The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) currently supports HIV services in Maputo, Cabo Delgado, Gaza, and Nampula provinces being the lead USG clinical partner in 3 provinces (Maputo, Cabo Delgado, and Gaza). Since initiation of this project in 2004, EGPAF has expanded support to 107 PMTCT; 61 HIV counseling and testing; and 38 care and treatment service sites. In FY 2009, EGPAF supported counseling and testing for 6,254 individuals and ARV's for PMTCT to 2,709 pregnant women, with approximately 17,500 individuals currently receiving ART.

EGPAF's approach to program implementation, in line with the GOM, is grounded on the following key principles and goals: 1) Increase communities' access to quality HIV prevention, care and treatment services, by improving service provision for: HIV counseling and testing (CT), laboratory services, PMTCT, adult care and treatment, pediatric care and treatment, prevention, diagnosis and treatment of HIV-TB co-infection; 2) Improve linkages and integration of HIV and primary health services to provide a continuum of services, including maternal and child health and reproductive health services, within and between facilities; and community-based services; 3) Support stronger and sustainable Mozambican systems through emphasis on strengthening government and community capacity to deliver and manage services at the provincial and district level with an explicit plan to handover project activities to Mozambican authorities. These activities include: human resource capacity strengthening; physical infrastructure development; developing MOH capacity and provision of technical assistance in program management and implementation as well as commodity logistics management at the provincial, district and health center level. This is an important component of EGPAF's Track1 transition strategy; 4) Support clinical services, logistics, M&E and laboratory technical advisors in each province where EGPAF 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 CT and PMTCT 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; strenghtening commodity procurement systems; and improving HIV services integration with other health services; Goal 4: By ensuring effective linkages, referral systems and patient tracking within and between health facilities and communities including 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.

EGPAF priority assistance is to strengthen local health systems in line with Government of Mozambique and the PF priorities: support MOH's decentralization process by building DPS and SDSMAS capacity; strengthen human resources and training at the provincial, district and site level; infrastructure rehabilitation; training to provinces, districts and sites in logistics management; and mobilisation 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 commuity services to improve nutrition through basic nutritional education and 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 ; couple counselling and consultations; and activities to reduce violence against women.

Cost efficiencies will be improved by utilizing existing resources (staff, services, structures and

relationships with communities), adapting promising practices and lessons learned from local, regional, and international initiatives, and strengthening linkages with public health services and taking advantage of the facility- and community-based services in target areas. In addition, eventual transition of technical and managerial responsibilities to DPS/DDS through 47 sub agreements (4 to DPS, 36 to DDS and 7 autonomous hospitals) and as part of the Track 1 transition process with reduced overheads. EGPAF will link with other USG and international donor projects providing facility- and community- based care to leverage resources.

EGPAF will also strengthen monitoring and evaluation (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 PEPFAR output indicators will be used for PMTCT, ARV treatment, CT, HIV/TB and CARE 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. 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 EGPAF received funds to implement the cervical cancer "see and treat" strategy in two sites. In FY2010 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 trough formation of support groups, education, training and improving linkages and referrals toappropriate services for care and treatment.

EGPAF currently supports the provision of quality ART services in Maputo, Gaza, Nampula and Cabo Delgado provinces.As of the end of September 2009 (APR 2009), EGPAF is supporting 37 sites (plus 5 satellites) in 34 districts; 17,437 patients received ART services (current); 51% of patients ever started on treatment were still alive (70% using cohort data from 1327 patients). EGPAF's support to treatment services is aligned with the Mozambique treatment guidelines, the Partnership Framework and Track 1.0 transition process.

In FY 2010, support will be expanded to 4 additional sites (plus 20 satellites) to reach a total of 41 supported ART sites (plus 40 satellites) in 36 districts. The target is to provide ART to 32,105 adults by September 2010. Site expansion plans are in accordance with the Ministry of Health's policies and priorities. Existing sub agreements with 4 Provincial and 36 District Health Directorates (DDS), 1 provincial hospital and 9 rural or general hospitals will continue. Additionally a sub agreement will be signed with the Provincial Police Directorate for services in a Police Health Center in Maputo province. Sub-agreements support training, supervision; program monitoring; quality improvements and commodities procurements. Scale up of positive prevention activities, early treatment initiation, cotrimoxazole prophylaxis and TB screening within all ART supported service sites will be prioritized.

Specific FY 2010 planned activities include: 1)Payment of MOH health-care provider's salaries to address human resources gaps at existing health facilities 2)Support in-service training and mentoring of clinical staff to develop capacity in provision of quality ART services 3)Procurement of health center commodities 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)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 sites 8)Implement and monitor the Track 1.0 transition process.

EGPAF will align FY 2010 activities with overall USG counseling and testing (CT) goals and strategies, with a focus on increased uptake and improved post-test counseling. The majority of effort within EGPAF CT portfolio will be allocated in this area, representing approximately 60% of effort. In FY 2010, EGPAF will provide support in 4 provinces (Maputo, Gaza, Nampula, Cabo Delgado). 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; EGPAF 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 EGPAF. 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 EGPAF 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. EGPAF 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. EGPAF CT funding will be applied towards subcontracts or grants to DPS / DDS / SDSMAS to the greatest extent possible.

EGPAF will continue to support the MOH in 38 sites in 4 provinces and focus on provision of quality comprehensive care and support services for HIV exposed and infected children. These services consist of: 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 prevention interventions. In FY10, EGPAF will prioritize health system strengthening to 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 and will increase its support to 4 sites in 4 provinces. All activities are aligned with the national priorities and the partnership framework. Specific interventions will include: 1-Strengthening linkages between PMTCT, MCH and 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 primarily through use of cell phone connected printers for DNA PCR results reporting. EGPAF will also conduct refresher training of health providers for EID and DBS sample collection 4-Supporting access to preventive interventions for malaria and diarrhea, ensuring 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 the 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 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 programmes. 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 7.9% of the total number of patients on treatment at 38 EGPAF-supported sites. This will increase to 10% in FY10. 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. EGPAF will suport the MOH to build capactity to provide and sustain high quality standards of HIV treatment services in 4 provinces, targeting 2,788 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 MISAU 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 positive prevention activities Other interventions will focus on: 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)Identifying developing and implementing interventions to improve patient tracking system, follow-up, identify and address treatment failures and adherence issues. Implement the HIV-QUAL program 7) Linkages to prevention activities targeting adolescents consisting of: education on risk reduction, family planning counseling, counseling and testing and promotion of youth friendly services.

The Ministry of Health 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, the 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.

EGPAF has been asked to place three M&E Advisor in Maputo Province, Gaza, and Cabo Delgado as part of their overall support to clinical services in these provinces.

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

EGPAF will support the MOH's decentralization process by building the institutional and technical capacity of DPS and SDSMAS placing Provincial Technical Advisors at the Cabo Delgado, Gaza and Maputo DPS to improve HIV clinical health care quality, and to strengthen drug supply at the health facilities. EPAF 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.

EGPAF 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.

EGPAF 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/AIDS at little or no marginal cost. As EGPAF 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 EGPAF will support MOH efforts to expand and institutionalize infection prevention and control (IPC) programs.

EGPAF 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; 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.

EGPAF will support two 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) Management of sexually transmitted infections (STI): EGPAF 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. Additional focus will be on most-at-risk populations (MARPs) as determined by local demographics. 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.

(2) Health care worker / workplace program (WPP): EGPAF will support facility-level WPP to boost awareness and understanding of HIV related issues of the personnel of the health sector and their families. EGPAF will implement national WPP package, including the following elements: a. Prevention: BCC, condom availability, VCT 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. EGPAF objectives include improved quality; access to a comprehensive package including psychosocial support; and improved nutrition support for reduced vertical transmission. EGPAF 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 EGPAF to provincial and district public health departments, will increase EGPAF 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 11)Linkages to system strengthening, including infrastructure projects for PMTCT 12) 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. EGPAF has standardized laboratory services in different sites throughout three provinces. The main activity has been to assess adequacy of laboratory sites and adjusting working environment to optimize laboratory services and practices in some key districts within available resources. This has included laboratory renovations in some districts to ensure that laboratory infrastructure was such that new equipment, provided by APHL, could be placed.

Funds in FY 2010 will support the hiring of a laboratory Technical Advisor based at the EGPAF National Office level. He/she will be responsible for overseeing the laboratory component of the PMTCT and Care and Treatment Program within the EGPAF supported districts and for providing supervision of laboratory services within the program. In addition, (s)he will function as a counterpart for the three Laboratory

Technical Advisors based at the DPS's of EGPAF lead provinces.

The Laboratory Advisor will liaise and coordinate activities related to laboratory services with other USG and non-USG funded partners assisting the MOH in lab capacity building, 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 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 shall also respond to priorities identified by EGPAF teams or other direct implementers in the province in the lead provinces, specifically regarding the EGPAF-FURJ laboratory mentoring program in the Province. Overall, the EGPAF Laboratory Technical Advisor will improve laboratory services as a crucial component of quality care in the provinces supported by EGPAF.

EGPAF has been working in Maputo, Gaza, Nampula and Cabo Delgado provinces 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 VCT services for TB clients that are yet to know their HIV status at the TB clinics.

In 2010 EGPAF 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 Consultation for Child at Risk (CCR), Counseling and Testing for Health (ATS), Prevention from Mother to Child to Child Transmission (PMTCT) and Ant-Retroviral Therapy (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.

EGPAF will also implement positive prevention 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.

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