The International Center for AIDS Care and Treatment Programs of Columbia University, Mailman School of Public supports HIV services in Maputo city, Gaza, Inhambane, Nampula and Zambezia provinces. Columbia is the lead USG clinical partner in Maputo city, Inhambane, and Nampula province. By FY2009 , Columbia had expanded support to 87 ANC sites providing PMTCT services to 6,596 pregnant women; 25 HIV counseling and testing (CT) that tested 15,904; and 49 care and treatment service sites that provided ART for 73992 ever on treatment.

Columbia's approach to program implementation, in line with the GOM, is informed by the following key principles and goals: 1) Increase communities' access to quality HIV prevention, care and treatment services, by improving service provision for: CT, laboratory services, PMTCT, adult and pediatric care and treatment, management of HIV-TB co-infection; 2) Improve facility and community linkages and integration of HIV and primary health services to provide a continuum of services, including maternal and child health and reproductive health services. 3) Support sustainable Mozambican systems through emphasis on strengthening government and community capacity to deliver and manage services at provincial and district level, and development of a handover plan of project activities to Mozambican authorities. These activities include: human resource and MOH capacity strengthening; physical infrastructure development; provision of technical assistance in program management and implementation; and commodity logistics management. 4) Support clinical services, logistics, M&E and laboratory technical advisors in each province where Columbia is lead partner. 5) Assist the MOH in the development of robust M&E systems for HIV-programs that can be adapted for use across the health field.

These program goals contribute to the following Partnership Framework (PF) goals: Goal 1: By reducing sexual transmission of HIV and improving access through increased geographic coverage and improved facility-community linkages for HIV services Goal 2: By utilizing innovative approaches to community mobilization and linking facility and community based care to reduce loss to follow up Goal 3: By increasing Provincial and District MOH capacity through technical and managerial support and sub agreements; supporting 'Gap Funding', training and supervision; renovating health facilities; strengthening commodity procurement systems; and improving HIV services integration with other health services Goal 4: By ensuring effective facility and community linkages, referral systems and patient tracking at ART and non-ART service sites; increasing emphasis on integrated child and adolescent services; strengthening of lab support Goal 5: By increasing access to a continuum of HIV care services through nutritional interventions and better community-facility linkages

Columbia priority assistance is to strengthen local health systems in line with GOM and the PF priorities: support MOH's decentralization process by building DPS and SDSMAS capacity; strengthen human resources at the provincial, district and site level; infrastructure rehabilitation; improved logistics management in provinces, districts and sites; and mobilization of community resources to foster linkages with health facilities and create demand for services.

Cross cutting issues addressed in program implementation include: 1) Linking clinical services with community services to improve nutrition through nutritional education, counseling and promotion of locally appropriate, nutritious foods. 2) Development of a gender strategy for each province, including activities designed to improve male access to HIV services e.g couple counseling and consultations; and activities to reduce violence against women.

3) Child Survival Activities: early infant diagnosis, infant feeding counseling, Cotrimoxazol prophylaxis, mothers groups for nutritional education. ???Safe motherhood: CT within Family Planning, family planning in MCH and PMTCT programs; supporting maternities for improved care, safe deliveries, and promoting appropriate breast feeding practices ???Malaria (PMI): collaborate with MoH and Malaria Consortium for the distribution of ITNs 6) End of program evaluation: analysis of routine data and formal evaluation of program performance using standard performance indicators

Cost efficiencies will be improved by utilizing existing resources (staff, services, structures and relationships with communities), adapting promising practices from local, regional, and international initiatives, and strengthening linkages with public health services and maximizing on facility and community based services in target areas. In addition, transition of technical and managerial responsibilities to DPS/DDS through 6 sub agreements as part of the will over time reduce overheads. Columbia will leverage resources through linking with other USG and international donor projects.

Columbia will strengthen monitoring and evaluation 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, supervision, and technical assistance with a focus on data quality and utilization. Next generation PEPFAR indicators will be used for program monitoring and Columbia will have detailed plans to report against these indicators.

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. One main strategy ICAP promotes, in coordination with MOH, is the Peer Educator Program. In order to improve, promote and retain membership of Peer Educators, will implement positive HIV positive prevention activities will be and the development of illness support groups and "positHIVe teas" 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. In 2009, ICAP received funds to implement the cervical cancer "see and treat" strategy in two sites. In FY 2010 this strategy will be expanded to 3 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.

ICAP currently supports the scale up and provision of quality ART services in Maputo City, and Gaza, Inhambane, Zambezia, and Nampula provinces. As of the end of September 2009 (APR 2009), ICAP is supporting a total of 49 sites in 28 districts; 73,992 patients ever treated of whom 51,622 (70%) were currently on ART (excluded is data from 6 sites that were transitioned to other partner support between January and June 2009 and one site that did not report in APR09 - 24 de Julho Health Center). ICAP's program is aligned with the Mozambique treatment guidelines, the Partnership Framework goals and with the Track 1 transition process.

In FY 2010, support will be expanded to 17 sites; including 5 additional sites in 6 priority districts in Inhambane (5) and Nampula (1) provinces to reach a total of 66 supported sites in 34 districts. The target is to provide ART to 59,078 patients by September 2010. Expansion plans are in accordance with the government's ART services decentralization and integration plans; a process initiated in January 2009 within the major urban treatment facilities including 6 newly Columbia supported sites for FY 2010. ICAP has been providing technical support for this activity to enable large urban sites to down-refer stable patients and ensure that patients are retained in care and treatment. Support will also be provided to enable urban Health Centers to absorb the referred patients and initiate ART for new patients.

Support to the DPS and Ministry of Defense through the 6 existing sub agreements will be increased to include provincial level monitoring and supervision of the HIV program. 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 MOH staff positions; 2) Train and mentor MOH staff; 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; 6) Strengthen linkages with CT sites, TB clinics, PMTCT centers and PLHIV services; 7)Expand prevention with positives programs within ART service sites; 8) Implement and monitor the Track 1.0 transition process; 9) Mainstream infection prevention control; support workplace programs including PEP.

ICAP will align FY 2010 activities with overall USG counseling and testing (CT) goals and strategies, with a focus on increased uptake CT and improved post-test counseling. The majority of effort within ICAP CT portfolio will be allocated in this area, representing approximately 60% of effort. In FY 2010 ICAP will provide support in 5 provinces (Maputo City, Gaza, Inhambane, Nampula, Zambezia. 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 HR dedicated to CT activities; ICAP will also develop a sustainable strategy to minimize HR constraints for CT. 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 for ICAP. QA systems and standard operating procedures to ensure bio-safety 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 bio-waste generated through the ICAP 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. ICAP 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. Supervision of activities will be conducted through an integrated approach in close collaboration with DDS, DPS, and the provincial laboratory. ICAP CT funding will be applied towards subcontracts or grants to DPS / DDS / SDSMAS to the greatest extent possible.

ICAP will continue to support 49 MOH sites to provide quality comprehensive care and support services for HIV exposed and infected children. These services consist of: early infant diagnosis, cotrimoxazole prophylaxis, management of opportunistic infections and other common childhood diseases including malaria, diarrhea, growth and development monitoring, nutritional assessment, infant feeding counseling and education, palliative care, psychological, social, and prevention interventions. In FY 2010, ICAP intends to increase its support to 17 sites in 5 provinces. ICAP is targeting 70% HIV exposed and/or infected children in follow-up, in the 66 sites. In FY 2010, ICAP will aim to improve identification of HIV-exposed and infected children; to increase enrollment of HIV-exposed and infected children into care and treatment services and to 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 and integration with MCH programs; 2) Expanding PICT services to all children with clinical manifestations of HIV in out and in-patient venues, 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 (water purification, IEC materials and soap) and access to ITNs for all children < 5 years; 5) Nutritional assessment and linkages with other partners and donors 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 service and with OVC

programs; 8) Implement an effective monitoring and evaluation program; scale up the electronic tracking system and the HIV QUAL 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 of these children and their families. As of the end of September 2009 (APR 2009), children represent 9% of the patients on treatment at 49 ICAP-supported sites.. This will increase to 10% in FY 2010. Realizing such an increase will require enhancing 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 prioritized.

ICAP will suport the MOH to build capactity to provide and sustain high quality standards of HIV treatment services in 5 provinces, targeting 7,230 children receiving treatment. 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 deveoped by MOH; 3) Training on the management and logistics of laboratory commodities such as CD4 reagents, ARV pediatric drugs and other HIV related medications; 4) Training, supportive supervisions and reproduction of materials to support prevention with positives activities; 5) Linkages to programs providing psychosocial support for children, adolescents and their families along with support for retention, HIV status disclosure and adherence to ART; 6) Linkages to prevention activities targeting adolescents consisting of: education on risk reduction, family planning counseling, counseling and testing and promotion of youth friendly services; 7) Identifying developing and implementing interventions to improve patient tracking system, follow-up,

identify and address treatment failures and adherence issues. Support the implementation of Pediatric HIVQUAL program.

This budget code includes two main activities, both of which are continuing activities from FY 2009: 1)Support for M&E Advisors in the three provinces in which ICAP is the lead clinical partner: Maputo Cidade, Inhambane, Nampula. 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.

2)Support for two technical advisors to be placed at the national level to strengthen health information systems, seconded to MOH Department of Health Information (DIS) and to its implementation partner, M- OASIS, based at the University of Eduardo Mondlane

Since 2007, USG has funded a technical advisor seconded to the MOH's DIS to assist with strategic planning and implementation of key activities in the DIS annual workplan. A key focus of this technical advisor is capacity building and systems strengthening within the DIS. The advisor will actively participate in the training of Mozambican counterparts, at all levels of the national health system and will assist with the integration of National Health Information System with other diverse vertical programs.

Starting in 2010, a second technical advisor position will be placed to strengthen the capacity of the implementation arm of health information systems, the M-OASIS project, based at the University of Eduardo Mondlane. This advisor will help to ensure strong linkages, coordination, and capacity building in informatics projects to support MOH's National Health Information Systems Strategy.

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

ICAP will support the MOH's decentralization process by building the institutional and technical capacity of DPS and SDSMAS placing Provincial Technical Advisors at the Nampula DPS and Maputo City Health Directorate to improve HIV clinical health care quality, and to strengthen drug supply at the health facilities. ICAP 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.

ICAP will strengthen human resources at the provincial (Maputo City, Inhambane and Nampula) 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.

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

ICAP 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 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.

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.

ICAP will support three distinct areas within the sexual transmission (other prevention) portfolio. 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: 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). ICAP has identified a focal person for PwP activities to coordinate and ensure successful implementation of PwP activities.

2) Management of sexually transmitted infections (STI): ICAP will support the management of STIs at provincial, district and health facility level in order to reduce the burden of STIs as well as HIV infections attributable to STI co-infection. 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): ICAP will support facility level PP will be supported to boost awareness and understanding of HIV related issues of the personnel of the health sector and their families. ICAP will implement national WPP package, including the following elements: a. Prevention: BCC, condom availability, CT access, PMTCT, reduction of stigma and discrimination; b. Health care and support: access to confidential counseling and testing, care and treatment, psychosocial support, and home based care; c. Impact mitigation including benefit scheme; d. 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. Columbia objectives include improved quality; access to a comprehensive package including psychosocial support; and improved nutrition support for reduced vertical transmission. Columbia 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 Columbia to provincial and district public health departments, will increase Columbia 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 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 technical assistance to central level and infrastructure projects for PMTCT; 13)Mainstream infection prevention control in PMTCT settings; support workplace programs including PEP.

Clinical partners have standardized laboratory services in ART care and treatment sites throughout the provinces in which we work and strengthening lab services is a key to their ability to provide quality HIV care and treatment services.

With FY 2010 funds, ICAP will hire a Laboratory Advisor for their program and support salary and benefits for a Lab Technical Advisor to the DPS in one of the provinces where they are the lead partner.

The Lab Technical Advisor based at the ICAP program will be responsible for overseeing the lab component of the partner's program within the partner-supported districts in Maputo, Gaza, Inhambane, Nampula and Zambezia province. In addition, s/he will function as a counterpart for the Lab Technical Advisor based in DPS of each province.

The ICAP 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, such as Clinton Foundation, SCMS, and APHL. The Lab Technical 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 USG supported sites.

ICAP will continue to provide a package of TB/HIV-integrated activities at USG-supported facilities

following WHO recommended and MOH recommended TB/HIV collaborative activities. ICAP will support

the MOH's implementation of the "Three I's": intensified case finding (ICF), isoniazid prophylaxis (IPT),

and infection control (IC). Training, mentoring and technical assistance (TA) will be offered to expand IPT

implementation meanwhile strategies will be identified to track patients to improve adherence and follow-

up. In addition, ICAP will continue to promote the engagement and commitment of Provincial Health

Directorates (DPS) in order to strengthen the implementation of TB/HIV activities in the provinces and

promote and support integrated TB/HIV districts supervision. Provincial meetings on TB/HIV with a

special focus on the "Three I's" will continue to be proposed, organized and supported by USG in

coordination with the DPS. Moreover ICAP will continue to give TA to the National TB Control Program

to review current Mozambican guidelines on IPT and TB screening participation in the National TB/HIV

Working Group and other coordination meetings, review of guidelines and manuals, and development of

tools. Finally ICAP will continue to address the need for implementation of administrative, environmental

and personal measures in both HIV and TB facility and will support training of staff in TB infection control.