The CDC Global AIDS Program (GAP) Mozambique office opened in August 2000. Since then, CDC has been supporting the Mozambique Ministry of Health by pursuing a balance between addressing the immediate needs and building long-term capacity to mitigate the impact of the HIV/AIDS epidemic. This approach is being implemented in all 11 provinces.

In 2003, US President George W. Bush announced the President's Emergency Plan for AIDS Relief (PEPFAR). Mozambique was designated a focus country of the initiative and CDC GAP Mozambique became a part of this unified US Government effort to turn the tide against the epidemic.

CDC supports USG efforts in the geographical expansion and quality of PMTCT programs through training, support to state of the art prophylaxis to HIV-infected pregnant women and newborns, ARV treatment to eligible pregnant women, safe delivery, and safe infant feeding practices to reduce the risk of vertical transmission.

The USG plays an important role in helping Mozambique to collect information for program improvement by supporting comprehensive strategic information efforts, helping to improve the availability, accessibility, quality, and use of service-delivery data, conducting HIV surveillance and behavioral surveys, designing and improving systems to support routine program monitoring, strengthening and expanding the health management information systems infrastructure, conducting data triangulation activities to assess key drivers of the epidemic and the national response, and supporting national data gathering efforts, including antenatal sentinel surveillance, behavioral surveillance surveys, improved mortality surveillance, and a population-based AIDS Indicator Survey.

The USG will continue to provide TA to the MOH in building the capacity to implement a comprehensive care package which includes the following:

1) prevention and improvement of diagnosis and management of OIs; and 2) implementation of palliative care activities within the existing health structure trough training mentoring and supportive supervision in coordination with provincial and district health authorities.

The MOH policy regarding the use of cotrimoxazole is not clear and has not been communicated clearly to care providers. Guidance on the use of CTX can be found mainly in small sections of the treatment guidelines for different areas of work (PMTCT, TB/HIV and ART). USG will continue advocacing at the central level for a common strategy for the use of CTX, and dialoguing with a stakeholders to identify and address programmatic challenges regarding the provision of CTX as part of the basic care package. USG will continue advocacing at the central level for a common strategy for the use of CTX, and dialoguing with a stakeholders to identify and address programmatic challenges regarding the provision of CTX as part of the basic care package.

There is recognition at the MOH that monitoring/surveillance of OIs is inadequate. There is not yet clarity on best strategies for strengthening these systems. USG will continue a dialogue with MOH counterparts and partners to actively identify activities and start to strengthen M&E/surveillance systems in this area. The MOH has requested TA to improve the meningitis surveillance within the MOH Epidemiology Department. The USG will support this TA and assist in the coordination of a national meningitis survey.

In regard to palliative care, the USG will assist the MOH to identify a suitable partner to assist in strengthening MOPCA's (Mozambican Palliative Care Association) working with MOH) managerial capacity to implement the palliative strategic plan, beginning with pain management and stepwise introduction of other components of palliative care for chronically ill and at the end of life stage. Funds will also be used to contract local short-term consultants to assist in the implementation of a

system for nutritional support within the heath care facilities based on the BMI calculation. Training materials and job aid tools will be adapted, printed and distributed widely. Moreover, For adherence, retention, linkages/referrals, training and supportive supervision will be conducted.

Laboratory monitoring is an important component of clinical management of patients receiving HIV care and treatment services. Biochemistry and hematology parameters are useful for monitoring drug side effects; CD4 counts provide an indication of improving immunological response; and plasma viral loads (VL) testing is used for detection of a possible virological failure to ARV drug combinations.. International HIV care and treatment guidelines describe measurement of VL as a possible way to detect treatment failure besides clinical screening and CD4 count monitoring.

In 2009 the MOH decided to make VL testing available at a selected number of laboratories and for a specific and limited group of patients receiving ART. Through an MOH led consensus meeting, specific guidelines for the use of VL and the necessary preconditions (laboratory, human resources, and training) for implementation were developed in August 2009. Furthermore set of indicators that would be used to track VL testing were defined. However, a detailed implementation plan is needed to guide the first phase of implementation and subsequent program activities.

The USG has allocated funding for priority HIV treatment activities as follows: conduct a basic program evaluation of phase 1 of VL testing implementation including convening a results dissemination meeting (70%); training of clinicians in VL testing (20%); development, translation and printing of implementation plans, guidelines and manuals to support ART service provision (10%).

Key activities for FY 2010 include: 1) In collaboration with the MOH conduct program evaluation of phase 1 implementation of VL testing. This includes hiring a consultant to develop the protocol, M&E tools and plan, field work and convene a results dissemination workshop that will result in evaluation report to inform future plans for use of VL in the national health system; 2) Support the MOH to run 3 training courses for clinicians on the use and interpretation of VL for adult and pediatric patients on ART; 3) Translation, reproduction, printing and distribution of guidelines, and manuals to support changing MOH priorities for ART service provision.

Since the beginning of Counseling and Testing (CT) service delivery in 2001, the USG has supported the establishment and expansion of CT services. The USG has been providing Technical Assistance (TA) to scale up Provider Initiated Counseling and Testing (PICT) in clinical settings, and promote, pilot and expand the Counseling and Testing in Health (CTH) approach in a national scale.

In relation to the goal 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), the narrative is already addressing this in the paragraph related to the strengthening of human resources dedicated to HIV CT.

The USG will continue to provide technical assistance to the MOH, for provision of comprehensive HIV care and treatment services and build capacity to improve quality of services provided.

The MOH does not have defined a minimum package of care services for HIV exposed and infected children. The USG through the implementing partners recommend provision of comprehensive care services that include among other interventions, cotrimoxazole prophylaxis, water purification products, educational materials and provision of insecticide treated nets (ITN) for all children under five years old. In FY 2010 USG clinical partners will coordinate with PSI on the logistic of the minimum package kit (water purification products, education materials and condoms). ITNs will be distributed through the PMI program. The CDC will convene meetings with key MOH staff to advocate, discuss and develop a sustainable plan to implement the basic care package in the already existing health system services in order to guarantee continuity of activities after PMI and PSI end their support.

Maternal-child health (MCH) clinics are often the point of entry to care for HIV-exposed and infected children. Child visits occur monthly from birth until age 5 within the MCH and child health framework, postnatal, immunization, well-child visits, child at risk consultation, out-patient, in-patient pediatric wards and community and outreach efforts offer key opportunities for identifying children in need of HIV-related services and for delivering counseling, testing, prevention, care, and treatment. However for children who are HIV-exposed /infected access to HIV prevention care and treatment programs remains weak and children are lost to follow within the various points of care in the health facility. The USG will assist the

MOH in identifying points of weaknesses and where interventions to improve the follow-up of these children should be prioritized.

FY 2010 funds will be allocated to implement the following activities: 1) Support the MOH in defining and developing tools for pediatric basic care package through Technical Working Groups framework; 2) Conduct program evaluation to identify where HIV-exposed and infected children are lost to follow up within the various points of care within the facility 3) Improvement of linkages between PMTC, MCH and Pediatric HIV based on the results from the program evaluation, through training, formative supervision and M&E. 4) Contract short term consultants to assist in the development of the tools, flowcharts, job aids and to update training manuals and guidelines 5) Printing and distribution of tools and training materials and guidelines.

The primary goal of this budget code is to increase USG access to rigorous, updated spatial data, to support of USG planning processes. OGAC guidance emphasizes the importance of service mapping for program planning, and this mapping requires good quality geocoded data, including the production of maps and tables and standardization and updating of geocoded datasets, A second goal of this mechanism is to share standards and data between USG and other donors and partners to facilitate harmonization of development activities and agendas. The final goal of this budget code is to procure services such as translation and-or printing of reports in support of the increasing number of USG- supported activities conducted in collaboration with other donors or agencies.

The objectives of this budget code are to 1) update the USG GIS data bank with recent census and survey data, including data from the 2007 health facility inventory, the 2009 AIDS indicator survey; 2) update the USG GIS data bank with 2009 APR and 2010 SAPR datasets; 3) create and clean a facility database linking health facilities with USG partner sites to allow integrated mapping of USG and MOH data; 4) update and develop thematic maps based on these data; 5) integrate these data into the planned web-based APR data warehouse; and 6) procure printing and other dissemination services.

Activities will operate at the national level. These activities will also help to strengthen planning among HIV donors and implementing partners, including the MOH, Statistics Office, and other government agencies, and by so doing will indirectly support strengthening of the health system. This budget code

will help the USG improve geographic distribution of support and improve coordination between partners working in different program areas in the same geographic areas or health facilities.

PMTCT priorities in FY 2010 focus on coordination with the MOH and scale up of PMTCT services within an integrated MCH system. Objectives include improved quality of MCH/PMTCT service provision; access to a comprehensive package of MCH/PMTCT including psychosocial support; and improved nutrition support for improved health and reduced vertical transmission. Activities will be aligned with the MOH through district-, and provincial-level support, technical assistance, training, quality improvement, and monitoring and evaluation. The district-based approach and collaboration at provincial level, including subcontracts or grants from implementing partners to provincial and district public health departments, will increase responsiveness, including support for overall systems strengthening and positioning for transition. For FY 2010 community platforms will be strengthened to increase demand for utilization of PMTCT services.

The major allocation of effort (at least 60%) will be towards scale up of PMTCT services, including training, supervision, and technical assistance. FY 2010 activities will be developed with the ultimate goal of 80% PMTCT coverage by 2014.

In this context, the USG will support evaluation activities regarding the PMTCT program in Mozambique, using a basic program evaluation approach with an additional focus on syphilis screening and treatment.

Laboratory services are an integral component to support optimal care and treatment to HIV patients. The USG has been working together with laboratory and treatment partners to support the MOH's overall efforts to strengthen laboratory capacity. The MOH's priority objective for 2010 is quality improvement through development and implementation of a National Laboratory Quality Management System (QMS).

In collaboration with Becton-Dickinson through a public private partnership and ASCP, the USG will contribute to the development of an MOH operational plan to implement a National Q MS. The overall goal of the QMS is that Provincial and Central Hospital laboratories attain ISO accreditation in the next 5 years and for district level and Health Centre Laboratories to work towards attaining WHO accreditation.

In FY 2010, funds will be allocated to the hiring of short term consultants to assist with the implementation of the QMS. An external auditor may be contracted to evaluate the implementation of the management system in the three central hospitals. The Auditor would present a comprehensive report and make recommendations for training and corrective action where required to ensure continuous improvement in laboratory systems and processes. Other consultants may be contracted as required.

Funding will also be directed at translation and production of relevant materials and manuals for distribution within the network as required by the QMS such as: quality manuals, equipment maintenance manuals, posters enforcing quality standards and safety messages and audit questionnaires.

In addition, following the MOH decision in 2009 to decentralize ART services , there is a need to develop and strengthen sustainable laboratory networks to increase access to testing services at health care facilities. To achieve this, in FY 2010 the USG will support, through a partner to be determined, the rollout of point of care systems for CD4, biochemistry and hematology.

The USG will continue to provide technical assistance to the MOH for the implementation of TB and HIV collaborative activities. The focus of this assistance remains the implementation of the PICT for all TB patients at the TB clinics and all of their known contacts. The USG will provide TA for the implementation of the 3 "Is" strategy: Intensified TB case finding, Isoniazid preventive therapy and Infection control. Actually co-infected patients receive TB and ART at two separated sites and sometimes in different health facilities. To decrease patient's travelling and waiting hours and increase adherence to treatment partners will pilot the one-stop of model of delivery of ART and TB treatment.until completion of TB treatment. Additionally treatment and prophylaxis for opportunistic infection will be offered to co-infected patients by trained staff at the same site sites until the completion of the TB treatment.

The USG will work closely with the NTP and Jhpiego to support the development of infection control plans to reduce the TB transmission in health care settings. Additional support will be given to NTP, HIV program and implementing partners to improve provision and reporting on the use of IPT.

Funds will also be allocated to update national guidelines and/or develop new ones in accordance with international standards for TB/HIV, X-MDR-TB management and infection control and purchase of commodities. Further, the updated policy documents and guidelines will be printed and distributed within

the country. Short-term local consultants will be hired to assist in the development of national guidelines and in the implementation of routine TB program evaluation. The new reporting system for drug resistant TB will be implemented to all provinces. To strengthen coordination between National TB Program and partners, coordination meeting will take place at different levels including at the national level.

A TB program external evaluation will take place in February 2010 and TA will be provided during the preparatory and implementation phase. Based on the results of the USG-supported 2009 contact tracing evaluation, the USG will help establish a new system for tracking, evaluation and follow-up of TB contact.