Under this mechanism, Jhpiego's overall goal is to support the national response to the HIV epidemic in Mozambique through the expansion of high-quality interventions in HIV prevention (counseling and testing, infection prevention control, male circumcision and gender-based violence), care and treatment (HIV/TB integration, infrastructure of treatment sites and biosafety in laboratories), and contribute to the capacity building of the MOH and other host country organizations to deliver services in a sustained manner (pre-service education, training and support, and information systems). Activities under this mechanism are guided by a comprehensive monitoring and evaluation plan and contribute to USG and GOM national HIV objectives as well as to the Partnership Framework priority areas of prevention and systems strengthening. All interventions are planned for nationwide scale-up, with implementation from central to local levels. Target populations include persons at behavioral risk for HIV in the general population, healthcare workers in both pre-service and in-service environments, community health workers, and PLHIV from community and clinical facility settings.

Prevention efforts focus on reducing sexual transmission of HIV through continued support for a demonstration project to integrate safe medical male circumcision into select minor surgical wards in the provinces of Gaza, Maputo, Maputo City, Sofala and Manica. Jhpiego will also assist with increasing the number of Mozambicans who know their HIV status by providing counseling and testing training and services in both community and clinical settings. An emphasis will be continue to be placed on ensuring that clients receive appropriate referrals and counseling based on their test results. Finally, Jhpiego's prevention efforts include decreasing the risk of occupational exposure for health care workers through its injection safety and infection prevention program.

Health system strengthening efforts focus on task-shifting and increased production of health care workers, and ensuring competency, support and retention of those health care workers. Jhpiego's key contributions include: introducing training information and monitoring systems; introducing the Standards- Based Management and Recognition approach (SBM-R); introducing "Model In-Patient Wards" in Mozambique; designing and implementing a task analysis for nurses; developing supervision tools; adapting training materials for health workers; assessing and designing a continuous education system; and developing and implementing workplace safety and health guidelines, including HIV post-exposure prophylaxis (PEP).

Cross-cutting issues addressed under this mechanism include gender (expansion of PEP guidelines to include victims of gender-based violence, and incorporation of GBV needs into policy and health care delivery system) and TB/HIV integration (IPC for nosocomial TB, PITC training for TB services, and incorporation of TB into national workplace safety and health guidelines).

Cost efficiency of activities under this mechanism is embedded into the approach to build capacity of local organizations and the MOH, strengthen educational and healthcare delivery systems, and implementation of low-cost performance monitoring.

A detailed comprehensive plan guides the monitoring and evaluation of all activities under this mechanism and builds upon Jhpiego's existing country program M&E system which includes: seasoned M&E staff, efficient systems for producing high-quality data and reporting, and regular meetings with donors, partners and the MOH. All activity plans are synchronized with appropriate national and USG goals and objectives.

In the past several years, Mozambique has made substantial progress in its response to the HIV epidemic. In order to cope with a still expanding epidemic, however, Mozambique needs to extend and sustain these efforts. HIV Counseling and Testing (CT) is one area that must be aggressively expanded in order to achieve national goals. The main objective of this area is to increase uptake of CT and focus on post-test results. Jhpiego will continue its support to the MOH to expand the Integrated Community CT (CCT) and Provider-Initiated Testing and Counseling (PITC) strategies. Emphasis will be given to referral systems especially for CT clients with TB symptoms to contribute to early TB case finding in the community. Another area to be strengthened is positive prevention for discordant couples.

This activity will directly contribute to the following goals of the Partnership Framework: • Goal 1: Reduce new HIV infections in Mozambique by getting to know the HIV status and expanding access to confidential HIV counseling and testing (Objective 1.3) • Goal 3: Strengthen the Mozambican health system, including human resources for health and social welfare in key areas to support HIV prevention, care and treatment goals.

Jphiego supports the MOH priorities outlined in the Human Resources National Development Plan (2008- 2015) and is coordinating with other USG implementing partners and other donors specifically in workplace safety, pre-service, and training information systems implementation. The overall goals of all

Jhpiego activities are to contribute to the human resource for health and health care delivery ensuring that health workers acquire the necessary competencies needed to provide high-quality services upon graduation, are properly deployed and integrated into the national health service, and that retention and support strategies are in place to enable their effective and sustained performance.

In particular, Jhpiego will continue to support the implementation of the quality assurance program for pre-service institutions that will strengthen training capacity of the Training Department at the central and pre-service levels. This program consists of several interventions: introduction of training information and monitoring systems for pre-service institutions and consolidation of the in-service training; Standards- Based Management and Recognition approach (SBM-R) to improve teaching quality; "Model In-Patient Ward" to strengthen clinical sites to serve as model sites for clinical training of pre-service students; design and implement a task analysis to define the scope of practice for pharmacy cadres to be used to begin development of a competence-based curricula; based on the revised scope of practice, a competence-based curriculum for general, MCH nurses and its implementation at the 13 pre-service institutions; development of tools for supervision and update of regulations for training institutions; and assessment and design of an in-service training system.

Additionally, Jhpiego will provide a short technical assistance to the Human Resource Directorate to look at financial and non-financial incentives for health care workers as a means for retaining and motivating the Mozambican health workforce.

Finally, Jhpeigo with the MOH's National Directorate for Medical Assistance and Human Resources will continue to provide technical support to roll out of training for ancillary workers and implementation of workplace safety and health guidelines including HIV post-exposure prophylaxis (PEP).

Ongoing HIV transmission in sub Saharan Africa necessitates vigorous prevention efforts, which is why the compelling evidence of effectiveness of male circumcision (MC) as an HIV prevention intervention has been met with great excitement. Thus, this intervention is being considered for implementation and scale-up in communities with high rates of HIV infection and low rates of circumcision of men globally.

In Mozambique, the MOH recently granted approval for a MC demonstration project in five sites, including one military facility. Jhpiego is currently working in coordination with the MOH, NAC, USG and other key partners to support a gradual implementation of safe MC/minor surgery services, in selected

facilities in high-HIV /low-MC prevalence provinces, including providing surgical equipment/supplies, training, development of educational materials, and ensuring that appropriate QA mechanisms are in place. MC services will not be a stand-alone intervention, but part of a comprehensive prevention strategy, which includes: the provision of HIV testing and counseling services; treatment for STIs; the promotion of safer sex practices; the provision of male and female condoms and promotion of their correct and consistent use; and linkages and referrals to prevention interventions and other social support services.

In 2010, Jhpiego will continue its support to the implementation and expansion of safe and integrated MC/minor surgery services in military and public facilities. Jhpiego will also provide technical assistance to implement operations research to assess and analyze specific elements of the provision of MC services in Mozambique, and advocacy with MOH and community leaders.

The goal of the injection safety program is to reduce the risk of transmission of HIV and other blood borne pathogens among health care personnel at health facilities. Since 2004, Jhpiego has provided technical assistance to the MOH to improve infection prevention and control (IPC) practices in hospitals using Standards-Based Management and Recognition approach to promote implementation of informative operational standards, periodic measurement and rewarding of good performance. The program, which expanded from six hospitals in 2004 to 87 in 2009, has gained strong support from senior leadership.

In 2010, Jhpiego will continue to support the MOH, working in close collaboration with USG partners, to institutionalize IPC efforts at the central, provincial and hospital levels, and expand these efforts to additional health centers and maternities. Jhpiego will also continue to improve waste management and disposal systems, and infrastructure and equipment for sterilization procedures. The improvement of the waste management and sterilization systems will reduce the risk of HIV medical transmission and will contribute to safe and high quality of services being available at those facilities.

Activities will strengthen and institutionalize the IPC program; utilize the surveillance system created to measure the impact of the improved IPC program (e.g., hand hygiene compliance), decrease the risk of medical transmission of HIV; and improve waste management systems and sterilization processes in selected facilities. In FY 2010 a rapid mapping will also be conducted to assess adequacy of IPC / injection safety in pre-service training.

Jhpiego will also assist other USG implementing partners with technical assistance and guidance in FY 2010 activities in this area, which focus on mainstreaming IPC activities: implementation of standard operating procedures, training, dissemination of educational and policy materials, support for availability of PEP to health care workers, and improved availability and use of personal protective equipment, including technical assistance at DDS / DPS level to improve management of stock levels and resupply of necessary items through existing MOH channels.

Due to the fact that up to 50% of PLHIV develop TB, and that TB has an adverse effect on HIV progression, the linkages between TB prevention and treatment and HIV programs should be a high priority. Recent increases in rates of TB among health care workers, as well as hospital-based outbreaks of MDRTB among HIV-infected patients, have led to increasing concern about the risk of Mycobacterium tuberculosis transmission in health care settings, which not only affects patients but may also result in temporary or permanent loss of health workers. Since 2006, Jhpiego has been working with the MOH in Mozambique to address TB-related issues in several ways: Infection Control (IC) for preventing nosocomial TB, PITC training activities for TB services, and incorporation of TB activities into the national MOH Workplace Safety and Health (WSH) Guidelines.

In FY 2010, Jhpiego will provide technical support to implement the National Plan for Infection Control for TB (IC/TB), including training, supervision and follow-up to selected sites (after the assessment) to monitor and improve compliance with IC/TB standards in the different areas. Jhpiego will also support simple environmental improvements at selected facilities (ventilation, flow, etc) to decrease TB transmission. Jhpiego will support the MOH to strengthen a "model care and training center for IC/TB" (e.g.; Machava Hospital) based on pre-defined standards.