Nampula is one of the provinces with a large number of troops due to various reasons (port of Nacala, Military Academy, etc.) and this fact turns the Nampula military hospital in a valuable resource to assist these troops and the civilians living close to this facility. Therefore, the USG will support the improvement of this health facility's quality of services through infection prevention. The renovation and equipment of the Maputo Military Hospital sterilization room is in good progress (company have been awarded and the completion of the project is to happen in 3 months). After completing this project, the focus is now to improve the sterilization room at the Nampula Military Hospital which is currently under rehabilitation. There is no sterilization capabilities for more than 20 years and USG wants to take advantage of the rehabilitation of the facility (funded by the GOM) to install a new sterilization equipment which will take in consideration a coherent flow of services in order to reduce and/or control infections. The improvement of the sterilization services will also support the MMC sterilization needs that may be required at this particular hospital where services are offered and USG will continue supporting these services. Beira Military Air Base and Chimoio health posts will continue to receive funds for fixed VMMC through Population Services International (PSI) and they have set a target of 10,000 men to be tested, counseled and then circumcised. Similar services will also be provided on a mobile approach to reach even more candidates as the mobile teams will offer the services at the military bases.The target set for the mobile VMMC is 25,000 and this number may include some members of communities surrounding the bases and family members of the troops.

Data from the 2009 military HIV prevalence study indicates an infection rate above the national infection rate among the general population. For several years USG is providing care and treatment services in 3 major military hospitals (Maputo, Nampula and Beira) and, at clinical level, UConn is implementing a Positive Prevention program with PLWHA. Due to the specificities of our target population (high mobility, concentration in specific locations military bases, and presence in all provinces of Mozambique), the clinical model to assist PLWHA is not benefiting the majority of the military population in need. The funding that is being requested is to provide care and support through PP activities in all military bases, expand the services to civilian communities and reinforce the linkages to care and treatment through military HIV focal points and their respective peer educators which will work on one-on-one basis and will promote the creation of support groups and facilitate their discussions, provide condoms, printed materials and clarify questions of the group. The military peer educators will also follow up patients benefiting from the UConn PP program at clinical level and reinforce the same messages over and over again for an effective positive living and treatment adherence. They will also have the role to reach out military members with AIDS and living outside the base due to their poor health condition, and partners of military people LWHA in the base surrounding communities to provide paliative care, ensure treatment adherence as part of the prevention strategy or that they are voluntarily tested and counseled and also referred for care and treatment if found to be HIV positives or with TB symptoms. Part of their role will also be to work directly with the base health officer and the commander, for nutritional support, health or ART medication issues and concerns related to stigma and discrimination attitudes among the troops. During the first year we expect that it will take six months to finalize materials production, training and other equipment procurements. Therefore during the first year of implementation we expect to reach 50% of the annual target (6,000). During years two and three we expect to reach 24,000 and 36,000 respectively. There may, in fact, be more people who test HIV positive and will benefit from PP and HIV care and treatment due to testing during the MC campaign.

To ensure sustainability, this program will be designed to be run by the FADM. It will be integrated into their line command programs with accountability to the base commanders as well as FADM Health Directorate.

To effectively accomplish the proposed activities the funding will be spent on:

- Quarterly regional program review meetings including discussion of implementation successes and challenges including reporting of achievement of targets, areas for improvement and lessons learned, and technical updates

- Printed and digital materials for IEC on various prevention aspects

- Communication tools (cell phones and/or netbooks) and costs (air time, internet, software, training, TA, etc.)

- Travel costs (to visit patients and for TA support)

- Regular monitoring, reporting, and evaluation of the activities

This activity was first funded in 2011 and, an initial assessment of the Health Information System situation in Mozambique was conducted. Measure Evaluation (USAID) completed a full HIS assessment, including recommendations to FADM for integration with available MoH HIS products (ICAP, OpenMRS, etc.). FADM requested a partner with military experience, and a grant has been awarded to Vista Partners to provide the FADM Electronic Health Record and associated HIS integration work. A technical assessment of requirements for Maputo, Nampula and Beria military facilities will detail requirements for FY2012 continuance and scale up parameters. In addition, medical content for FADM medical personnel capacity building has been initiated.

DOD will support the Mozambican Military Health (FADM) with a mobile Health Information System (HIS) and supporting ICT infrastructure to be used by Mozambican military health staff (physicians, nurses, lab technicians and nurses) and prevention personnel. This mobile health (mHealth) platform will allow military health units in remote locations to communicate with health staff at central locations, initially the military Public Health Office in Maputo. Data related to malaria, STIs, HIV, diarrhea, TB and other health information will be accessible and disseminated in digital formats, in order to improve program monitoring and reporting requirements for FADM and PEPFAR management. Target locations for this activity are the military installations in Maputo, Nampula and Beira which, for being the central nerve system, will have their internet connection capabilities improved through cable and wireless systems.

The military health is understaffed and, over the years, it suffered a huge brain drain mainly due to the obsolete condition of the military health infrastructure, lack of equipment as well as poor investment in training of new health staff. The skilled staff were absorbed by private clinics and also by the civian health system run by the Mozambican Ministry Of Health. The reality, however, is that with all these difficulties, over 60% of patients served at the military health facilities are civilians. considering these facts, the USG is now proposing to support the Mozambican military health with 30 scholarships for the same number of health staff distributed in cadres such as basic and medium nurses, surgical and medical technicians which will be enrolled and trained at ISCISA. After completing their 3 year respective courses, these military staff will be regionally distributed according to the needs (number of troops, prevalence identified, remotely located, existance of understaffed health facility, ongoing mobile or fixed MC program, etc.) and to fill the gaps at military health institutions which are gradually being renovated. The student's education progress will be continuously monitored and gradually reported as they writte, pass or fail final exams so that we have a good estimate of the possible number of candidates that will successfuly complete the trainings and how much money will be needed to support the ones that stay behind for another year or two. This proposed activity is linked to goal 2 of the GHI strategy which is to improved retention and management of the Health Workforce and we believe that it will all be achieved with education and improvement of military health facilities through renovations and provision of medical and surgical equipment.

USG will continue supporting the Mozambican Military to scale-up male circumcision interventions. Data from the two military SABERS conducted show that military people in general tend to be circumcised at older age and the majority of uncircumcised people are willing to accept the intervention if the services are available. However, considering the few military health facilities with conditions and staff to offer MMC, DOD will now take the services to the potencial candidates at their bases through MMC mobile campaigns expecting to reach the target of 30,000 men. The funding previously requested was spent with fixed costs (vehicles, tents, surgical beds and disposable MC kits, etc). e are now requesting yearly recurring costs tom implement the 3year MC campaign primerily targeting the military but also offering the services to civilian populations that access the military units for health services.

In the process of improving the sterilization capabilities at military health facilities, USG supported the Maputo Military Hospital using FY11 plus previous years funds to improve the hospital's sterilization room. Now, the plan is to support the military hospital in Nampula improving their (non-existing) sterilization room. The timing is perfect considering that the hospital is under rehabilitation.

The USG through the Department of Defense (DOD) will continue funding HIV related international and national courses for military health care providers. This activity focuses on developing the capacity of health providers responsible for ARV roll-out for the military because an effective response to the HIV epidemic requires expertise, experience, and training in the positive prevention and treatment of people infected with HIV. This Implementing Mechanism is linked to the Goal 3 of the Partnership Framework which aims to strengthen the Mozambican health system, including human resources for health.

Therefore, some military health staff will attend the Military International HIV Training Program (MIHTP) which gives training in HIV related patient management, epidemiology, and public health for medical military personnel actively caring for HIV infected patients. MIHTP top priority is to train key medical personnel (clinicians in practice) both in San Diego and abroad with the goal of transferring appropriate knowledge and technology to each country. The training programs and projects are developed in collaboration with each military organization to meet specific needs. Emphasis is placed on training, consultation, and operational support for prevention and clinical management of HIV and its complications as well as courses in epidemiological surveillance and laboratory diagnosis from a clinical physician perspective. A large emphasis is placed on the experiential part of the program to understand the military's policies and procedures regarding service members with HIV.

Other medical staff will continue attending training courses at the Infectious Diseases Institute (IDI) on the campus of Makerere University, Kampala, Uganda.

The primary goals of the training program in Uganda are to:

1) Review the latest HIV diagnostic and treatment approaches;

2) Discuss major issues concerning comprehensive HIV care;

3) Discuss military-specific issues related to HIV care;

4) Enhance the clinical skills of practitioners dealing with patients who are infected with HIV and associated illnesses.

5) Provide up to date laboratory techniques (diagnosis, quality control, monitoring and evaluation, etc)

These goals will be accomplished through featured expert speakers on a range of HIV topics, interactive assignments, and practical demonstrations. Lectures will be delivered in a classroom setting to the group as a whole, followed by inpatient and outpatient clinical sessions that will include bedside teaching rounds, an overview of systematic HIV patient care and management, and exposure to community-based HIV care and prevention programs.

These trainings provide a practical experience on how to deal with HIV cases within the armed forces, maintaining the confidentiality of one's HIV status and supporting the patient's willingness to disclose it to fellow soldiers and/or family members. It was found that after returning from these trainings, the people trained are motivated and in general they make critical changes on their programs improving it based on the knowledge acquired. The Maputo Military Hospital lab is one example of the success an impact of these trainings as this lab is considered one of the best since it reports less problems with equipment handling and malfunction and good record of reliable lab analysis results. This activity links to our GHI Strategy and Goal #2.