The five-year Clinical HIV/AIDS Services Strengthening Project in Sofala, Manica, and Tete provinces (CHASS-SMT) was awarded in January 2011 to a partnership led by Abt Associates Inc. with primary service delivery sub recipient, Family Health International (FHI).CHASS-SMT directly contributes to the goals of the PF by expanding on existing USAID-funded programs in the country to reduce HIV transmission and mitigate the impact of the epidemic. The project is also aligned with GHI priorities and it is driven by the principles of sustainability, country ownership and health systems strengthening. The foundation is HSS through quality improvement and sustainability planning. The main objectives are: (1)To increase access, quality and use of HIV care and treatment services to rural communities by intervention in 7 areas: HVCT, laboratory services, scale-up of PMTCT, scale-up of adult care and treatment, scale up pediatric care and treatment, palliative care, and prevention, diagnosis and treatment of HIV-TB co-infection; support the implementation of mobile units(2) To provide a continuum of accessible HIV and related primary health care services including MCH and RH services and to improve linkages and referrals within and between facilities and communities; (3)To support stronger and more sustainable Mozambican systems and institutions through emphasis on strengthening government and community capacity to deliver and manage services at the district level with an explicit plan to handover project activities to Mozambican authorities; including piloting of PBF in Manica and Sofala (4)To assist the MOH in the development of robust systems of monitoring and evaluation for HIV-related programs that can be adapted for use across the health field.

The clinical service project implemented in Sofala, Manica and Tete Provinces will support the increase coverage of non-ART clinical and preventative services and commodity distribution to the target population, especially in rural areas. CHASS SMT will continue to support the roll out of MoHs GAAC (Grupo de Apoio a Adesão Comunitária) strategy, aimed at improving patient retention in treatment and care. CHASS-SMT will coordinate with CBOs through the community case manager network to promote adherence of PLHIV, increase demand for services, and mobilize communities. The project will be prepared as well to support APEs as needed under future DPS negotiations, activities include creation mother to mother groups, chá positive, etc

There are 5 main areas of intervention:

1) Mainstreaming of PwP activities including expansion of PwP programs within ART and non ART service sites and community based settings, through training of health providers and counselors; supportive supervision and monitoring; strengthening community linkages through organizing and empowerment of support groups and PLHIV organizations; and designation of a PwP focal person for each province;

2) Management of sexually transmitted infections at ART and non ART sites with a focus on MARPs;

3) Implementation of the national Health Care Worker / Workplace Program including access to: BCC, condoms, CT, PMTCT, reduction of stigma and discrimination; CT; care and treatment; psychosocial support; HBC; benefit schemes; and HR management;

4) Strengthening of HIV clinical services at ART and non-ART sites: support for improved access to and quality of services for family planning, STIs, palliative care, OIs, CT, CXTp, preventative treatment for malaria, TB treatment and laboratory testing for CD4, hepatitis B and syphilis; improved linkages and referral pathways within and between facilities and communities, supported by a focal person for linkages and follow up in facilities and sub-agreements with DPS/DDS; support the roll out of the Pre-ART packag and to support NAC

5)Implementation of a full package of PP interventions as part of their routine care (risk assessment, partner testing, adherence, Sexually Transmitted Infections (STIs) screening and treating, Family planning, PMTCT, referral to support services and care and treatment (both facility- and community- based).

Partners will use existing resources to accommodate the increased supervision and monitoring needs of these activities, Training in all areas will utilize materials developed in collaboration with the MOH.

CHASS SMT has been allocated a proportion of HKID funding to compliment Counseling and Testing for vulnerable children and OVC clinical services received as part of the OVC clinical service package-

For Counseling and Testing vulnerable children- OVC will contribute 5%- Targets will be Sofala- 13549 Manica 8375 and Tete 11485. ATS-C program should have close communication with case managers and activistas and should target partners of people living with HIV, and OVC programs including children who may be at risk for HIV.

For scale up of pediatric treatment services which will include OVC at 25% proportional allocation for those under 15 receiving one service at the facility level is Sofala 4948 Manica 4401 Tete 2521 and at the community level is Sofala 1237 Manica 1100 and Tete 630 children in FY 2013.

Support to MMAS with gap funding in order to be able to add one Social Worker in the priority districts.

The MOH is prioritizing the scale-up of pediatric HIV treatment services through rollout of universal treatment for children under 2 years of age, continued decentralization of treatment to peripheral health centers and integration of HIV services into existing child health programs. Currently, children represent 8% of the total number of patients on treatment at supported sites. The goal for FY 2012 is that 15% of new HIV treatment patients will be children. For all HIV infected children receiving ART, cotrimoxazole prophylaxis will be prioritized. The primary focus continues to be on improving early infant diagnosis, treatment initiation and retention.

All USG-supported treatment partners, including CHASS- SMT, 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 CHASS- SMT 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 they 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 project 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) 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 materials, including stigma reduction materials.

7) Implementation of surveillance of TB among health workers

8) Continuing coordination and collaboration with key partners in the province to identify gaps, avoid duplication and make the rational use of resources.

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. The project will suport the MOH to build capactity to sustain high standards of HIV treatment services in Sofala Manica and Tete provinces, targeting 7,790 children. Currently, children represent 10% of the total number of patients on treatment at supported sites and the aim is that will increase to 15% in FY 2012. This will require enhanced capacity of sites and health care providers to identify, treat and care for HIV-infected children. For all HIV infected children receiving ART, cotrimoxazole prophylaxis will be prioritized. In FY 2012, all clinical partners will start to report on the percentage of children who are PCR positive and on treatment. In addition they will help MOH implement the new WHO guidelines.

The main activities will include:

1) Improving access to care and treatment services, through early identification of HIV exposure and infection status, strong linkages of HIV services within the existing child health programs (including TB, PMTCT, MCH) and increased community awareness of pediatric HIV. Enrollment of HIV exposed and infected children into care will be increased through a functional referral system of care and treatment services for HIV-infected children and their families within and between health facilities (including those providing non ART HIV services) and communities using PMTCT, MCH flow charts and referral forms;

2) Human capacity development through: in-service training on pediatric HIV care and treatment, supportive supervision, provision of job aids and the printing and dissemination of the new Pediatric Treatment Guidelines developed by MOH; training on the management and logistics of laboratory commodities such as CD4 reagents, ARV pediatric drugs and other HIV related medications; training, supportive supervisions and reproduction of materials to support positive prevention activities;

3) Interventions to improve patient tracking systems to follow-up ART patients and to identify and address treatment failures and adherence issues;

4) Implementation of the HIVQUAL program;

5) Improvement of linkages to care, support and prevention services such as psychosocial support for children, adolescents and their families, support for retention, HIV status disclosure.

SI will continue to support provincial M&E advisors for Manica and Tete provinces during the period. Sofala did not request for this staff as this staff is being funded through the Doris Duke Foundation Grant in Health Systems Strengthening. These provincial M&E advisors will provide technical assistance and capacity building support to the DPS in building institutionalized support for M&E. 150,000 (50,000 for each province)

CHSS SMT will receive treatment 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 participating in joint supervision visits with the DPS/DDS. Partners will have additional funds to also 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. Partners will support the expansion of the logistics management information system (SIMAM) to additional districts in line with the SIMAM implementation strategy. This support will also include technical assistance in use of data for decision-making. A major bottleneck in the provinces is lack of funds for fuel and lack of available transportation for medicine distribution. Due to significant distribution and transportation challenges, USG is looking for short and medium term solutions in a few focus provinces. Partners in the focus provinces, Zambezia, Sofala, and Gaza, as well as Niassa, Cabo Delgado will carry out multiple strategies to improve distribution from provinces down to the health facilities, including a identifying a fixed sum in the provincial and district agreements for medicine distribution and operations; procurement of vehicles if necessary; outsourcing distribution through the DPS or in collaboration with World Food Program to a 3PL provider (third party logistics); or partnering with Village Reach in line with the Last Mile initiative incorporating rapid HIV test kits and ARVs. Partners will receive funds for all provinces to support distribution. There is additional funding to support HR issues with scholarships for pre-service training at provincial level, funding for provincial advisor positions in lab and logistics, support to subagreement assistance needed in provincial planning managing and budgeting. There will be close collaboration with training and mentoring partners in the key areas of HIV/AIDs. (see ITECH, JHPIEGO, Health Systems 20/20 and TBD Leadership and Governance).

For male circumcision, CHASS SMT will scale up medical male circumcision services in Manica and Tete- Targets: Manica 39168 Tete 19628. Unit cost estimates for this service using Expenditure Data was $81.94. CHASS SMT will expand these services through selected sites in agreement with the provincial health office and in accordance with MMC service delivery guidelines.

CHASS SMT HMIN funds have also been allocated proportionally to TX services-The total targets include a proportional allocation of HMIN to HTXS budget code- Sofala 24830 Manica 19,526 and Tete 14,029 in FY 2013, all clinic/facility and community/home-based programs should include a package

of behavioral and biomedical prevention interventions that are consistent with guidelines outlined in the Positive Prevention package These interventions should be provided within 2-3 visits and delivered either onsite or (where specifically noted above) through a referral program where the client is enrolled.

Partners using referral USG partners continue to support designated pediatric and adult ART sites whereby treatment and care are provided at the same health facilities and supported by the same implementing partners. Support will focus on increasing uptake and retention and linkages to selected non ART sites providing HIV services.

Many of the above strategies that are used to improve retention will also improve adherence such as the identification of facility and community counterparts working together to actively follow up ART patients including via the use of the GAAC model, community drug distribution; paper and computer based records; sub agreements with community partners and PLHIV to train peer educators and develop innovative community interventions to track patients and promote adherence; PP initiatives with PLHIV and DPS/DDS using existing nationally approved materials. Linkages with existing home based care support will also be strengthened to track defaulters, ensure their return to care and treatment, document transfers, deaths, or losses to follow up.

CHASS SMT will continue to provide facility based counseling and testing services and a proportional allocation of HMIN has been given to CT activities, following the national algorithm, through provider initiated CT (PITC) and facility based voluntary CT (ATS). CHASS SMT will also begin new community based counseling and testing (ATS-C) in partnership with locally based organizations. In line with PEPFAR Mozambiques strategy to prioritize PITC, CHASS SMT will continue to improve and mainstream PITC service delivery for patients and their partners in all health care settings. A percentage of the CT funding has been allocated to HMIN to cover- The targets costed to achieve under CT 99% and HMIN 1% is

PITC- Sofala- 40,443 Manica 33,375 Tete 40,424, ATS- Sofala 31,750 Manica 28,923 Tete 37280

HMIN funds will also be used to support Post Exposure Prophylaxis at CHASS sites Targets in COP 13 will reach Sofala- 211 Manica 121 and Tete 49

CHASS SMT will continue to provide facility based counseling and testing services, following the national algorithm, through provider initiated CT (PITC) and facility based voluntary CT (ATS). CHASS SMT will also begin new community based counseling and testing (ATS-C) in partnership with locally based organizations. In line with PEPFAR Mozambiques strategy to prioritize PITC, CHASS SMT will continue to improve and mainstream PITC service delivery for patients and their partners in all health care settings. They will continue to operationalize recommendations from the JHPIEGO PITC evaluation, provide TA to facilities to ensure consistent service delivery and supervision, data management, quality and logistics related to PITC in all services. Most PITC is provided in ANC, followed by TB. Funding for PITC is $956,760. Voluntary Counseling and Testing in Health (ATS) will be a total of $254,000.

In 2011, MISAU made a unilateral decision to stop all expansion of new ATS-C programs and sites. CT TWG members, including CHASS, continue to discuss with DNAM about this decision and continue to work on improvement of the EQA tool and process. Due to limited funds and in line with the PEPFAR Mozambique COP 12 CT strategy to expand ATS-C only for MARPs and higher risk populations, limited COP 12 CT funds for ATS-C are available only for Sofala province. ATS-C program should have close communication with case managers and activistas and should target partners of people living with HIV. This activity will continue to strengthen and monitor linkages from all CT services to appropriate follow-up prevention, treatment, care and support services. Service- to-service and facility-to-community referral and support systems will be implemented through existing case managers and CBO activistas. QA/QI CHASS SMT will continue to ensure quality assurance and quality control for both HIV testing and counseling components in all approaches in all CT sites, support biannual EQA panels, continue efforts to develop standardized quality management tools for CT, utilize peer supervision, and implement routine supervisory visits. Supervision will consider implementation of client exit interviews and provider self-reflection tools for monitoring and improving counseling quality.

CHASS SMT is requested to support provincial level distribution of rapid test kits. This can be done through support to CMAM or to an organization such as Village Reach, which has provided distribution support and TA to MOH. CHASS SMT provincial pharmacy, CT, M&E, lab and logistics officers should work closely with and provide TA to their DPS counterparts to ensure strong supply planning, logistics, distribution and data management. As the lead clinical partner in these three provinces, CHASS SMT is expected to play a strong role in supporting the DPS to strengthen CT and commodity logistics. CHASS SMT will receive funding for two linked pilot activities for Sofala province focused on partners of PLH: Pilot Treatment as Prevention (TasP) partner identification, tracking and incidence monitoring in one or two facilities plus catchment areas in Beira and design and implementation of innovative strategies (e.g. conditional cash transfers, public private partnership with cell phone company to communicate with partners of PLH) that successfully promotes partners of newly diagnosed PLH to seek CT services in one or two facilities plus catchment areas in Beira.

CHASS SMT will receive $348,750 of COP 12 HVOP funds for HIV prevention activities for general population individuals age 15-49, specifically for partners of PLH, with special emphasis on discordant couples, and their families. In addition to promoting healthier behavior change and norms, this years utilization of STP funds will have a stronger focus on promotion of HIV and health service uptake. CHASS SMT will continue to use a mix of interventions that include risk reduction message training for providers in facility settings, positive prevention, and in community settings, local radio, interactive drama, and small group interpersonal communication activities.

This activity will continue to promote HIV risk reduction messages, especially in a positive prevention approach and will promote services, such as CT, PMTCT and family planning. Equal amounts of funding per province are allocated for scale up of facility based positive prevention services ($93,000/province) and reinforcement of healthy behaviors among PLH and their partners, (e.g., condom use, risk of multiple partners, GBV prevention, knowing ones sero-status, disclosure, adherence $23,250/province).

PMTCT services delivery targets were used for expenditure analysis and budget allocation. In FY 12, capacity building measures will be extended to MCH nurses and peer case managers and will include nutrition issues, NACS among pregnant and post-partum women and infants, promotion of exclusive breastfeeding, introduction of complementary feeding at 6 months of age and food support where appropriate, improving 2-year HIV-free survival. PMTCT F&N plus-up funds will be used to scale-up postnatal care support in the context of the Mozambique roll-out of Option A. The MCH nurses are trained on HAART administration and management. MCH providers and peer case managers will play a key role in encouraging the participation of husbands in their wives antenatal and postpartum care. The utilization of peer case managers for follow-up care.. Efforts will also be made with DPS on sensitizing them to a One-Stop Shop model for PMTCT services for implementation in sites. The district-based approach, collaboration at provincial level (including funding to provincial and district public health departments) and scale up to ANC facilities will increase responsiveness, including support for overall systems strengthening and positioning for transition. Community platforms will be strengthened to increase demand for PMTCT services and increase retention in services using outreach tools . Emphasis will be on intensified (active follow up) models, such as longitudinal tracking through ithe chronic care model in MCH and linking mother-infant pairs; improving integration of immunization and consultation for child at risk (CCR) programs; implementation of electronic systems (such as focusing on a system that identifies defaulters); and options for incentive programs, through education or otherwise (possibly linking to transport or conditional cash transfers). Key activities that support integration of MCH/RH, PMTCT scale up and cross cutting activities include: expanded support for sites without PMTCT services, and enhanced support for low-performing sites; activities to increase community demand for services; expanded PICT and couples counseling; ARV for PMTCT focusing on more effective regimens and ART initiation; CTX prophylaxis focusing on improved coverage for pregnant women and harmonization with IPTM, TB and STI and syphilis screening, GBV screening; linkages with pediatric care and treatment programs for EID Support the establishment of point-of-care diagnostics including CD4. Support Hemoglobin monitoring by provision of relevant commodities and training to streamline rapid initiation of ARVs for PMTCT among pregnant women. Support for prevention of unintended pregnancies among HIV-infected women; ensure the establishment of HTC within ANC, expand long acting permanent methods, support for PLHIV and community involvement; dissemination of nationally approved IEC materials; safe infant nutrition interventions integrated into routine services, including counseling and distribution of commodities in collaboration with a procurement partner; support for reproduction and roll out of revised registers; institutionalize data analysis and use. PMTCT clinical mentoring based on the national model; linkages to system strengthening, including infrastructure projects; mainstreaming infection prevention control in PMTCT settings; support for workplace programs including PEP. In FY12, an evaluation of MTCT transmission rates may be conducted

In FY 2012, USG partners continue to support designated pediatric and adult ART sites whereby treatment and care are provided at the same health facilities and supported by the same implementing partners. Support will focus on increasing uptake and retention and linkages to selected non ART sites providing HIV services. In collaboration with DPS/DDS a pyramid approach is being developed which enables major urban sites to down refer stable patients to smaller peripheral units. Complicated patients can be referred up to larger centers, thus promoting a patient journey that ensures retention in comprehensive care and treatment. To achieve this support, capacity building will be done at ART sites to absorb the referred patients and initiate new patients on ART, improve service delivery and integration of non ARV sites, emphasize the referral pathways and linkages within and between facilities and communities and support infrastructure improvement.

Additionally with the eminant rollout of the recommended CD4 count threshold for ART initiation of <200 it is anticipated that not only will there be benefits in terms of improved retention and reduced mortality, morbidity, and hospitalization. This coupled with the roll out of the pre-ART care package will not only increase the number of patients accessing treatment early on but will also aid in freeing up health facilities to expand services and better care for those who are seriously ill. One stop TB/HIV model will also help streamline efficiencies allowing for increase in treatment coverage and retention.

To better support retention parts are focusing on strengthening facility and community relationships and linkages including through the establishment of committees comprised of various stakeholders and clients who act as a type of community advisory board providing support to each other and feedback to the facility. Other key activities for retention include the use of the GAAC, community drug distribution, and standardization of peer educators in all supported health facilities.

Many of the above strategies that are used to improve retention will also improve adherence such as the identification of facility and community counterparts working together to actively follow up ART patients including via the use of the GAAC model, community drug distribution; paper and computer based records; sub agreements with community partners and PLHIV to train peer educators and develop innovative community interventions to track patients and promote adherence; PP initiatives with PLHIV and DPS/DDS using existing nationally approved materials. Linkages with existing home based care support will also be strengthened to track defaulters, ensure their return to care and treatment, document transfers, deaths, or losses to follow up.

Specific training and support includes in-service training and mentoring of clinical, M&E, pharmacy and administrative staff, joint site visits with DPS/DDS staff and subagreements with DPS/DDS and CBOs to develop the capacity to transition activities to local partners.

Clinical outcomes and drug management are tracked by routine M&E which aligns with national reporting systems. Partners participate in the CLINIQUAL program and staff are trained in the utilization of supervision and mentoring visits to reinforce the use and adherence to national treatment guidelines and the use of routine data for service improvement.

The MOH is prioritizing the scale-up of pediatric HIV treatment services through rollout of universal treatment for children under 2 years of age, continued decentralization of treatment to peripheral health centers and integration of HIV services into existing child health programs. Currently, children represent 8% of the total number of patients on treatment at supported sites. The goal for FY 2012 is that 15% of new HIV treatment patients will be children. For all HIV infected children receiving ART, cotrimoxazole prophylaxis will be prioritized. In FY 2012, all clinical partners will start to report on the percentage of children who are PCR positive and on treatment. The primary focus continues to be on improving early infant diagnosis, treatment initiation and retention. The main activities will include: 1) Improving access to care and treatment services, improving early infant diagnosis and monitoring in collaboration with local partners early identification of HIV exposure and infection status and the introduction of point of care diagnostics in focus provinces, universal treatment for HIV infected children under 2 years of age, strong linkages of HIV services within the existing child health programs (including TB, PMTCT, MCH) and increased community awareness and skills building in provision of care for children with HIV. Enrollment of HIV exposed and infected children into care will be increased through a functional referral system of care and treatment services for HIV-infected children and their families within and between health facilities (including non ART HIV services) and communities using PMTCT, MCH flow charts and referral forms; 2) Human capacity development through: in-service training on pediatric HIV care and treatment, supportive supervision, provision of job aids and the printing and dissemination of the new Pediatric Treatment Guidelines developed by MOH; training on the management and logistics of laboratory commodities such as CD4 reagents, ARV pediatric drugs and other HIV related medications; training, supportive supervisions and reproduction of materials to support positive prevention activities; 3) Interventions to improve patient tracking systems to follow-up ART patients and to identify and address treatment failures and adherence issues; 4) Implementation of the HIVQUAL program; 5) Improvement of linkages to care, support and prevention services such as psychosocial support for children, adolescents and their families, including specific support to parents and guardians to assist them to lay a strong foundation with their young children in all HIV related areas so as to improve the chances of better outcomes in adolescents. 6) Support for adherence and retention via various models including GAAC, commodity distribution systems, improved psychological and social support, and HIV status disclosure based on the beneficial disclosure model. 7) In COP 12 there will also be an increased focus on the often complex treatment care and other support needs of adolescents living with HIV, both those perinatally and horizontally infected with HIV. Areas to be addressed improved care and treatment, adherence, retention, sexual and reproductive health, psychological and social support, increasing self management and transitioning of care and other services.