The goal of the clinical services project is to improve HIV clinical services in Manica, Niassa, Sofala and Tete provinces within a strengthened, comprehensive primary health care and community care system.

The main objectives are: (1)To increase access, quality and use of HIV care and treatment services to rural communities by intervention in seven areas: HIV CT, laboratory services, PMTCT, adult care and treatment, pediatric care and treatment, palliative care, and the prevention, diagnosis and treatment of HIV-TB co-infection; (2) To provide a continuum of accessible HIV and related primary health care services including MCH and RH services (including support at clinics which do not provide ART or PTV) and to improve linkages and referrals within and between facilities and communities; (3)To support stronger and more sustainable Mozambican systems and institutions through emphasis on strengthening government and community capacity to deliver and manage services at the district level with an explicit plan to handover project activities to Mozambican authorities; (4)To assist the MOH in the development of robust systems of monitoring and evaluation for HIV-related programs that can be adapted for use across the health field.

This project will directly contribute to the following goals of the Partnership Framework: Goal 1 by reducing sexual transmission of HIV (Obj. 1.1) and by improving access through increased geographic coverage and improved facility-community linkages for CT and PMTCT services (Obj 1.2 & 1.3); Goal 2 by utilizing innovative approaches to mobilize community resources to link facility and community based care and reduce loss to follow up (Obj 2.4); Goal 3 by increasing capacity of provincial and district MOH through technical and managerial support and sub agreements, supporting 'Gap Funding', training and supervision for MOH staff; renovating health facilities, strenghtening commodity procurement and forcasting systems; and improving integration of HIV services with other health services; Goal 4 by ensuring effective linkages, referral systems and patient tracking within and between health facilities and communities including health facilities not directly providing ART or PTV (Obj 4.1, 4.2), increasing emphasis on integrated child and adolescent services plus strengthening of lab diagnosis and logisitics (Obj 4.5, 4.6); Goal 5 by increasing access to a continuum of HIV care services through better community-facility linkages (Obj 5.1), increased suport for sites providing non ARV HIV services and support for nutritional interventions (Obj 5.2).

The clinical services project will target 4 provinces with a total population of 6,065,121. HIV prevlance in Manica, Tete and Sofala is 18% to 23% vs 16% nationally. Tete has a very mature epidemic and the existing infrastructure is unable to accommodate the numbers of patients requiring care and treatment. Niassa is a particularly underserved province with vastly inadequate infrastructure. Clinical programmes will target adult, pregnant women and children and will include specific activities designed to address gender and age inequalities in access.

Clinical partners will prioritize assistance to strengthen the local health systems in line with the priorities of the GOM and the PF through: support to the MOH decentralization process by building the institutional and technical capacity of Provincial Health Directorates (DPS) and District Health and Social Welfare Services (SDSMAS); strengthened human resources and training at the provincial, district and site level; rehabilitation of existing infrastructure; training to provinces, districts and sites in logistics management; and mobilisation of community resources to foster linkages with health facilities and create demand for services.

The clinical services agreement will address cross cutting issues as follows:clinical services will link with community services to improve nutrition through basic nutritional education and counseling and the promotion of locally appropriate, nutritious foods; implementer(s) will develop a gender strategy for each province, including specific activities designed to improve male access to HIV services (e.g. ANC, CT, treatment, CCR), couple counselling and consultations and activities to reduce violence against women.

Cost efficiency strategies will include: utilisation of exisiting resources including staff, services, structures and relationships with communities; adaption of promising practices and lessons learned from other initiatives in Mozambique and internationally, rather than "reinventing the wheel"; strengthening of linkages with public health services and taking full advantage of the facility- and community-based services in the target area; links with USG and other donor projects providing clinical and community based care; the transistion of technical and managerial responsibilities to DPS/DDS through sub agreements with reduced overheads; improved data quality and use to direct programme improvements.

Next generation indicators will be used for PMTCT, ARV treatment, CT, HIV/TB and partners will have detailed plans to report against these indicators. The clinical services project will provide support at the DPS and DDS and service delivery levels capacity building in collection, quality, interpretation and use of data to improve service delivery and outcomes.

The clinical service project will support 64 ART sites (23 Sofala, 13 Manica, 23 Tete, 5 Niassa) and increase support to selected non ART sites providing HIV services. This strategy will increase coverage of non ART clinical and preventative services and commodity distribution to the target population, especially in rural areas. There are 5 main areas of intervention: 1) Mainstreaming of PwP activities including expansion of PwP programs within ART and non ART service sites and community based settings, through training of health providers and counselors; supportive supervision and monitoring; strengthening community linkages through organizing and empowerment of support groups and PLHIV organizations; and designation of a PwP focal person for each province; 2) Management of sexually transmitted infections at ART and non ART sites with a focus on MARPs;

3) Implementation of the national Health Care Worker / Workplace Program including access to: BCC, condoms, CT, PMTCT, reduction of stigma and discrimination; CT; care and treatment; psychosocial support; HBC; benefit schemes; and HR management; 4) Strengthening of HIV clinical services at ART and non ART sites: support for improved access to and quality of services for family planning, STIs, palliative care, OIs, CT, CXTp, preventative treatment for malaria, TB treatment and laboratory testing for CD4, hepatitis B and syphilis; improved linkages and referral pathways within and between facilities and communities, supported by a focal person for linkages and follow up in facilities and sub-agreements with DPS/DDS; 5) Distribution of the 'Basic Care Kit' (condoms, 'certeza', soap, IEC materials) promoted through ART and non ART facilities as well as in community settings.

Partners will use existing resources to accommodate the increased supervision and monitoring needs of these activities, Training in all areas will utilize materials developed in collaboration with the MOH. The extension of additional support, monitoring, evaluation and supervision to non ART sites will initially be conducted as a pilot to identify best practice which can be extended to additional sites.

In FY 2009, USG partners supported 62 sites in 37 districts; 51,070 patients received ART services; the retention rate at 12 months of treatment initiation was 75% in Sofala, Manica and Tete and 92% in Niassa. The project will support 64 ART sites (23 Sofala, 13 Manica, 23 Tete, 5 Niassa) and increase linkages to selected non ART sites providing HIV services. In collaboration with DPS/DDS a pyramid approach is being developed which enables major urban sites to down refer stable patients to smaller peripheral units. Complicated patients can be referred up to larger centers, thus promoting a patient journey that ensures retention in comprehensive care and treatment. To achieve this support, capacity building will be done at ART sites to absorb the referred patients and initiate new patients on ART, improve service delivery and integration of non ARV sites, emphasize the referral pathways and linkages within and between facilities and communities and support infrastructure improvement.

Specific training and support includes in-service training and mentoring of clinical, M&E, pharmacy and administrative staff, joint site visits with DPS/DDS staff and subagreements with DPS/DDS and CBOs to develop the capacity to transition activities to local partners.

Clinical outcomes and drug management are tracked by routine M&E which aligns with national reporting systems. Partners participate in the HIVQUAL program and staff are trained in the utilization of

supervision and mentoring visits to reinforce the use and adherence to national treatment guidelines and the use of routine data for service improvement.

Adherence activities include: identification of facility and community counterparts working together to actively follow up ART patients; paper and computer based records; sub agreements with community partners and PLHIV to train peer educators and develop innovative community interventions to track patients and promote adherence; PP initiatives with PLHIV and DPS/DDS using existing nationally approved materials. Linkages with existing home based care support will also be strengthened to track defaulters, ensure their return to care and treatment, document transfers, deaths, or losses to follow up.

The clinical services project will scale up services across the 4 provinces focusing on increased uptake of CT and improved post-test counseling for pregnant women, children, discordant couples, hospitalized patients and most at risk populations (MARP). Services will be integrated with facility level (clinics providing ARV and those not providing ARV) and community level services including HBC, TB screening, ART, family planning, cotrimoxazole (CTX) prophylaxis etc. Sub-agreements with DDS/ DPS and CBOs will be used to strengthen referral pathways and linkages between and within service areas.

Activities to scale up CT will include: sub-agreements with DPS/DDS to train lay counselors in risk reduction counseling and post-test counseling; couples counseling; improvement of links to community prevention activities, including positive prevention for discordant couples and stigma prevention; PICT will be expanded to all sites where HIV care and treatment is being implemented regardless of signs or symptoms; exploration of opportunities for home based testing and innovative ways to increase uptake of MARP through tailored services and approaches; interventions to increase male access to CT and reduce gender based violence; interventions to ensure that positive and negative tested persons are retained in the continuum of care through effective linkages and referrals pathways; and uptake will be increased by working with PLHIV and in collaboration with local leaders to ensure coordination and mobilization of the population for CT services.

Performance assessment will be supported by training providers in new reporting documents, data management and data use for program monitoring. Quality assurance (QA) systems and standard operating procedures to ensure biosafety will be developed, in close collaboration with labs. Supervision of activities will be in close collaboration with DDS/DPS, and the provincial laboratory.

The clinical services project will support the MOH in 64 ART sites in 4 provinces to provide quality comprehensive care and support services for 80% of HIV exposed and infected children at these sites. To improve access and continuity of care the project will integrate with non ART sites providing HIV and MCH. Services consist of CXTp, management of opportunistic infections and other related complications including malaria, diarrhea, growth and development monitoring, nutritional assessment, infant feeding counseling and education, palliative care, psychological, social, spiritual and prevention interventions. In FY 2010, the clinical services project will prioritize health system strengthening to improve identification and referral of HIV exposed and infected children; increase enrollment of HIV exposed and infected children into care and treatment services and improve retention of children in care and treatment. All activities are aligned with the national priorities and the partnership framework.

Specific interventions will include: 1) Strengthening linkages between PMTCT, MCH and pediatric HIV; 2) Expanding PICT services to all children with signs or symptoms of HIV in out-patient and in-patient venues, including MCH clinics, TB clinics and nutrition services, plus systematic testing of children of adults enrolled on ART; 3) Strengthening the logistic system for early infant diagnosis using HIV DNA PCR. Partners will conduct refresher training of health providers for EID and DBS sample collection; 4) Supporting access to preventive interventions for malaria and diarrhea, ensuring logistic, storage and distribution of the Basic Care Kit (certeza, IEC materials and soap) and access to LLIN for all children < 5 years through the PMI program; 5) Nutritional assessment and linkages with other partners and donors (UNICEF and WFP) to access therapeutic and supplementary food; 6) Supportive supervisions, in-service trainings of health workers on pediatric care; 7) Strengthen linkages and referral between clinical and community based services including OVC programs; 8) Implement an effective monitoring and evaluation program by scaling up the electronic tracking system and the HIVQUAL program.

The MOH is prioritizing the scale-up of pediatric HIV treatment services through decentralization of

treatment to peripheral health centers and integration of HIV services into existing child health programs. The project will suport the MOH to build capactity to sustain high standards of HIV treatment services in 4 provinces, targeting 4,235 children. Currently, children represent 2.4% of the total number of patients on treatment at supported sites and the aim is that will increase to 10% in FY 2010. This will require enhanced capacity of sites and health care providers to identify, treat and care for HIV-infected children. For all HIV infected children receiving ART, cotrimoxazole prophylaxis will be prioritized.

The main activities will include: 1) Improving access to care and treatment services, through early identification of HIV exposure and infection status, strong linkages of HIV services within the existing child health programs (including TB, PMTCT, MCH) and increased community awareness of pediatric HIV. Enrollment of HIV exposed and infected children into care will be increased through a functional referral system of care and treatment services for HIV-infected children and their families within and between health facilities (including those providing non ART HIV services) and communities using PMTCT, MCH flow charts and referral forms; 2) Human capacity development through: in-service training on pediatric HIV care and treatment, supportive supervision, provision of job aids and the printing and dissemination of the new Pediatric Treatment Guidelines developed by MOH; training on the management and logistics of laboratory commodities such as CD4 reagents, ARV pediatric drugs and other HIV related medications; training, supportive supervisions and reproduction of materials to support positive prevention activities; 3) Interventions to improve patient tracking systems to follow-up ART patients and to identify and address treatment failures and adherence issues; 4) Implementation of the HIVQUAL program; 5) Improvement of linkages to care, support and prevention services such as psychosocial support for children, adolescents and their families, support for retention, HIV status disclosure.

Effective Monitoring and Evaluation (M&E) systems are critical components to accurate and timely program evaluation and monitoring. Clinical partners are continuing to provide monitoring and evaluation support at national and provincial level GOM MOH national and provincial level staff and at clinical sites. The primary activities here are the development and implementation of effective patient tracking and monitoring and evaluation systems at all levels to improve program monitoring and improved client outcomes.

Funds in FY 2010 will support the hiring of a M&E Technical Advisor by clinical partners in Sofala,

Manica, Tete and Niassa provinces to support M&E capacity building and technical assistance at the provincial-level MOH office. The M&E Technical Advisor will be responsible for overseeing the M&E component of all MOH related activities in the respective province. These activities may include such things as providing M&E training and capacity building to other provincial level, district level and facility based staff, assist USG clinical partners in provinces in the standardized implementation of patient tracking and M&E systems and data collection and reporting from facility-based and CBO to national level.

The M&E Technical Advisors will liaise and coordinate activities with USG clinical partners, CBOs, National level MOH staff and other key GOM Ministries and stakeholders. The M&E Technical Advisor will identify weaknesses in the existing provincial M&E systems, such as data collection, reporting and quality and gaps in information systems and data use and propose strategies and approaches to bridging these gaps. The M&E Technical Advisors will be responsible for ensuring that these needs are communicated at both the national-level and at the provincial-level, and where possible, assist in developing systems of collaboration.

In FY 2010, clinical partners will prioritize assistance to strengthen the six building blocks of the health system in line with the priorities and goals of the GOM.

Clinical partners will support the MOH's decentralization process by building the institutional and technical capacity of DPS and SDSMAS. Lead clinical partners will place Provincial Technical Advisors in each DPS to improve HIV clinical health care quality, and to strengthen drug supply at the health facilities. Partners will also provide technical assistance to SDSMAS to build their capacity to plan and coordinate activities at the district level. Partners will explore innovative funding arrangements to SDSMAS to further increase the ownership and sustainability of HIV clinical service delivery.

Clinical partners will strengthen human resources at the provincial, district and site level by supporting pre-service training opportunities for health personnel. Partners will also support DPS to improve retention of health personnel through gap year funding. Partners will strengthen DPS and SDSMAS capacity to provide in-service training, mentoring and supportive supervision to clinicians and administrators.

Clinical partners will provide support for the rehabilitation of existing infrastructure to accommodate the

decentralization process. Lastly, partners will provide additional support and training to provinces, districts and sites in logistics management to complement implementation of the Pharmaceutical Logistics Master Plan.

Improved district coordination, technical assistance provided by the provincial advisors, scholarships, gap year funding, mentoring, rehabilitation of infrastructure all have spillover benefits as they strengthen the broader health system beyond HIV at little or no marginal cost. As the clinical partners will support national health systems, they will leverage the inputs from the GOM, who directly provide all services, as well as maximizing additional resources and linkages with other donors and programs (e.g. PMI and other USG programs, the Global Fund, Clinton Foundation, DFID, WFP, UNICEF).

TBD Clinical Health System Strengthening Partners will support three distinct areas within the other prevention portfolio. Activities will be carried out in coordination with support from the care and treatment portfolio and injection safety.

(1) Mainstreaming of prevention with positive (PwP) activities: TBD partner will expand PwP programs within ART service sites through training of health providers and counselors; supportive supervision; monitoring the implementation of PwP activities; and strengthening community linkages through organizing and empowerment of support groups and PLHIV organizations. PwP will be integrated into existing HIV program activities, including facility-based (antenatal care, care and treatment facilities, home based care, TB treatment settings, etc.), and community-based settings (community HIV counseling and testing, peer support programs, etc). TBD Partner is recommended to identify a focal person for PwP activities to coordinate and ensure successful implementation of PwP activities.

(2) Management of sexually transmitted infections (STI): TBD clinical partner will support the management of STIs at provincial, district and health facility level in order to reduce the burden of STIs as well as HIV infections attributable to STI co-infection. Additional focus will be on most-at-risk populations (MARPs). Key activities will include basic STI care; training and job aids; infrastructure support (equipment, privacy); Coordinate and support mechanisms to ensure availability of all medications necessary for following Mozambique's 2006 STI Syndromic Management Guidelines in the pharmacies; and M&E.

(3) Health care worker / workplace program (WPP): TBD partner will support facility-level WPP to boost

awareness and understanding of HIV and AIDS related issues of the personnel of the health sector and their families. In coordination with other partners, TBD partner will implement national WPP package, including the following elements: > Prevention: BCC, condom availability, VCT access, PMTCT, stigma and discrimination > Health care and support: access to confidential counseling and testing, care and treatment, psychosocial support, and home based care > Impact mitigation including benefit scheme > Human resource management including HIV/AIDS policy

Priorities in FY 2010 are coordination with the MOH and scale up of PMTCT services within an integrated MCH system. Objectives include improved quality; access to a comprehensive package including psychosocial support; and improved nutrition support for reduced vertical transmission. Activities will align with the MOH through district and provincial level support, TA, training, quality improvement, and monitoring and evaluation. The district-based approach, collaboration at provincial level (including subcontracts or grants to provincial and district public health departments) and scale up to ANC facilities will increase responsiveness, including support for overall systems strengthening and positioning for transition. Community platforms will be strengthened to increase demand for PMTCT services.

The major allocation of effort (at least 60%) will be towards scale up, including training, supervision, and technical assistance, in line with the goal of 80% PMTCT coverage by 2013.

Key activities that support integration of MCH/RH, PMTCT scale up and cross cutting activities include:expanded support for sites without PMTCT services, and enhanced support for low-performing sites; activities to increase community demand for services; expanded PICT and couples counseling; ARV for PMTCT focussing on more effective regimens and ART initiation; cotrimoxazole prophylaxis focussing on improved coverage for pregnant women; linkages with pediatric care and treatment programs for EID; support for prevention of unintended pregnancies among HIV-infected women; support for PLHIV and community involvement; dissemination of nationally approved IEC materials developed by a lead partner; safe infant nutrition interventions integrated into routine services, including counseling and distribution of commodities in collaboration with a procurement partner; support for reproduction and roll out of revised registers; PMTCT clinical mentoring based on the national model; linkages to system strengthening, including infrastructure projects; mainstreaming infection prevention control in PMTCT settings; support for workplace programs including PEP; and increased support for delivery.

Laboratory services are an integral component to support optimal care and treatment to HIV patients. Clinical partners provide standardized laboratory services in different sites throughout four provinces. The main activity has been to assess adequacy of laboratory sites and adjusting working environment to optimize laboratory services and practices in some key districts within available resources. This has included laboratory renovations in some districts to ensure that laboratory infrastructure was such that new equipment could be placed.

Funds in FY 2010 will support the hiring of a Laboratory Technical Advisor for each partner based at the national office level. He/she will be responsible for overseeing the laboratory component of the PMTCT and Care and Treatment Program within the USG supported districts and for providing supervision of laboratory services within the program. In addition, s/he will function as a counterpart for the three Laboratory Technical Advisors based at the DPS's of the four provinces.

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, Supply Chain Management Systems (SCMS), and Association of Public Health Laboratories (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. He shall also respond to priorities identified by partner teams or other direct implementers in the province in the lead provinces. Overall, the Clinical Laboratory Technical Advisor will improve laboratory services as a crucial component of quality care in the provinces supported by the USG.

The TB/HIV programmatic strategies are in line with the STOP TB global strategy and the MOH and USG priorities. The clinical services project will work in collaboration with the DPS and DDS directorates.

Partners have achieved improvement in the integration of TB and HIV services through use of the HIV screening tool and the HIV/TB referral forms, training clinicians on HIV/TB co-infection and management of MDR-TB, and training of TB lay persons to provide HIV CT services for TB clients.

In 2010, partners will continue providing interventions targeting the general population and high risk group such as miners, prisoners, refugees and internal displaced population. Priorities include: increased access to testing; PICT in HIV/TB settings; TB case management and treatment; strengthened linkages with Community Based DOTS, home based care and public private partnerships; implementation of the "3 Is"(intensified case finding, Isoniazid prophylaxis, Infection Control); adherence support and defaulter tracing; strengthening laboratory diagnostic services; provision of CTX and IPT; implementation of national infection control guidelines; strengthening of the referral system and linkages with other services (CTH, PMTCT, AR); provision of ART; management of MDR- XDR/TB; and strengthening of procurement and supply of TB medicines and other commodities.

Positive prevention activities will occur in all sites by intervening, in both the transmission of infection and the development of illness, to form support groups, provide education and training and improve linkages and referrals to appropriate services for care and treatment among clients co-infected with HIV/TB

Ensuring quality services and strengthened surveillance and M&Esystems will be achieved by improving documentation of TB status and treatment regimen of HIV+ patients in HIV care and treatment programs; evaluating the implementation of the TB symptoms screening tool in HIV care settings; providing TA and clinical mentoring to ensure appropriate follow-up for all HIV+ patients who are eligible for INH prophylaxis; and implementing the National Infection Control plans at selected facilities.