CARE currently supports HIV services in four districts in northern Inhambane, consisting mainly of remote rural areas with isolated population centers and poor infrastructure. Since initiation of this project in 2007, CARE has expanded support to include PMTCT services at 22 facilities and HIV counseling and testing,

care, and treatment at 4 facilities. In FY 2009, CARE provided counseling and testing to 7122 individuals and ARV's for PMTCT to 808 pregnant women, with 2379 individuals currently receiving ART. In FY 2010, CARE will support the MOH to increase access to and uptake of high quality HIV care and treatment services by improving service coverage and quality in HIV CT services; laboratory services; PMTCT; adult and pediatric care and treatment; care and support; and the prevention, diagnosis and treatment of HIV-TB co-infection.

CARE goals and activities are aligned with the five goals of the USG-Mozambique Partnership Framework:

1) To reduce new HIV infections in Mozambique: CARE will focus on reducing sexual transmission of HIV by improving access through increased geographic coverage and improved facility-community linkages for CT and PMTCT services. 2) To strengthen the multisectoral HIV response in Mozambique: CARE will utilize innovative approaches to mobilize community resources to link facility- and community- based care and reduce loss to follow up, through scale up of psychosocial support groups and strengthening of working relationships with local PLHIV organizations to create demand for services. 3) To strengthen the Mozambican health system: CARE will support the the MOH's decentralization process by building the institutional and technical capacity of DPS and SDSMAS; strengthening human resources and training at the provincial, district and site level; infrastructure rehabilitation; and training to provinces, districts and sites in logistics / commodity management. CARE will continue development of an explicit plan for handover of project activities to Mozambican authorities. In FY 2010 CARE will increase the capacity of provincial and district MOH through technical and managerial support and direct sub agreements. 4) To improve access to quality HIV treatment services for adults and children: CARE will ensure effective linkages, referral systems and patient tracking within and between health facilities and communities. CARE will increase emphasis on child and adolescent services plus strengthening of laboratory, as well as improve linkages and integration of HIV and related primary health care services to provide a continuum of accessible services, including MCH/RH 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: CARE will 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.

In FY 2010 CARE will mainstream prevention with positives, injection safety and biomedical waste, and health worker protection (including PEP) by integrating activities into routine clinical workflow and

providing additional training. Cross-cutting gender issues will be addressed, with specific activities designed to improve male access to HIV services and male involvement in prevention efforts, as well as couple counseling and consultations. PMTCT services in an integrated MCH context are linked to safe motherhood, family planning for prevention of unintended pregnancies among HIV positive women, and child survival activities (in close collaboration with pediatric care and treatment). In FY 2010 CARE will continue to support the MOH to strengthen the identification, treatment and management of TB in adults and children.

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 new 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. Linkages with other USG and international donor projects providing facility and community based care will be strengthened to leverage resources.

CARE will also support the MOH to strengthen M&E activities through support for robust systems for HIV- related programs that can be adapted for use across the health field. Activities will include support for roll out and scale up of new M&E tools, training, supportive supervision, and technical assistance at site level with a focus on improved data quality and utilization to direct programs. Next generation indicators will be used and CARE will have detailed plans to report against these indicators.

CARE International 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) 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; 4) 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; 5) 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; 6) 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.

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

CARE International currently supports the provision of quality ART services in northern Inhambane province in the districts of Govuro, Inhassoro, Mabote and Vilanculos.

FY 2009 APR data showed that: CARE supported a total of four (4) fixed and two mobile ART clinics sites in 4 districts; 2379 patients were currently receiving ART services; and 93% of those ever started on ART were alive and on treatment. Support to treatment services is aligned with the Mozambique treatment guidelines and the goals of the Partnership Framework.

In FY 2010, support the DDS of Vilanculos district is provided through expanding support of the ART program to one additional site in Mapinhane which has been functioning as a mobile clinic, however this site alone accounts for close to 50% of patients receiving services in Vilanculos district. With this expansion, a total of 5 supported sites in 4 districts will be reached. Site expansion plans are in accordance with the MOH's policy and plans of ART services integration. Smaller rural sites in which services are already integrated are also supported. In addition, scale up of prevention with positive activities, early treatment initiation, cotrimoxazole prophylaxis and TB screening within ART service sites will be prioritized.

Specific activities planned in FY 2010 include: 1) Finance 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 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.

CARE will align FY 2010 activities with overall counseling and testing goals and strategies, with a focus on increased uptake of CT and improved post-test counseling. The majority of effort within the CT portfolio will be allocated in this area, representing approximately 60% of effort. In FY 2010 CARE will provide support in one province (Inhambane). The target population includes general population, as well as higher risk groups including ill and hospitalized individuals.

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 dedicated to CT activities; a sustainable strategy to minimize HR constraints for CT will be developed. Training of lay counselors and CBO's will be developed in FY 2010 to help strengthen linkages between health facilities and the community.

Quality assurance (QA) will also be a key area. 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 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.

Support to strengthen M&E systems will also be provided. FY 2010 funds will support training of partners and providers in new reporting documents, data management and data use for program monitoring.

Supervision of activities will be conducted through an integrated approach in close collaboration with DDS, DPS, and the provincial laboratory. FY 2010 funding provided to CARE will be applied towards subcontracts or grants to DPS / DDS / SDSMAS to the greatest extent possible.

CARE currently supports pediatric care and support in 4 districts in Inhambane province, including two satellite sites and focus on the provision of quality comprehensive care and support services for HIV exposed and infected children. These services consist of: early infant diagnosis (EID), cotrimoxazole prophylaxis, management of opportunistic infections and other related complications including malaria and diarrhea, growth and development monitoring, nutritional assessment, infant feeding counseling and education, palliative care, psychological, social, and spiritual and prevention interventions. In FY 2010 the focus will be on strengthening the health system, improve identification 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 services. All activities are aligned with the national priorities and the Partnership Framework.

Specific interventions will include: 1) Strengthening linkages between PMTCT, MCH, pediatric HIV; 2) Expanding PICT services to all children with signs or symptoms of HIV in out-patient and in-patient venues, including TB clinics and nutrition services and systematic testing of children of adult patients enrolled on ART; 3) Strengthening the logistic system for early infant diagnosis using HIV DNA PCR, use of cell phone connected printers for PCR DNA results and refresher training of health providers; 4) Supporting access to preventive interventions for malaria and diarrhea assuring logistic, storage and distribution of the basic care package (certeza for water purification, IEC materials and soap) and access to ITNs for all children < 5 years through 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 continuous quality improvement programs.

Universal antiretroviral treatment for infected children is a top priority of the MOH aiming to improve the survival and quality of life of these children and their families. Currently, children represent 5.6% of the

total number of patients on treatment in the four CARE supported sites in Inhambane province (this includes 2 satellite sites), based on APR data 09. The goal is having 10% individuals receiving treatment being children. Refresher trainings, mentoring and supportive supervisions will be coordinated with the provincial and district directorates and enhance the capacity of sites and health care providers to identify, treat, and care for HIV-infected children. For all HIV infected children receiving antiretroviral treatment, cotrimoxazole prophylaxis will be part of the care services provided.

The main activities will include:

1) Access to care and treatment services, through early identification of HIV exposure and infection status, strong linkages and integration of HIV services within the existing child health programs, TB, PMTCT, MCH and increased community awareness of pediatric HIV; 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 prevention with positives activities; 3) Linkages to psychosocial support programs for children, adolescents and their families along with support for retention, HIV status disclosure and adherence to ART; 4) Linkages with prevention targeting adolescents consisting of: education on risk reduction, family planning counseling, counseling and testing and promotion of youth friendly services; 5) Identifying developing and implementing interventions to improve patient tracking system, follow-up, identify and address treatment failures and adherence issues; implement the a continuous quality improvement program.

In FY 2010, assistance to strengthen the six building blocks of the health system will be prioritized in line with the priorities and goals of the GOM

CARE will support the MOH's decentralization process by building the institutional and technical capacity of SDSMAS (District Health and Social Welfare Services). CARE will also provide technical assistance to SDSMAS to build their capacity to plan and coordinate activities at the district level. CARE will explore innovative funding arrangements to SDSMAS to further increase the ownership and sustainability of HIV clinical service delivery.

CARE will strengthen human resources at the district and site level by supporting DPS to improve retention of health personnel through gap year funding. CARE will strengthen SDSMAS capacity to provide in-service training, mentoring and supportive supervision to clinicians and administrators.

CARE will provide support for the rehabilitation of existing infrastructure to accommodate the decentralization process of HIV services. Lastly, CARE will provide additional technical support and training to districts and sites in logistics management to complement implementation of the Pharmaceutical Logistics Master Plan.

Improved district coordination, technical assistance provided by the logistician advisor, 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 CARE 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, 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 Mozambique. In FY 2010 CARE will support MOH efforts to expand and institutionalize infection prevention and control (IPC) programs.

CARE will mainstream 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 the 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;

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.

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

CARE 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.

1) Mainstreaming of prevention with positives (PwP) activities: The PwP programs will be expanded 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). CARE has identified a focal person for PP activities to coordinate and ensure successful implementation of PwP activities.

2) Management of sexually transmitted infections (STI): CARE will support the management of STIs at provincial, district and health facility level in Inhambane 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), with focus on mobile populations and commercial sex workers. 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): Facility-level WPP will be supported to boost awareness and understanding of HIV related issues of the personnel of the health sector and their families. CARE will support the MOH to implement national WPP package, including the following elements: a. Prevention: BCC, condom availability, CT access, PMTCT, stigma and discrimination; b. Health care and support: access to counseling and testing, care and treatment, psychosocial support, and home based care; c. Human resource management including HIV policy.

Priorities in FY 2010 are coordination with 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 MOH through district, and provincial level support, technical assistance, training, quality improvement, and M&E. The district-based approach and collaboration at provincial level, including subcontracts or grants from CARE to provincial and district public health departments, 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 for FY 2010 include: 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) Linkages to treatment programs for ARVs for PMTCT: Focus on more effective regimens and ART initiation; 4) Cotrimoxazole prophylaxis: Focus on improving coverage for pregnant women; 5) Linkages to pediatric care and treatment programs for 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.

CARE has standardized laboratory services in ART care and treatment sites in which they work and strengthening lab services is a key to their ability to provide quality HIV care and treatment services. In FY 2010, CARE will contract a Lab Technical Advisor that will be based at the CARE program office. The Lab Technical Advisor will be responsible for overseeing the lab component of the Partner's Program within the Partner-supported districts. In addition, s/he will function as a counterpart for the Lab Technical Advisor based in DPS in Inhambane.

The Clinical Partner Lab Advisor will liaise and coordinate activities related to lab services with other USG and non-USG funded partners assisting the MOH in lab capacity building. The Lab Advisor will identify weaknesses in lab 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 lab advisor shall be integrated with on-going or new MOH national and provincial lab activities and policies and will improve lab services as a crucial component of quality care at CARE- supported sites.

CARE has been working in Inhambane province in collaboration with the DPS and DDS directorate 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; 3) Hiring and training of TB lay persons that provide CT services for TB clients that are yet to know their HIV status at the TB clinics.

In FY 2010 activities will continue to strengthen the identification, treatment and management of TB in adults and children as well as continue to strengthen TB/HIV activities.

The priorities will be: 1) To increase TB detection rates and TB cure rates; 2) To strengthening of PICT; 3) Routine provision of CTX and IPT; 4) Implement infection control measures; 5) Strengthen the referral system and linkages with other services (CCR, CTH, 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.

CARE will also support the GOM to implement prevention with positives activities in all sites by intervening in both the transmission of infection and the development of illness trough 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.

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