Mozambique faces the combined health challenges of a high HIV prevalence as well as poor uptake of family planning (FP). The Extending Service Delivery Project (ESD), administered by Pathfinder International, is an integrated agreement, with majority wrap-around funding from health, focused on a results-oriented approach to enhance the use of HIV and FP services in four provinces- Cabo Delgado, Gaza, Inhambane, and Maputo. These geographic locations reflect priorities for PEPFAR and family planning expansion. These regions have high HIV prevalence rates, under served populations for HIV/FP services and low contraceptive prevalence rates. Currently, there are no USG FP partners working in Inhambane and agreements for FP work in Gaza and Maputo are ending soon. Cabo Delgado requires intensive support to improve contraceptive coverage and maternal health indicators because it has one of the lowest rates of modern contraceptive use in the country (4.5%) and high unmet need for contraception.

This project will strengthen the capacity of nurses and other health care providers from PEPFAR clinical sites to deliver combined HIV/FP services, to include improved capacity for appropriate referrals; improved client awareness of and demand for long-acting contraceptive methods; improved understanding of HIV risks and prevention; promotion of dual protection, and strengthened community outreach for HIV/FP/RH services.

The project's goals are to : 1) strengthen the delivery of FP counseling and services into existing health sites that offer HIV services; 2) increase demand for and availability of HIV, STI and FP services for students, faculty, and staff in pre-service training institutions; 3) expand youth access to to HIV/FP/RH/ services through youth-friendly centers; and, 4) in Cabo Delgado increase community access to quality FP services.

ESD will train health workers at pre-service training institutions to provide HIV, FP, and RH services while also being able to assess their own risks; improve the quality of HIV and FP services delivered through health services; teach community health workers to promote HIV and FP services; and, address harmful gender norms, particularly those that normalize gender inequality through gender-based violence, inter- generational and transactional sex.

Importantly, men will be engaged in reproductive health services, as partners of women, as fathers, and as community members in need of services. ESD will ensure that youth have greater access to HIV/FP/RH/ by strengthening youth-friendly centers which offer information, education, and FP as well as

HIV services. ESD will work with Geracão Biz, a national youth-centered health program, to scale it up in provinces where a gap exists. Local organizations will be strengthened to provide these services and manage such centers. This will l foster Mozambican ownership and capacity development while increasing the number of youth who receive services.

This linkage of HIV and FP through the ESD project affords a strong opportunity for maximizing delivery of comprehensive HIV prevention to the adult population and particularly to young adults. Additionally, in FY 2010 PEPFAR funds are earmarked for programming related to gender-based violence as it relates to HIV transmission and prevention.

This program supports the goals of the Partnership Framework with its focus on evidence-based HIV prevention and sustainability by building the capacity of local organizations, supporting country ownership and leadership, and strengthening the health systems to deliver and monitor heath services for PLHIV.

ESD will develop a monitoring and evaluation plan, as well as a performance monitoring plan (PMP) with appropriate indicators and targets.

The ESD program aims to integrate family planning and reproductive health with HIV prevention, care

and treatment at existing PEPFAR sites. ESD will receive abstinence and behavior change program

funding to improve understanding among young adults and within the general adult population that

certain accepted norms and practices increase the risk of HIV transmission and acquisition. ESD will

develop approaches that address male norms in particular as they are related to the practice of multiple

concurrent sexual partners, in addition to implications these norms may have for access to and use of

family planning and reproductive health services. ESD will adapt the successful Geracão Biz program

approaches and materials to address HIV prevention and gender among young people. Additionally,

ESD will focus on pre-service training institutions to reach future cadres of nurses and health providers to

increase understanding and practice of HIV preventive behaviors. They will be trained in an integrated

approach to HIV, FP, and RH which will include community outreach for HIV prevention and screening for

gender-based violence. Communities' capacity to increase quality and access to integrated HIV/FP/RH

will be strengthened and programs will emphasize changing harmful gender norms, attitudes and

behaviors, particularly those related to gender-based violence and the acceptability of intergenerational

and transactional sex. Male participation in HIV/AIDS, family planning and reproductive health services

will be encouraged. ESD will promote youth-friendly clinics which will provide increased and improved

services to individuals 15-24 years old, and will also promote gender-sensitive behavioral interventions

such as those to delay sexual activity or reduce multiple partnerships. Youth-centered services will also

target at-risk, out-of-school youth with innovative approaches, including linkages with local organizations

such as the Lourdes Matola Foundation that are working to improve educational and employment

opportunities for young men and women.