EGPAF receives PEPFAR funds to implement HIV program activities in Maputo Province, Gaza, Nampula and Cabo Delgado. Approximately 40% of Mozambiques HIV-infected population resides in these 4 provinces. The programs goal is to scale-up quality care, treatment and evidence-based prevention activities and contribute to PF goals 1-5 through by: 1)Reducing sexual transmission of HIV; 2)Community mobilization and linking of facility and community based care; 3)Increasing Provincial and District Ministry of Health capacity; 4)Ensuring effective referral and patient tracking systems; 5)Ensuring and improving nutrition services. GHI focal areas addressed are: Expanded Access and Uptake of Quality MNCH services and Strengthened Governance. In FY12 EGPAF will provide ARVs for PMTCT to 19,237 pregnant women; HIV counseling and testing to 242,342 people; and ART to 51,024 patients. Expenditure analysis placed EGPAF within the normal distribution. Increased capacity and program transitions to MOH and local partners are expected to further reduce program costs over time. FY12 is second year funding, so pipeline analysis was not available at the time this budget was being developed. Activities to increase local ownership are: 1)Transition management of clinical services in Maputo Province and Cabo Delgado to a Mozambican NGO (Ariel Foundation); 2)Increase the number of direct awards to provinces and districts in FY12; 3)Expand performance based financing to include all districts in Nampula and Gaza; An M&E system captures standard data related to quantity, quality and impact of HIV clinical services, systems strengthening activities, financial accountability and administrative management. EGPAF has to date purchased 28 vehicles. Additionally, this IM receives Central GBVI funds

In FY 12, the Elizabeth Glazer Pediatric AIDS Foundation (EGPAF) will continue to support the Ministry of Health through the Provincial Health Directorates (DPS) of Maputo Province TA and capacity building to Ariel, DPS and DDS), Gaza, Cabo Delgado and Nampula provinces as well as the District Health Directorates (SDSMAS) in these provinces.The focus will be capacity-building for ARIEL and DPSs to improve program management and delivery of services in Maputo Province, and Cabo Delgado, with particular attention to latter. According to the data provided in the last retention meeting organized by the MoH, this province presents low retention rates in Pre-ART.In Gaza and Nampula EGPAF will intensify its support to ensure high quality services for patients in care (pre-ART and ART patients), improve the retention rates, strengthen referral systems within health facilities and the community with particular attention to Nampula since data shows low retention rates in pre-ART.A performance based financing (PBF) initiative will be expanded to include all districts in Nampula and Gaza. Some of the indicators EGPAF will be using to measure and subsequently incentivize performance are key care and support indicators.The main activities are:1) Roll out Pre-ART package of care and support services to HIV infected patients. This activity will allow a better follow up of patients in care in standardized manner. The objective is to ensure all patients in care, either pre-ART and ART benefit from a comprehensive set of intervention such as diagnosis of opportunistic infections (OIs), provision of cotrimoxazole prophylaxis, TB screening, INH prophylaxis, STI diagnosis and syndromic management, nutrition assessment and counseling (NAC), psychosocial support, adherence support, positive prevention and other services that will contribute to link to and retain patients in care2) Integration of Pre-ART with positive prevention (PP) interventions. In line with the MoH vision, Pre-ART and PP interventions will be integrated. PEPFAR recommends a whole range of interventions that should be offered to all patients in care. Efforts will be done to ensure that at health facility the following 7 interventions are provided(including the data reporting as long as the monitoring and evaluation systems are in place) within the pre-ART package: 1)Condom provision and education; 2) Partner testing and referral; 3) STI management and partner testing; 4) Family Planning; 5) Adherence assessment and support;6) Assessment of support needs and referral (i.e: home-based care, support groups, post-test-clubs); 7)Alcohol use, assessment and counseling3) Provincial trainings and supervision to improve syndromic management of STIs4) Scale up of the `screen and treat` cervical cancer program5) Train nurses and medical agents in OIs (new guidelines) to ensure appropriate and early diagnosis of and provision of CTX prophylaxis6) Implementation of universal access of peer educators (PE) support7) Capacity building to the DPS,DDSMAS and local organizations to manage and implement quality HIV/AIDS Prevention, Care, and Treatment related sub agreements8) Expand Performance Base Financing to all districts of Gaza and Nampula

All USG-supported treatment partners, including EGPAF, will be funded to implement TB/HIV activities in HIV and TB treatment settings for adults and children. These proposed activities are in line with the MoH priorities and at a minimum will include: 1) Strengthening the implementation of the 3 Is- intensified TB case finding (ICF), Isoniazid preventive therapy prophylaxis (IPT) and infection control (IC); 2) provision of cotrimoxazole preventive therapy (CPT); 3) universal anti-retroviral treatment (ART) for all HIV-infected person who develops TB disease (irrespective of CD4); 4) integration of TB and HIV services including scaling up the implementation of one stop model 5) strengthening of the referral system and linkages with other services (ATS, PMTCT) to ensure that TB suspects are diagnosed with TB and successfully complete TB treatment under DOTS, 6) IC assessment and developing to reduce nosocomial TB transmission in health facilities; 7) ensuring that all key clinical receive training on TB/HIV, and MDR-TB including management of pediatric TB.

In addition EGPAF will develop linkages with the community groups and TB programs and other USG partners to ensure that adherence support is provided to co-infected individuals, and that monitoring and evaluation systems are in place to track HIV-infected patients at the clinics who are screened, diagnosed, and treated for TB.As part of provincial team EGPAF will continue to participate in the provincial planning, provincial and district technical working groups and in monitoring the implementation of the activities with the DPS and other partners in respective geographic area.Additionally EGPAF will collaborate with existing TB diagnostic and treatment facilities to ensure that:1) Minor renovations in out-patients, wards with TB and/or MDR-TB patients, waiting areas, laboratory and X-ray departments to improve cross ventilation will be carried out in selected health facilities.2) A good laboratory system for sample referral for GeneXpert and including in communication and information system are in place.3) Clinicians and nurses at provincial and district/rural hospitals are trained to perform sputum induction in children and strengthening evaluation and management of pediatric TB.4) EGPAF in Gaza Province will assess the need to support or hire a TB/HIV focal person.5) Motorcycles will be purchased to support supportive supervision to peripheral health facilities, community based DOTs volunteers/activists and to trace defaulters and contacts of TB.6) Print and disseminate IEC materials7) Implementation of surveillance of TB among health workers8) Continuing coordination and collaboration with key partners in the province to identify gaps, avoid duplication and make the rational use of resources.

During FY12 EGPAF will support Pediatric HIV care services in Maputo Province (for TA and Capacity building to Ariel, DPS and DDS), Gaza, Cabo Delgado and Nampula provinces.

Support for the provision of comprehensive care and support services to HIV exposed and infected children includes: Early infant diagnosis; cotrimoxazole prophylaxis; management of opportunistic infections; growth and development monitoring; nutrition assessment, counseling and support; psycholo- social support. In FY12 EGPAF will provide cotrimoxazole prophylaxis to 6326 HIV exposed infants.

The systems strengthening and capacity building activities that will be supported in Fy12 include: in-service training on comprehensive pediatric HIV care, supportive supervisions and mentoring; provision of job aids; and strengthening of commodity, drug and reagent distribution systems within the provinceRoutine supervision, monitoring and collection of data on infant diagnosis, cotrimoxazole prophylaxis and enrollment in ART programs will be ensured through implementation of QI activities.

Activities promoting integration and linkages of pediatric services with other routine care will be implemented and include:1) Expanding PICT: - to all hospital admitted children, TB clinics and nutrition services; systematic testing of children of adult patients enrolled on ART;2) Strengthening the HIV DNA PCR infant diagnosis logistic system, use of cell phone printers technology to transmit test results and reduce the waiting time to HIV diagnosis.3) Improving referral systems between pediatric Care and treatment and child at risk consultation clinics (CCR):- using escorts (peer educators) for mother/baby pairs between maternity and CCR; in EPI/MCH services, verification of HIV status/ exposure in the child health card and referral for testing and follow up in CCR clinics4) Integration of HIV in MCH services by including MCH nurses in ART management committee meetings, reviewing patient flow to reduce loss to follow and conducting home visits for HEI within the first month of delivery.5) Supporting access to malaria and diarrhea prevention assuring storage and distribution of basic care commodities (water purification, IEC materials and soap) and access to ITNs for all children < 5 years;5) Nutritional assessment and counseling and provision or referral to access therapeutic and supplementary food that is provided through other partners and donors (e.g WFP and UNICEF)6) Strengthen referral systems between clinic and community services including OVC programs;

EGPAF has implemented a few adolescent HIV care activities such as support groups and youth friendly services. The USG will develop a comprehensive strategy on adolescent HIV care including disclosure which will be implemented by clinical partners.

Clinical outcomes are tracked routinely on paper and electronically. Monthly reports are submitted to MoH. EGPAF also reports quarterly, semi and annual PEPFAR reports. USG Clinical partners meetings take place every 6-8 weeks to review and analyze performance data.

EGPAF has been asked to place 1 M&E Advisor in Gaza and Nampula provinces as part of their overall support to clinical services in these Provinces.While strengthening systems for M&E and Health Information Systems (HIS) remains a priority, the model of providing assistance is currently under review in a joint process by USG and MOH. During FY12, these discussions should provide updated guidance on the most effective model for providing technical assistance that results in greater MOH ownership and capacity (e.g. via seconded technical advisor or another model of technical assistance.) The overall objectives of this technical assistance continues to be to strengthen MOH systems at provincial level*To coordinate routine activities related to M&E and HIS at the Provincial Directorate of Health, giving priority to endemic diseases, including HIV.*To reinforce and support the implementation of the decentralization of HIV services including related routine data collection systems.*To strengthen MOH 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.*To support the Provincial Directorate of Health in the analysis and dissemination of data (for example, to the site level, Ministry of Health, and partners.)

While the primary focus of this technical assistance is to strengthen HIV-related M&E, by strengthening systems and human capacity at the provincial level, this technical assistance should also positively impact M&E systems in other MOH systems beyond HIV.

EGPAF supports Ministry of Health (MOH) priorities outlined in the Human Resources National Development Plan (2008-2015) and is coordinating with other PEPFAR implementing partners and other donors in the provinces of Maputo Province (Ariel), Cabo Delgado, Gaza e Nampula. In 2012 will continue to support in the following activities:Given the urgent need for increasing the number of qualified health care workers at all levels, PEPFAR funds are used each year to pay the entire course expenses associated with training for clinical officers, general nurses, MCH nurses, laboratory technicians, and pharmacy technicians from both basic (3 semesters) and middle level training programs (5 semesters) at the provincial Health Institutes. The goal of this activity is to increase the production of healthcare workers and decrease the numbers who drop out of training due to financial constraints. The partner will provide annual support to health training institutes in their province areas through the Provincial Health Directorate (DPS) per the needs identified by the province.Based on the laboratory program model of support, in FY12 partners will continue to provide support to supply chain management of medicines and reagents at the periphery by supporting the position of a pharmaceutical supply chain advisor for the province. This advisor will work with the DPS and DDS to incorporate pharmacy supervision visits into joint integrated supervisions visits; coordinate with the provincial advisors in other areas, CMAM, MoH laboratory section, and SCMS around bottlenecks or problems with essential commodities, including laboratory reagents; help coordinate and support trainings in collaboration with the DPS an CMAM.Laboratory services are integral service component to support optimal care and treatment to HIV patients. FY12 funds will continue to support Laboratory Technical Advisors based at the DPSs. The laboratory advisor will liaise with and coordinate activities with NGOs and partners, MoH, SCMS, APHL, and others. The advisor will identify weaknesses in laboratory processes, procedures, and logistics, propose adequate strategies for improvement, and contribute to a plan towards building capacities at provincial and district levels.Minor renovations and infrastructure. FY12 funds will support rehabilitation of existing infrastructure to accommodate the decentralization process. Partners will have funds to support minor rehabilitation to facility and district pharmacies, including paint, ventilation or air conditioning systems, racking and other material/infrastructure requirements for improved storage conditions for medicines.Supply chain & commodities support. Partners will receive OHSS funds to provide additional support to the supply chain system below provincial level, in collaboration with SCMS and SIAPS. Partners will provide general support to strengthening quality of pharmaceutical management services, including ARV dispensing services through improved monitoring of the MMIA system, monitoring pharmacies and adherence to standard operating procedures, and participation in joint supervision visits with the DPS/DDS. Partners will also support the expansion of the logistics management information system (SIMAM) to additional districts.In GAZA and NAMPULA, EGPAF will expand its performance based financing (PBF) initiative to include all districts in those 2 provinces.

Prevention of medical transmission of HIV is addressed through the MOH Infection Prevention and Control program, which goal is to reduce the risk of transmission of HIV and other blood borne pathogens at health facilities. Activities include: compliance with Infection Prevention and Control/Injection safety (IPC/IS) standards; reinforce of biomedical waste management; Post Exposure Prophylaxis (PEP) to HIV and work place safety. The program started in 2004 with PEPFAR technical and financial support. Since 2010 USG/PEPFAR supported Clinical partners are requested to mainstream IPC/IS activities at their sites.In alignment with PEPFAR FY 2012 goals, EGPAF will continue to reinforce IPC implementation including: compliance with IPC standards and guidelines; adequate sharps and other infectious waste disposal; PEP scale-up and M&E; dissemination and implementation of the National waste management plan. In FY12 EGPAF will pilot a model waste management approach using autoclaves in 3 facilities ( Xai-Xai provincial hospital and Chokwe Rural Hospital in PEPFAR focus province Gaza and in Ndlavela health Center in Maputo province), with support of JHPIEGO and in close coordination with CDC Mozambique and support of CDC HQ International medical waste Program manager.

FY 12 Key activities include: 1) Strengthen and expand implementation of PEP services for victims of sexual or gender based violence as well as occupational exposure in clinical settings and including monitoring and evaluation 2) Strengthen implementation and compliance of IPC standards and support regular measurement of good performance using Standards-Based Management and Recognition approach, and improve M&E system for IPC and work place safety 3) improvement of the waste management system including assessment, implementation and supervision of a non burning waste management system using autoclavesAs part of provincial team EGPAF will continue to participate in the provincial planning and district technical working groups and in monitoring implementation of the activities with the DPS and other existing partners in their geographic area.

EGPAF will continue its support to MOH through an alignment of FY 2012 activities with overall PEPFAR Counseling and Testing goals and strategies, with a focus on strengthened linkages from HTC to other services.EGPAF will target populations for HTC in health-care setting: provider Initiated testing and Counseling (PICT) for all patients accessing health care services and their partners as well Voluntary CT for all patients wanting to access CT services with a special focus on men, adolescent girls, partners of PLHIV and couplesEGPAF will also be instrumental in the regional CT campaigns planned for FY12 as demand creation activities will be carried out in Gaza. The target population for the HTC regional campaigns will be mainly partners of PLHIV, couples and men, as these particular groups have had low coverage in years past.SYSTEM STRENGTHENING AND CAPACITY BUILDING:Quality assurance is a priority and EGPAF will continue using on-going supportive supervision including direct observation approach to be sure that each counselor performs HTC service delivery correctly. Additionally, all of EGPAFs counselors will participate in a training designed by the National health Institute to improve the quality of HIV rapid diagnostic testing.

INTEGRATION AND LINKAGES:

Whereas in previous years, counselors simply gave referral slips to HIV positive clients, with COP 12 funds, EGPAFs counselors and health care service providers will have a stronger role supporting newly diagnosed clients by personally introducing them to existing peer educator/peer navigator/case manager volunteers who will navigate or escort clients to enroll or register for follow up services, including positive prevention or the new MOH pre-ART service delivery package and support groups. For those newly diagnosed who do not enroll in HIV care and treatment services, CT counselors will continue using the door to door approach to re-visit already diagnosed HIV positive to monitor their enrollment and adherence to recommended treatment and care through the positive prevention or pre-ART support groups. HIV negative clients will be encouraged to bring their partners in for testing and reduce their risk through condom use and partner reduction. Where available, counselors will refer HIV negative men to medical male circumcision services.

MONITORING AND EVALUATIONEGPAF will work closely with the USG and partner Strategic information teams to develop and utilize instruments to document and measure CT service uptake as well as service-to-service and facility-to-community linkages to ensure follow-up, retention and adherence of clients diagnosed with HIV.

The USG portfolio on MARPs has been growing in the last year with interventions focused on different population groups, particularly female sex workers and their clients, men who have sex with men, incarcerated populations and injection drug users (IDUs). These population groups (with the exception of IDUs) have been reached through a comprehensive package of information and services that include behavior change, risk reduction activities and bio-medical interventions. In the coming year, more attention will be given to exploring innovative ways to increase the number of MARPs using care and treatment services in order to ensure linkages between prevention and clinical partners including humanization of care and treatment services for MARPs through dissemination of national guidelines for care, treatment and follow-up with the goals of reducing and removing barriers to the access of services and information and decreasing stigma and discrimination of MARPs. In coordination with the prevention partners in the province of Inhambane, the activities will include the strengthening of linkages between community and care and treatment facilities through the establishment of effective referral mechanisms with functioning tracking systems in place (referral charts, monitoring instruments). Activities might also include support the implementation of surveillance system at designated night clinics (to be determined by Ministry of Health after approval of protocol and data collection forms) for FSW and other MARP groups in order to provide much needed qualitative and quantitative information around specific MARPs needs in the clinical setting. In addition, collaborate in the training of clinical partners and health center staff on appropriate STI diagnosis, treatment and MARP friendly services and provide support to the clinical interventions for HIV/STI prevention and care, based on local protocols.

EGPAF priorities in FY 2012 is coordination with MOH for accelerating the scale up of effective PMTCT interventions within an integrated maternal, neonatal and child health (MNCH) system towards the goal of virtual elimination of mother-to-child transmission of HIV by 2015.In FY2012 EGPAF will support the following activities:1) Prevention of HIV in women of childbearing age:a. Re-enforce provider initiated counseling and testing for women and couples in all components of MCH services;b. In coordination with community partners, develop IEC activities and promote health fairs focusing in areas with high concentration of women.2) Prevention of unwanted pregnancies among HIV+ women:a. Re-enforce targeted family planning and contraception for HIV+ women in both HIV care and treatment as well as FP settings;b. Integration of family planning component in routine mobile brigades;3) Prevention of mother-to-child transmissiona. Scale up training of Option A;b. Scale up exposed child follow up to all facilities with PMTCT services;c. Develop strategies to increase institutional delivery.4) Care and support for HIV+ women, infants and families including support for safe disclosure within families to reduce risks of HIOV disclosure related gender based violence :a. Training of MCH nurses for provision of ART in ANC settings;b. Increase delivery of ART to eligible HIV+ pregnant women and infected children;c. Support positive prevention and family planning at HIV care and treatment sites;d. Scale up mothers support groups interventions and community involvement including male involvement to reduce gender inequities in HIV counslling and testing.Additionally, EGPAF will support implementation of the following cross cutting activities:5) Develop interventions to strengthen capacity of networks, civil society and support groups of women living with HIV. Collaboration with communities and traditional birth attendants to increase facility-based deliveries.6) Develop interventions to ensure continued availability of supplies and commodities for PMTCT;7) Support PMTCT related training activities;8) Nutrition - safe infant nutrition interventions integrated into routine services;9) Support dedicated personal with M&E expertise to directly work with DPS and health facilities for ensuring quality M&E system; support roll out of new M&E tools; support implementation of supervision, QA/AI cycles, strengthening data flow and data entry at facility level.

EGPAF supports adult ART services in Maputo Province (TA and Capacity building to Ariel, DPS and DDS),Gaza, Cabo Delgado and Nampula provinces.Priority areas are increased treatment access; ART retention; ART Quality assurance; program linkages and integration especially with CT, TB, PMTCT, nutrition, pre-ART services, and prevention with positives. Gender distribution of access to treatment shows that currently about 66% of patients on ART are female. There are alsocomparytively more females teting HIV positive than men. Continued efforts to promote family centred approached to treatment and care will be promoted to ensure gender equity in access to service. FY 12 targets are 46,913 patients on ARTThe strategies that will be employed to address these challenges are:Intensification of testing and recruitment strategiesUniversal ART for TB/HIV co-infected patientsImplementation of the 350 cells/mm3 CD4 count thresholdTest and treat strategy for all HIV-infected pregnant women accessing antenatal care at ART sites, irrespective of CD4 countMobile clinics to bring services closer to patients living in rural isolated areas (in Gaza)Scale-up of Community Adherence and Support GroupsStandardizing and universalizing peer educators in all PEPFAR supported health facilitiesStandardized quality improvement programScale-up of POC CD4 count technologyImplementation of a pre-ART packageAdditional task-shifting to include nursing cadres and medical assistantsOn-site peer educators and follow-up of patients using community volunteers, electronic patient tracking systems, diary/agenda systems and home visits are conducted to trace defaulters or lost to follow up cases and to improve retention rates. The peer educator program will be standardized in all sites in FY12.Programmatic efficiencies are increased by deployment of multi-disciplinary teams of clinicians, psychosocial support, M&E to provide technical assistance in ART program management and capacity building in finance and administration management to site and district health teams. Each team is assigned to 3-4 districts.The following are systems strengthening and capacity building activities supported by EGPAF:1) DPS sub agreements to finance staff priority activities2) Performance based financing pilot in Gaza and Nampula3) Task shifting ART to nurses, middle-level health and mentoring of providers4) Hiring provincial Clinical Advisors for Maputo Province, Cabo Delgado and Gaza province.5) Joint EGPAF/DPS supervision visits that are linked to Continuous Quality improvement (CQI) program activities.6) Participation in development and implementation of a national QI system. EGPAF participates in the periodic HIVQUAL program activitiesIn FY12 clinical services management responsibility in Maputo Province and Cabo Delgado shall transfer from EGPAF to Ariel Foundation, EGPAF shall provide managerial capacity building to DPS, districts and to Ariel foundation.In Nampula province ICAP shall be provide site level clinical technical assistance while EGPAF will provide all Systems strengthening support.Clinical outcomes are tracked routinely on paper and electronically. Monthly reports are submitted to MoH. EGPAF also reports quarterly, semi and annual PEPFAR reports. USG Clinical partners meetings take place every 6-8 weeks to review and analyse performance data.

During FY12 EGPAF will support Pediatric ART services in Maputo Province (for TA and Capacity building to Ariel, DPS and DDS), Gaza, Cabo Delgado and Nampula provinces.Scale-up of pediatric HIV is a national priority that EGPAF will support MoH work towards including ensuring implementation of new guidelines within supported provinces, districts and sites. EGPAF will support sites to achieve pediatric new ART enrollments rates of at least 15% of all new patients on treatment and ART retention of 85%. The following are the expected pediatric treatment targets for the next two years: FY12 targets are 4111 currently on treatment.Activities to expand pediatric enrollments and access to diagnostic services include:1) improving patient flow and specimen referrals to increase access to EID2) POC CD4 testing3) implementation of continuous quality improvement programs4) early initiation of treatment5) An active case finding model6) Improved linkages between services (i.e.: TB, MCH, inpatient wards etc)7) Increased community awareness of the importance of testing children and accessing care early

The systems strengthening and capacity building activities that will be supported in FY12 to enhance capacity of sites and health care providers include: in service training on pediatric HIV care and treatment, supportive supervisions and mentoring; provision of job aids, implementation of new national Pediatric Treatment Guidelines; assistance in monitoring stocks of ARV drugs and support distribution systems within the province.

Routine supervision, monitoring and collection of data on pediatric treatment will be ensured through implementation of QI activities, Patient tracking systems and strengthening of district and provincial ART management committees.

The USG will develop a comprehensive strategy on the management of HIV-infected adolescents which will be implemented and supported by the clinical implementing partners.

Adherence and retention strategies are provision of psychosocial support, improved quality of care, caregiver counseling, support groups, and community follow up. There will also be emphasis on the importance of disclosure.

Strategies to ensure increased integration and linkages of HIV services with the existing child health and other programs to reduce loss to follow and improve retention include: prioritization of children in ART clinics, assuring same day consultations for mother and child in PMTCT services, developing formal referral systems between ART clinics with TB, PMTCT, Counseling services, CCR and EPI programs and with the community; ART initiation within CCR clinics.

Clinical outcomes will be tracked routinely on paper and electronically. Monthly reports will be submitted to MoH as well as quarterly, semi and annual PEPFAR reports. USG Clinical partners meetings take place every 6-8 weeks to review and analyse performance data and the TBD partner will also partcipate in these meetings.