Columbia University received funds in FY10 through this award to support capacity building and technical assistance to Maputo city, Gaza, Inhambane, and Nampula provincial Health Directorates. The program activities funded through this mechanism complement current efforts of the USG to transition responsibility for program and financial management of HIV prevention, care and treatment programs from international partners to Mozambican (Indigenous) organizations. These indigenous organizations include Provincial Health Directorates and other local non governmental organizations. Capacity building in organizational development and financial management are key components of these activities.

Columbia University's approach to program implementation, is aligned and integrated 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 ICAP 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; 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 nonART 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

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 sub agreements 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.

Funds provided to Columbia University will be used to implement activities that are aimed at building the capacity of the Provincial Health Directorates (DPS) of Maputo City, Inhambane and Nampula provinces as well as the District Health Directorates (DDS) in these provinces. The primary focus will be capacity building for program oversight and implementation of 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) Provision of a comprehensive pre- ART package of services to HIV infected patients, improving access to positive prevention, diagnosis, OI management, OI prophylaxis (focusing on increasing cotrimoxazole prophylaxis for eligible patients), STI diagnosis and management, and nutritional assessment using the BMI calculation; through training, clinical mentoring and formative supervision. 2) Expand the cervical cancer "see and treat" strategy using the VIA/cryotherapy for diagnosis and treatment, and provide support for training and supervision. 3) Improved palliative care activities within the existing health structure; 4) Improved screening for treatable conditions such as syphilis and anemia; 5) 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; 6) 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; 7) 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; 8) Improved district-level coordination and effective linkages between health facilities, community-based organizations and other existing support services. 9) Provision of Nutrition assessment and counseling.

Additionally, funds will be used to strengthen Palliative Care (hosting provincial level ToT trainings, logistics, IEC materials). In relation to Pre-ART funds will be also allocated to support 2 provincial/regional training on pre-ART package.

The HIV treatment program activities implemented by Columbia University are aligned with the Mozambique treatment guidelines, the Partnership Framework goals and with the Track 1 transition process.

In FY 2011 funds allocated to Columbia University will support the Provincial Health Directorates (DPS) in Inhambane and Nampula provinces, and Maputo City to expand and sustain high quality ART services for adults and pediatric patients in these provinces. Expansion plans are in accordance with the government's ART services decentralization and integration plans.

Through existing sub agreements with the DPS, Columbia will increase support for provincial as well as district 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 supporting the DPSs and districts to:

1) Finance MOH staff positions;

2) Train, mentor and build capacity of MOH staff;

3) Improve patient management, drug management and strategic information systems;

4) Reinforce patient follow-up and referral systems;

5) Strengthen linkages with CT sites, TB clinics, PMTCT centers and PLHIV services;

6)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.10) 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 as well as the PwP Next Generation Indicator; 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). Columbia will have a dedicated person / technical counterpart for prevention by province focal person for PwP activities to coordinate and ensure successful implementation and monitoring of PwP activities.; will focus on scale up access to Positive Prevention (PP), (e.g. integration of PP services in existing HIV activities, and expansion in geographical and technical scope) through training of health providers, monitoring, including the PwP indicator, supportive supervisions and reproduction of training materials / dissemination (job aides, leaflets, etc) funds for training and reproduction of materials available (in coordination with lead TA partner): Target population: People living with HIV-Individuals and support groups. ($100.000).

Columbia will align FY 2011 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 Columbia CT portfolio will be allocated in this area, representing approximately 60% of effort. In FY11 Columbia will support the Provincial Health Directorates (DPS) and District Health Directorates (DDS) in Maputo City, Inhambane and Nampula province to provide CT services to the general population, as well as higher risk groups including ill and hospitalized individuals.

Activities will i include ensuring that technical and programmatic capacity is developed within the DPS and DDS in the following: 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; Columbia will also develop a sustainable strategy to minimize HR constraints for CT. Training of lay counselors and CBO's will be developed in FY 2011 to help strengthen linkages between health facilities and the community.

Quality assurance (QA) will also be a key area for Columbia. QA systems and standard operating procedures to ensure bio-safety will be developed, in close collaboration with lab. FY 2011 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 Columbia 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 2011.

Columbia will continue to support strengthening of M&E systems. FY 2011 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. Columbia CT funding will be applied towards subcontracts or grants to DPS / DDS / SDSMAS to the greatest extent possible.

In FY11 Columbia will continue to support the Provincial Health Directorates (DPS) and District Health Directorates (DDS) in Maputo City, Inhambane and Nampula province to provide and sustain high quality standards of HIV care and support services for pediatric HIV exposed and/or infected populations within these geographic regions.

The main activities will include ensuring that technical and programmatic capacity is developed within the DPS and DDS for them 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. Columbia will support improved 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 support that will be provided to the DPS and DDS 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.

In FY11 Columbia will be funded to continue to support the Provincial Health Directorates (DPS) and District Health Directorates (DDS) in Maputo City, Inhambane and Nampula province to provide and sustain high quality standards of HIV treatment services for pediatric HIV exposed and/or infected patients in these geographic regions.

The main activities will include ensuring that technical and programmatic capacity is developed within the DPS and DDS for the following:

1) Increase 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)Continued 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;

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) Promoting and ensuring the development of 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) Creation of 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.

SI funds have been allocated to ensure resources for capacity building at the provincial and sub-provincial level in strategic information. These funds will be used to develop, strengthen, and/or implement MOH HIV/AIDS data management and monitoring and evaluation systems by improving data collection, verification, analysis, use, and reporting. This may include strengthening of patient monitoring systems, capacity building in SI related human resources, harmonizing data collection and flow, support for data verification and other supportive supervision activities, and other cross-cutting strengthening SI support identified as a priority by the partner, USG, and MOH.

In FY 2011, Columbia University will prioritize assistance to strengthen the health system in line with priorities and goals of the GOM.

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

Columbia will strengthen human resources at the provincial, district and site levels by supporting pre-service training providing scholarships opportunities for health personnel will provide extra lab courses at Nampula Province and will support retention of newly assigned graduates to rural areas by providing resources to support the installation kit and 3 months of subsistence kits via DPS. Additionally, Columbia will support retention of health personnel through gap year funding.

Columbia 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.

Provided technical assistance by the provincial advisors, scholarships, installation kit and 3 months of subsistence kits, gap year funding, rehabilitation of infrastructure all have spillover benefits as they strengthen the broader health system beyond HIV at little or no marginal cost. As Columbia 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.. Funds provided to Columbia University in FY11 will be used to implement activities that are aimed at building the capacity of the Provincial Health Directorates (DPS) of Maputo City, Inhambane and Nampula provinces as well as the District Health Directorates (DDS) in these provinces for the expansion of infection prevention and control (IPC) programs.

Columbia support the DPS and DDS to 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 and other infectious waste disposal / IPC;

2) Ensure that all health facility staff receive updated training in injection safety / IPC/ waste management; PEP

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 IPC/injection safety measures at national 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.

In FY11 Columbia will continue to support the Provincial Health Directorates (DPS) and District Health Directorates (DDS) in Maputo City, Inhambane and Nampula province to implement HIV prevention activities. Columbia University 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 and include ensuring that technical and programmatic capacity is developed within the DPS and DDS for the following:

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). Columbia has identified a focal person for PwP activities to coordinate and ensure successful implementation of PwP activities.

2) Management of sexually transmitted infections (STI): Columbia 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): Columbia 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. Columbia 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.

In FY11 Columbia will continue to support the Provincial Health Directorates (DPS) and District Health Directorates (DDS) in Maputo City, Inhambane and Nampula province to provide and sustain high quality standards of PMTCT services through improved quality; access to a comprehensive package including psychosocial support; and improved nutrition support. 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.

Key activities include ensuring that technical and programmatic capacity is developed within the DPS and DDS for the following: :

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.

Columbia will continue to support the Provincial Health Directorates (DPS) and District Health Directorates (DDS) in Maputo City, Inhambane and Nampula province to provide a package of TB/HIV-integrated activities at USG-supported facilities following WHO recommended and MOH recommended TB/HIV collaborative activities. This support will be provided through mentoring, coaching as well as ensuring that the DPS hires staff with the appropriate technical skills to oversee TB/HIV program activities. Columbia 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, Columbia will continue to promote the engagement and commitment of Provincial Health Directorates (DPS) and District Directorates (DDS) in order to strengthen the implementation of TB/HIV activities and promote and support integrated TB/HIV districts supervision. Moreover Columbia will continue to expand the implementation of "one stop model" to additional sites. 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 Columbia will continue to give TA to the National TB Control Program to implement the revised Mozambican guidelines on TB and the revised M&E tools. Additionally, Columbia will continue to support the improvement of the management of HIV/TB and MDR-XDR/TB, in adult, children and high risk group.

Finally Columbia 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