The overarching goal is consistent with the Partnership Framework priorities, aligned with GHI priorities and it is driven by the principles of sustainability, country ownership and the GRM Mozambiques National HIV Strategic Plan. Its aim is to strengthen the provinces health system by maximizing access, quality and sustainability in the delivery of comprehensive HIV/AIDS and related primary health services by reducing HIV transmission, mitigating the impact of HIV, and improving health through : Improve the accessibility of high-quality HIV services by strengthening clinical service delivery and their utilization through increased retention and demand by clients, create an integrated system of HIV/AIDS and primary health care with strong linkages to community services, strengthen MOH capacity at the provincial and district levels to effectively manage high-quality, integrated HIV services by building management and financial capacity, reducing human resource constraints, and increasing the capacity to use data for program improvements. The project collaborates and leverages resources from TB CARE, ComCHASS and receives GBV Initiative funds in year 1 so they can implement the MOH GBVs minimum package. Community case managers including PLHV will play a role in demand creation by identifying, referring client to health or community services. Key focus is placed on developing and implementing a performance-based graduation plan to ensure a transition from project support to sustainable MOH service delivery, build the DPS ownership and strengthen the capacity for developing plans and retaining health care workers.

CHASS/Niassa will facilitate the tracking of patients to minimize loss-to-follow-up and promote treatment adherence. CHASS/Niassa will leverage the breadth and depth of community-based care and support services outlined in ComCHASS to facilitate patient tracking and retention system. Patient tracking and tracing systems will include both pre-ART and ART patients. CHASS/Niassa will support MoHs retention strategy by rolling out the GAAC (Grupo de Apoio a Adesão Comunitária) strategy.

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;

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 package 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).

CHASS/Niassa 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 Niassa 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 25%- Targets will be 3140. 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 649 and at the community level is 169 children in FY 2013.

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 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.

CHASS- Niassa, will be funded in the amount of $ 119,000 US 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- Niassa 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 CHASS- Niassa 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 CHASS- Niassa 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) CHASS- Niassa in Niassa province will assess the need to support or hire a TB/HIV focal person.

5) Print and disseminate IEC materials, including stigma reduction materials.

6) Implementation of surveillance of TB among health workers

7) 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 Niassa province, targeting 1,094 children. Currently, children represent 11% of the total number of patients on treatment at supported sites and the aim is that the number 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 Niassa provinces during the period. This provincial M&E advisor will provide technical assistance and capacity building support to the DPS in building institutionalized support for M&E. (50,000 for province)

Implementing partners 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 in Niassa. 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).

CHASS Niassa HMIN funds have also been allocated proportionally to TX services-The total targets include a proportional allocation of HMIN to HTXS budget code- Niassa 4877. 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 Niassa 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 Niassa will continue community based counseling and testing (ATS-C) in partnership with locally based organizations. In line with PEPFAR Mozambiques strategy to prioritize PITC, CHASS Niassa 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- Niassa 28271 ATS- Niassa 26348

HMIN funds will also be used to support Post Exposure Prophylaxis at CHASS sites Targets in COP 13 will reach Niassa 46

CHASS Niassa will receive $277,432 in HVCT to continue facility based counseling and testing (CT)services, following the national algorithm, through provider initiated CT (PITC =$152,760 ) and facility based voluntary CT (VCT=$42,672 ). In line with PEPFAR Mozambiques strategy to prioritize PITC, CHASS Niassa will continue to improve and mainstream PITC service delivery for patients and their partners in all services; continue to operationalize recommendations from the PITC evaluation; and provide TA to ensure consistent service delivery and supervision, data management, quality and logistics related to PITC in all services. Service- to-service and facility-to-community referral ,support systems and monitoring of these linkages will be implemented through existing case managers. $82,000 will ensure quality assurance and quality control for CT in all approaches in all sites, support biannual EQA panels, continue efforts to develop standardized quality management tools, 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. Pharmacy, CT, M&E, lab and logistics officers should work closely with and provide TA to their DPS counterparts to support RTK supply planning, logistics and distribution. Services are aimed at general population individuals, including adolescents, and men and partners of PLH. HIV prevalence for 15-49 year olds in Niassa is 8.0% for women and 5.7% for men) . 12% of Niassa women reported having received a test and results in the last 12 months compared with 10% of men. Coverage of HIV testing among TB cases is 95%.

SAPR 11 + Q3 results is 30,552, almost doubling the previous years target of 16,131. Their COP 12 target is 17,500 individuals reached, much lower than their capacity and due to limited service delivery HVCT funds and low-prioritization of Niassa in the PEPFAR Mozambique strategy. Targets per modality are PITC 11,250 and VCT 6,250. Supervision in coordination with the provincial directorates of health, women and social action will continue. They will ensure that all sites report on the latest MOH-approved register which captures information on number of individuals testing in a couples setting and number of indeterminate results. Planned trainings for DPS staff include: supply planning and distribution, waste management, QA/QI, proficiency panel methodology and process, GBV prevention and screening, and use of new MOH data collection tools.

CHASS Niassa will receive $93,000 of COP 12 HVOP funds to scale up facility based positive prevention services with special emphasis on discordant couples and families with HIV positive members. 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. This activity will continue to promote HIV risk reduction messages, address GBV, condom use and distribution, and promotion of uptake of CT , pre-ART and ART services. An estimated 22,000 people in Niassa are believed to be HIV+, representing 2% of Mozambicans living with HIV. Program will build on existing activities related with prevention for people living with HIV to scale up facility based services for PLWHA. Package of services will include both behavioral and biomedical interventions with strong linkages to other services and community interventions (prevention, care, and support programs in the community) for PLWHA with strong foundations on the principle of continuum of response. Package of services includes: 1) HIV Counseling and Testing; 2) interventions for HIV Sero-discordant couples; 3) Sexual risk reduction counseling; 4) Assessment and treatment of other STIs; 5) Family planning and safer pregnancy counseling; 6) Condom distribution and promotion; 7) Alcohol use assessment and counseling; and, 8) Support of safe disclosure to sex partner and family members.

Integration of interventions for PLWHA into existing HIV program activities, including facility-based (antenatal care, care and treatment facilities, home based care, TB treatment settings, etc.) will also be emphasized.

Capacity building measures will be extended to MCH nurses, peer case managers and a range of issues, including 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, to 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 trained on HAART and peer case managers will encourage the participation of husbands in their wives antenatal and postpartum care. Job aids and tools will be used in collaboration with partners such as Food for Hungry, focusing in strengthening referral mechanisms for tracking pregnant women and ensuring mother-baby follow-up by using peer case managers. Efforts on the implementation of One-Stop Shop will be made. TA, training, quality improvement, and M&E and scale up to ANC facilities will increase responsiveness, support for overall systems strengthening, communities to increase demand and services increase retention, including resources such as motorcycles. Innovative models as longitudinal tracking through implementation of the chronic care model in MCH and linking mother-infant pairs will be encourage; improving integration of immunization and consultation for child at risk (CCR) programs; implementation of electronic systems, and incentive programs, through education, transportation or conditional cash transfers to encourage follow up.

Other activities include: expanded support for sites without PMTCT, and enhanced support for low-performing sites; activities to increase community demand for services; expanded PICT and couples counseling; ARV 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, 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. Clinical mentoring on the national model, system strengthening, infrastructure, prevention control, workplace programs, delivery and evaluation of MTCT transmission rates will be conducted. IP are encouraged to implement innovative approach where national sampling at immunization visits is conducted periodically.

In the FY011 the project will support 10 ART sites in Niassa and increase 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.

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.

Adherence activities include: identification of facility and community counterparts working together to actively follow up ART patients; 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.

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 Niassa province. Currently, 322 children are on treatment in CHASS supported sites and the aim is that will increase to 670 children on treatment 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.