As a key PEPFAR implementing partner in Mozambique, Vanderbilt University (VU), through its affiliate NGO Friends in Global Health (FGH), has been supporting the Ministry of Health in Zambezia province since February 2007 to increase access to quality HIV care and treatment services in rural communities in this populous province.

FGH's goals are aligned with the five goals of the Partnership Framework:

1) To reduce new HIV infections in Mozambique by improving access to essential CT and PMTCT services and implementing robust prevention and positive prevention programs; 2) To increase access and use of high quality HIV care and treatment services in rural communities by supporting the expansion of the number of sites where care and treatment is available and improving service quality in seven important 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; 3) To improve linkages and integration of HIV and related primary health care services to provide a continuum of accessible services, including maternal and child health (MCH) and reproductive health (RH) services, within facilities and between facility and community-based services; 4) 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. By increasing capacity of Provincial and District MOH through technical and managerial support and sub agreements; supporting 'Gap Year Funding', training and supervision for MOH staff; renovating health facilities; strenghtening commodity procurement systems; and improving integration of HIV and other health services; 5) To ensure care and support for pregnant women, adults and children infected or affected by HIV in communities and health and social welfare systems: FGH will work with local health authorities to increase access to a continuum of HIV care services through better community-facility linkages and support for nutritional interventions, including community links to improve nutrition through basic nutritional education and counseling and the promotion of locally appropriate, nutritious foods.

FGH supports 18 sites in 12 districts in Zambezia province. With a population of 3,892,854 people,and an estimated HIV prevalence of 19%, Zambezia is Mozambique's second most populated province and one of its most heavily affected by HIV. Due to poor physical infrastructure and geographic constraints, access to healthcare in Zambezia is very difficult. The decentralization process mandated by the MOH and supported by FGH has resulted in a significant improvement in access to HIV care and treatment services for the citizens of Zambezia province. Supported by PEPFAR funds, the FGH supported program has expanded from their starting point of 6 districts in 2007 to 12 districts in INSERT where, as

of APR 2009, they are supporting comprehensive HIV services for over 17,000 people (15,000 in care and treatment, 1247 in PMTCT, and 772 exposed children in CCR). Almost 6000 patients have ever started ART at FGH supported sites.

FGH will address cross cutting issues as follows: 1) Clinical services will link with commuinty services to improve nutrition, malaria control, safe motherhood and child survival through nutritional interventions, net distribution, education and enhancing preventive services for children respectively. 2) FGH will assist in the development of a gender strategy in Zambezia 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.

The project will become more cost efficient over time by utilizing existing resources (staff, services, structures and relationships with communities), adapting promising practices and lessons learned from local, regional, and international initiatives rather than developing de novo interventions, and strengthening linkages with public health services and taking full advantage of the facility- and community-based services in the target area. In addition, eventual transition of technical and managerial responsibilities to DPS/DDS through sub agreements with reduced overheads. FGH will also link with other USG and international donor projects providing facility- and community- based care to leverage resources.

Next generation PEPFAR output indicators will be used for PMTCT, ARV treatment, CT, HIV/TB and partners will have detailed plans to report against these indicators. FGH will support capacity building in collection, quality, interpretation and use of data to improve service delivery and outcomes. FGH provides equipment and technical assitance to the DPS and specific health centers to improve disease surveillance and epidemiologic capacity.

FGH FY 2010 funds will be used to build the capacity of the MOH and local organizations to implement a package of comprehensive care that complements the ART treatment program and addresses issues that lie at the core of the HIV epidemic in Mozambique. The package will consist of:

1) Improved prevention, diagnosis and management of OIs. There will be a specific focus on increasing coverage of Cotrimoxazole prophylaxis for eligible patients; 2) Improved palliative care activities within the existing health structure; 3) Improved screening for treatable conditions such as syphilis, cervical dysplasia and anemia; 4) Provision of comprehensive, high quality patient and family-centered HIV care and support services through training, mentoring, and formative supervision conducted jointly with SDSMAS and DPS; 5) Training and formative supervision will include district health staff in management and supervisory roles to enhance their skills in supervising and improving the quality of clinic-based care and support services; 6) Increased capacity within community-based organizations to provide quality patient and family centered HIV care and support services, through training and technical assistance, including the provision of job aids; 7) Improved district-level coordination and effective linkages between health facilities, community-based organizations and other existing support services.

Additionally, funds will be used to strengthen the MOH's capacity to develop the national palliative care strategic plan and its roll out. Funds will be also used to strengthen MOPCA's (Mozambican Palliative Care Association working with MOH) managerial capacity to roll out a palliative care strategic plan. In 2009 Vanderbilt University received funds to implement the cervical cancer "see and treat" strategy in two sites. In FY 2010 this strategy will be expanded to three additional sites in Zambezia province.

HIV prevention with positives activities will be implemented in all sites by intervening in both the transmission of infection and the development of illness through formation of support groups, education, training and improving linkages and referrals to appropriate services for care and treatment.

FGH currently supports the scale up and provision of quality ART services in Zambezia province. FY 2009 APR data showed that: FGH supported a total of 18 sites in 12 districts; 5948 patients ever received ART services; and 69% of those ever started on ART were alive and on treatment by the end of the reporting period. FGH's support to treatment services is aligned with the Mozambique treatment guidelines, and the goals of the Partnership framework. The FY 2010 target is to provide ART to 2808 new adult patients by the end of the fiscal year. Site expansion plans are in accordance with the MOH's policy and plans of integration of ART services. . Provide support to the Provincial Health Directorate (DPS) in Zambezia province through a sub agreement that will be established in FY 2010 to finance recruitment of MOH staff, training and supervision, and monitoring and evaluation of program implementation. Scale up of positive prevention activities, early treatment initiation, cotrimoxazole prophylaxis and TB screening within all ART supported service sites will be prioritized.

Specific activities planned in FY 2010 include: 1) Finance key staff positions through payment of MOH health-care providers salaries to address the gaps in human resources at existing health facilities; 2) Provide support for in-service training and mentoring of clinical staff in order to develop local capacity in the provision of quality ART services; 3) -Provide equipment and supplies for facility operations; 4) -Improve patient management, drug management and strategic information systems; 5) -Reinforce patient follow-up and referral systems by implementing activities to promote adherence to ART and psychosocial support;

6) Support the establishment and improvement of referral systems and linkages; between HIV prevention, care, treatment, TB/HIV, and Counseling and testing services within and between service sites; 7) -Expand positive prevention programs within ART service sites.

FGH will align FY 2010 activities with overall PEPFAR counseling and testing (CT) goals and strategies, with a focus on increased uptake and improved post-test counseling. The majority of effort within FGH CT portfolio will be allocated in this area, representing approximately 60% of effort.

Activities will include training in risk reduction counseling and tailored post-test counseling; scale up of couples CT; strengthening linkages with community-based activities; and expansion of provider-initiated CT (PICT).

Increased uptake is linked to strengthening human resources (HR) dedicated to CT activities; FGH will also develop a sustainable strategy to minimize HR constraints for CT. FGH will training lay counselors and strengthen the capacity of CBO's to improve linkages between health facilities and the community.

Quality assurance (QA) will also be a key area for FGH. QA systems and standard operating procedures to ensure biosafety will be developed, in close collaboration with lab. FY 2010 CT funds will leverage biomedical transmission/injection and blood safety funds to ensure that systems are improved for appropriate disposal of biowaste generated through the FGH CT program.

Referrals and linkages between CT and other health and HIV services, including community-based prevention, care and treatment activities and gender based violence interventions will also be improved in FY 2010. FGH will continue to support strengthening of M&E systems. FY 2010 funds will support training of partners and providers in new reporting documents, data management and data use for program monitoring. In FY 2010 FGH will provide support in one province (Zambezia). The target population includes general population, as well as higher risk groups including ill and hospitalized individuals.

Supervision of activities will be conducted through an integrated approach in close collaboration with DDS, DPS, and the provincial laboratory. FGH HVCT funding will be applied towards subcontracts or

grants to DPS / DDS / SDSMAS to the greatest extent possible.

FGH currently supports pediatric care and support in 12 districts in Zambézia province, including 6 peripheral health centers with a focus on provision of quality comprehensive care and support services for HIV exposed and infected children. These services consist of: EID, CTXp, management of OI and other related complications including malaria, diarrhea, growth and development monitoring, nutritional assessment, infant feeding counseling and education, palliative care, psychological, social, and spiritual and prevention interventions.

In FY 2010, FGH will create a continuum of care by strengthening referrals between PMTCT, maternal HIV care and treatment, and pediatric HIV clinics. Targeted activities will be aimed at improving identification of HIV exposed and infected children, increasing enrollment of HIV infected children into care and treatment, and improving retention of these children at all levels of the continuum. FGH is targeting 80% of HIV exposed and infected children in all its supported sites. FGH will assist the DPS with strategic plans for the expansion and implementation of CCR clinics in all sites supported by FGH where it also supports PMTCT (up to maximum 5 sites per district). Key Activities include: 1) Strengthening linkages between PMTCT, MCH and pediatric HIV 2) Expanding PICT services to all children with signs or symptoms of HIV, including TB clinics and nutrition services, and systematic testing of children of adult patients enrolled on ART 3) Strengthening the logistic system for EID using HIV DNA PCR. 4) Supporting access to preventive interventions for malaria and diarrhea 5) Support the performance of nutritional assessments on all children in the HIV care and treatment and CCR clinics and support linkages with other partners and donors to access therapeutic food and supplementary food 6) Participate in supportive supervisions with DPS as well as targeted clinical mentoring for providers of pediatric care. FGH will support 1 provincial level in-service training of health workers on pediatric care. 7) Strengthen linkages and referral between clinical and community based services including OVC programs 8) Implement an effective M&E 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. Universal antiretroviral treatment for infected children is a top priority aiming to improve the survival and quality of life. Based on 2009 APR data, children represent 6.8% of the patients on treatment at 18 FGH supported sites. The FY 2010 goal is 10%. Realizing such an increase will require enhancing the capacity of sites and health care providers to identify, treat and care for HIV-infected children, FGH will support the MOH to build capactity to provide and sustain high quality standards of HIV treatment services in Zambezia province, targeting 540 children receiving treatment in FY 2010.

Key activities include: 1) Increase access to care and treatment services through early identification of HIV exposure and infection, strengthen linkages and integration of HIV services within and between existing child health programs and TB, PMTCT and MCH services and increased community awareness of pediatric HIV; 2)-HCD through in-service training focused on pediatric HIV care and treatment, supportive supervision, provision of job aids and the reproduction and dissemination of the new Pediatric Treatment Guidelines developed by MOH; 3) Training on the management and logistics of laboratory commodities; 4)Training, supportive supervisions and reproduction of materials to support positive prevention activities; 5) Psychosocial support for children, adolescents and their families along with support for retention, HIV status disclosure and adherence to ART; 6) Identifying developing and helping to implement interventions to improve patient tracking and follow- up, as well as identifying treatment failures and adherence problems. The structure of these interventions will be informed by the results of the comprehensive evaluation conducted by the HIVQUAL program in FY 2010; 7) Implementing prevention activities targeting adolescents consisting of: education on risk reduction, family planning counseling, counseling and testing and promotion of youth friendly services.

MOH 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 FY 2008, MOH 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 (M&E).

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. Recruitment has begun for these positions; USG will support training of these Advisors through another USG supported partner (South to South collaboration with Brazil).

The role of the M&E Provincial Advisor is to provide support in the coordination 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.

FGH has been asked to place 1 M&E Advisor in Zambezia as part of their overall support to clinical services in these Provinces.

In FY 2010, FGH will prioritize assistance to strengthen the six building blocks of the health system in line with the priorities and goals of the GOM. Vanderbilt will support the MOH's decentralization process by building the institutional and technical capacity of DPS (Provincial Health Directorates) and SDSMAS (District Health and Social Welfare Services) placing Provincial Technical Advisors at the Zambezi DPS to improve HIV clinical health care quality, and to strengthen drug supply at the health facilities. The implementing partner will also provide technical assistance to SDSMAS to build their capacity to plan and coordinate activities at the district level and will explore innovative funding arrangements to SDSMAS to further increase the ownership and sustainability of HIV clinical service delivery. FGH will strengthen human resources at the provincial, district and site level by supporting pre-service training opportunities for health personnel and will also support DPS to improve retention of health

personnel through gap year funding. The implementing partner will strengthen DPS and SDSMAS capacity to provide in-service training, mentoring and supportive supervision to clinicians and administrators. FGH will provide support for the rehabilitation of existing infrastructure to accommodate the decentralization process. Lastly, the implementing partner 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 FGH will support national health systems, they will leverage the inputs from the government of Mozambique, 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, Global Fund, Clinton Foundation, DfID, WFP, UNICEF).

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.. In FY 2010 FGH will support MOH efforts to expand and institutionalize infection prevention and control (IPC) programs.

FGH will assist in the mainstreaming of relevant activities into the routine functioning of health facilities where USG activities are supported. In coordination with national guidance and in collaboration with a central level technical assistance partner also supported by USG, IPC efforts will be expanded and institutionalized in the following areas:

1) Implementation of standard operating procedures regarding sharps disposal / IPC 2) Ensure that all health facility staff receive updated training in injection safety / IPC 3) Dissemination of written procedures for handling and disposal of sharps and infectious waste 4) 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 5) Support for availability of PEP to health care workers 6) Appropriate data collection and reporting/record keeping, including PEP 7) Other activities include supportive supervision/empowerment of health workers with knowledge and tools to protect themselves and patients; demand creation for safe conditions in the workplace with all

health facility staff cadres; increasing IPC awareness including hand hygiene and universal precautions; and consideration of strategies aimed at both the community and HCW to reduce unnecessary injections

USG clinical services partners will pursue these activities in collaboration and coordination with a single central-level technical assistance partner, which will also specifically support the development and implementation of injection safety measures at a national policy level.

HMIN activities are linked to workplace programs supported under the HVOP budget code. Implementation and supervision of activities will be conducted through an integrated approach in close collaboration with DDS and DPS.

FGH will support three distinct areas within the other sexual prevention portfolio. These activities will be carried out in coordination with support from the care and treatment portfolio and injection safety.

Key Activities: (1) Mainstreaming of positive prevention (PP) activities: (2) Management of sexually transmitted infections (STI): FGH will support the management of STIs at provincial, district and health facility level (18 sites in 12 districts) 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): FGH 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.

Priorities in FY 2010 are coordination with MOH and scale up of PMTCT services within an integrated MCH system. FGH objectives include improved quality; access to a comprehensive package including

psychosocial support; and improved nutrition support for reduced vertical transmission. FGH activities will align with MOH through district and provincial level support, technical assistance, training, quality improvement, and monitoring and evaluation (M&E). The district-based approach and collaboration at provincial level, including subcontracts or grants from FGH to provincial and district public health departments, will increase FGH 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 2014.

Key activities: 1) Expansion: Support for sites without PMTCT services, and enhanced support for low-performing sites receiving partner or MOH support; increased community demand for services; 2) Provider-initiated counseling and testing and couples counseling; 3) ARVs for PMTCT: Focus on more effective regimens and early ART initiation; 4) Cotrimoxazole prophylaxis: Focus on improving coverage for pregnant women; 5) Early infant diagnosis; 6) Support for prevention of unintended pregnancies among HIV infected women; 7) Support groups and community involvement based on national model; 8) Information, education, communication: Dissemination of materials developed by a central / lead partner; 9) Safe infant nutrition interventions integrated into routine services, including counseling and distribution of commodities in close collaboration with central / lead nutrition technical assistance and procurement partner; 10) M&E: support for reproduction and roll out of revised registers; 11) PMTCT clinical mentoring based on national model; 12) Linkages to system strengthening, including infrastructure projects for PMTCT; 13) Mainstream infection prevention control in PMTCT settings; support workplace programs including PEP.

Laboratory services are an integral service component to support optimal care and treatment to HIV patients. FGH (Vanderbilt) has standardized laboratory services in different sites throughout the Province

of Zambézia. The main activity in the area of lab strengthening has been to assess adequacy of laboratory sites and to adjust working environments to optimize laboratory services and practices within available resources. This has included laboratory renovations in some districts and placement of prefabricated containers to ensure that laboratory infrastructure was such that new equipment could be placed.

Funding in FY 2010 will support a Laboratory Technical Advisor based at the FGH Provincial Office level that be responsible for overseeing the laboratory component of the PMTCT and Care and Treatment Program within FGH supported districts and supporting FGH staff in providing supervision of laboratory services within the program. In addition, he/she will function as a counterpart for the Laboratory Technical Advisor based in the Provincial Health directorate (DPS) of Zambézia.

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. He/she 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/she shall also respond to priorities identified by the FGH team or other direct implementers in the Province. Overall, the FGH Laboratory Technical Advisor will improve laboratory services as a crucial component of quality care in the supported province.

FGH works in collaboration with the DPS and DDSs in Zambezia province to improve TB related services As a result of this partnership, there has been significant improvement in the integration of TB and HIV services at the health center level. These achievements are due to: 1) Implementation of the HIV screening tool and of HIV/TB referral forms; 2) Training of clinicians on TB/HIV co-infection and management of MDR-TB.

In 2010 FGH will continue to strengthen the identification, treatment and management of TB in adults and children and to strengthen other TB/HIV-related activities.

The priorities will be to: 1) Increase TB detection rates and TB cure rates; 2) Strengthen PICT; 3) Support Routine provision of CTX and IPT; 4) Implement infection control measures; 5) Strengthen the referral system and linkages with other services Consultation for Child at Risk (CCR), Counseling and Testing for Health (ATS), PMTCT and ART and inpatient wards; 6) Strengthen laboratory diagnostic services through training of new and existing laboratory technicians on smear microscopy techniques and establish a referral system for the regional laboratory for performing TB culture and DST.

FGH will also implement positive prevention activities in all sites by intervening in both the transmission of infection and the development of illness through formation of support groups, education, training and improving linkages/referrals to with appropriate services for care and treatment among the clients co- infected with TB/HIV in ensuring a better and prolonged life.

FGH will strengthen the TB surveillance and M&E systems in collaboration with DPS.

FGH will continue to support LEPRA to strengthen their successful community-based TB programs. These programs are intended to: a) Increase TB case detection and cure rate by increasing TB literacy and adherence support by establishing a system of defaulter tracing carried out by private providers of health care services, community leaders, community health workers and volunteers b) Strengthen the M&E system that ensures proper recording of the activities, reporting to the appropriate level and conducting supportive supervisions