
Activity 1: FGH will support the salary and fringe benefits of one Clinician advisor secunded to the DPS-
Zambezia. This position will work one-on-one with DPS officials to provide Technical Assistance with
regards to health sector program oversight, organization, and implementation. This position will aid the
DPS-Zambezia with regards to USG PEPFAR partner harmonization within the province, as well as
integration of programs with other USG and International Health development programs (PMI, TB-CAP etc.
The overall goal of this position is to develop the tools necessary within the DPS to contribute to
strengthening the health system and developing program infrastructure at an administrative level which is
sustainable in the future.
Estimated budget: $150,000.00
Program Area: Health Center renovations
Activity 1: In 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 mechanisms will be employed to
deal with large- and medium-scale construction. Treatment partners will be relieved of the burden of having
to manage activities that are somewhat removed from their primary fields of excellence. However there will
still be cases where it is more efficient and appropriate for these partners to organize minor building repairs
and improvements locally rather than through a central mechanism. FGH will continue to provide assistance
to DPS-Zambezia to improve the physical infrastructure needed to support the rapid scale-up of HIV Care
and Treatment, PMTCT and Counseling and Testing services. As such, the health system physical
infrastructure is often in need of renovations of equipment to function efficiently. Working directly with DPS,
FGH will identify areas of support for physical infrastructure which integrates with MISAU plans for
infrastructure development and compliments other USG funded renovation projects. FGH will focus its
renovation plans on minor projects in 6 peripheral health units in the 6 districts of Zambezia which it will
assume support activities (average $15,000 per health center) focusing on energy and water needs.
Estimated budget: $90,000.00
Program Area: Gap Year Funding
Activity 1: In an attempt to increase the number of health care workers in the work force to meet the growing
demand of the rapid scale-up of ART, FGH will support the salaries of mid and basic level health care
workers graduating from health care institutions for a maximum of 12 months until they find placement
within the MISAU system. In concert with DPS-Zambezia, FGH will identify those types of health care
workers (tecnico de medicina, enfermeira´s, tecnico de laboratorio) most in need in the Province at the time
and bring them to Zambezia to fill the gaps in the Zambezia heath care work force. Depending on the type
of positions most needed by the Province at the time, salary support will increase by 15 health care workers
brought into Zambezia Province (Average base salary + subsidio de isolamento 50% + Subsidio de Risco
10% + Subsidio de Alojamento = $4000.00/yr). In calendar year 2009, it is anticipated that the MOH will
institute salary reform and therefore raise salaries so the number of staff supported may change.
Estimated budget: $60,000.00
Program Area: Scholarships
Activity 1: Human capacity development is an essential investiment to ensure the long term sustainability of
HIV Care and Treatment programs in the future. As well as increasing the capacity of those health care
workers already in the system, increasing the number of health care workers in the Province is vital to
ensuring the long term success of programs implemented with support of USG funds. FGH will continue to
support scholarships for pre-service training at the Instituto de Ciencias de Saude de Quelimane (ICSQ). In
concert with the DPS and ICSQ, FGH has identified the type and level of health care worker most in need
within the province (Tecnico de Medicina Geral, Tecnico de Medicina Preventiva, and Enfermagem SMI)
and will support 3 courses of 30 students (each lasting approximately 3 years). Funds allocated here will
cover expenses for 1 year of the three year training.
Activity Narrative: Estimated budget: $100,000
Program Area: District Coordination
Activity 1: To support improved coordination of activities between the district and provincial levels,
coordination between the provincial and central levels, as well as coordination between USG funded
partners working in Zambezia Province, FGH will provide institutional support to the DPS-Zambezia with
regards to program coordination. In response to its needs for better ability to communicate from a
Provincial level to the districts, DPS-Zambezia has requested that FGH provide technical assistance and
equipment to develop its information technology infrastructure. FGH proposes to provide equipment and
technology infrastructure to build upon existing DPS IT infrastructure which will create a DPS-Computer
networking system which will provide improved coordination of health indicator data collected at a Provincial
level as well as improved focusing of DPS resources to meet the health care demands identified by this
information. This system will include appropriate antivirus protections as well as internet capabilities to
improve email communication and coordination of services. This system will integrate with already existing
FGH information technology invested into the province for improved coordination of services between DPS
and USG funded partners. FGH will support the salaries of one national DPS- network manager and two
"IT help desk" personel for IT trouble shooting within the DPS. Due to the FGH IT infrastructure already in
place in the province FGH will be able to provide technical assistance to this DPS IT team to build its
capacity for managing the IT needs of the Province in the long term. As well, this system will integrate with
already existing FGH supported IT technology at the ICSQ for medical reference and continued medical
learning through its electronic library.
Activity 2: As lead agency for Zambezia Province, FGH will provide guidance and technical assistance to
DPS-Zambezia with regards to overall management of programs. This will include integrated program
planning and implementation as well as technical assistance with regards to budgeting. FGH will create a
Provinical working group to coordinate activites of USG PEPFAR partners to eliminate overlapping services
and improve integration into DPS-Zambezia yearly implementation plans. FGH will support DPS-Zambezia
and corrdinate with other USG partners to ensure an organized and efficient integrated supervisions system
between the provincial and district levels.
Estimated budget: $74,249
Program Area: Palliative Care Action
Activity 1: Support to Palliative Care Action Plan in collaboration with MOH, CDC, APCA, ANEMO.
Activities include:
a) Training: Materials development (pre-service for Physicians, Mid-levels, Nurses and Community),
Training (Uganda for 3 Pharmacists),
b) Policy development support for greater access to medicines including: formulations, planning/forecasting
and lowering prescription levels of key OI and pain medications
c) Advocacy (attitudes of health staff and public regarding pain management)
Products/Deliverables
- One Clinical Advisor hired for DPS Zambezia
- 3 health courses funding for one year at the Healths Science Institute of Quelimane
- 6 health units with minor repairs
- up to 15 health workers benefited with salaries
- DPS Zambezia supported in terms of coordination, planning process and supervision visits
Estimated amount of funding that is planned for Human Capacity Development $310,000
Estimated amount of funding that is planned for Education $160,000
Table 3.3.18:
