Columbia University has been funded by PEPFAR since 2004 to support HIV programs in Mozambique. The Capacity building mechanism will be used to fund Columbia supported activities in 5 districts in Zambezia province. The PROGRAM GOAL is increased access to quality evidence-based HIV prevention, care and treatment services through integration, early access to care, community outreach and retention in care. Zambezia is USG Mozambique focus province. Columbia will support the province in implementing the mobile unit strategy to increase access to comprehensive HIV and health services.

Columbia will provide both health systems strengthening and technical assistance to Zambezia province. Key activities include training and mentoring of District Health management teams and health workers staff in clinical competency, laboratory support, logistics management, M&E; planning and data quality; Infrastructure renovations; and sub agreements to the Zambezia DPS.

The GHI Focus areas are expanded access and uptake of quality MNCH services and Strengthening Governance in the Health Sector. FY 12 targets for Zambezia are: - 9442 pregnant women receive ARVs for PMTCT in ANC clinics; CT for 36,000 people; and 6867 ART to patients.

Program costs will reduce by transition of USG programs to provinces and local partners. The USG will award cooperative agreements to additional DPSs. Zambezia may be one of the new DPS to be funded.

An M&E system captures standard data related to quantity, quality and impact of HIV clinical services, systems strengthening activities, financial accountability and admin management.

Columbia has to date purchased 37 vehicles. In FY12, CDC will monitor & keep records of all vehicle acquisitions. Pipeline showed that this IM is in line with the 18 stdrd

In FY 12, Columbia University will continue to support the Ministry of Health in implementing HIV related services in Zambezia province. Capacity building will be the main focus to ensure integration, high quality of services, early access to care and retention in care, leveraging existing resources, promoting cost efficiencies and sustainability. ICAP will also ensure that health facilities coordinate with community partners on bi directional linkages. Specific activities are:

1) Roll out the 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 a standardized manner. The objective is to ensure that all patients in care, either pre-ART and ART benefit from a comprehensive set of interventions 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 care.

2) Delivery of a HIV preventive basic care package (BCP) of commodities and goods, in selected sites of Cabo Delgado (to be piloted). This is another retention strategy that aims to ensure that patients return to the scheduled medical appointment every six month and also improve linkages to care and support services, prevent the occurrence of OIs such as diarrhea, Malaria and other HIV related complications and promote a culture of hand washing and use of safe drinking water among patients.

3) Integration 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)condoms (assessment of sexual activity and provision of condoms (and lubricant) and risk reduction counseling);) Partner testing (assessment of partner status and partner testing provision or referral);v 3) STI (assessment for STIs and (if indicated) treatment/partner treatment provision or referral (including TB); 4) Family Planning (assessment of FP/PMTCT needs and (if indicated) family planning services provision or referral); 5) Adherence(assessment of adherence and (if indicated) support or referral for adherence counseling; 6) Support(assessment of need and (if indicated) refer or enroll PLHIV in community-based program such as home-based care, support groups, post-test-clubs); 7)Alcohol (use, assessment and counseling).

4) Provincial trainings and supervision to improve the syndromic management of STIs (includes reproduction of tools and algorithms).

5) Scale up of the `screen and treat` cervical cancer program (includes training, supervision, tools and equipment).

6) Train nurses and medical agents in OIs (new guidelines) to ensure appropriate and early diagnosis of and provision of cotrimoxazole prophylaxis.

7) Revitalize the management of Kaposi Sarcoma (includes organization of treatment teams, training, referral systems, data collection and reporting; and job aids).

8) Implementation of universal access of peer educators (PE) support.

All USG-supported treatment partners, including Columbia University, 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 Columbia University 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 Columbia University 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 Zambezia.

Additionally Columbia University 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) 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.

5) Print and disseminate IEC 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.

During FY12 Columbia will support Pediatric HIV care services in Zambezia province.

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 Columbia 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 province

Routine 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 clinics

4) 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;

Columbia 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. Columbia also reports quarterly, semi and annual PEPFAR reports. USG Clinical partners meetings take place every 6-8 weeks to review and analyze performance data

In FY 13, Columbia University will continue to support the Ministry of Health in implementing HIV related services in Zambezia province. Capacity building will be the main focus to ensure integration, high quality of services, early access to care and retention in care, leveraging existing resources, promoting cost efficiencies and sustainability. ICAP will also ensure that health facilities coordinate with community partners on bi directional linkages. Specific activities are:

1) Roll out the 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 a standardized manner. The objective is to ensure that all patients in care, either pre-ART and ART benefit from a comprehensive set of interventions 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 care.

2) Delivery of a HIV preventive basic care package (BCP) of commodities and goods, in selected sites of Cabo Delgado (to be piloted). This is another retention strategy that aims to ensure that patients return to the scheduled medical appointment every six month and also improve linkages to care and support services, prevent the occurrence of OIs such as diarrhea, Malaria and other HIV related complications and promote a culture of hand washing and use of safe drinking water among patients.

3) Integration 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)condoms (assessment of sexual activity and provision of condoms (and lubricant) and risk reduction counseling);) Partner testing (assessment of partner status and partner testing provision or referral);v 3) STI (assessment for STIs and (if indicated) treatment/partner treatment provision or referral (including TB); 4) Family Planning (assessment of FP/PMTCT needs and (if indicated) family planning services provision or referral); 5) Adherence(assessment of adherence and (if indicated) support or referral for adherence counseling; 6) Support(assessment of need and (if indicated) refer or enroll PLHIV in community-based program such as home-based care, support groups, post-test-clubs); 7)Alcohol (use, assessment and counseling).

4) Provincial trainings and supervision to improve the syndromic management of STIs (includes reproduction of tools and algorithms).

5) Scale up of the `screen and treat` cervical cancer program (includes training, supervision, tools and equipment).

6) Train nurses and medical agents in OIs (new guidelines) to ensure appropriate and early diagnosis of and provision of cotrimoxazole prophylaxis.

7) Revitalize the management of Kaposi Sarcoma (includes organization of treatment teams, training, referral systems, data collection and reporting; and job aids).

8) Implementation of universal access of peer educators (PE) support.

In FY 13, Columbia University will continue to support the Ministry of Health in implementing HIV related services in Zambezia province. Capacity building will be the main focus to ensure integration, high quality of services, early access to care and retention in care, leveraging existing resources, promoting cost efficiencies and sustainability. ICAP will also ensure that health facilities coordinate with community partners on bi directional linkages. Specific activities are:

1) Roll out the 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 a standardized manner. The objective is to ensure that all patients in care, either pre-ART and ART benefit from a comprehensive set of interventions 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 care.

2) Delivery of a HIV preventive basic care package (BCP) of commodities and goods, in selected sites of Cabo Delgado (to be piloted). This is another retention strategy that aims to ensure that patients return to the scheduled medical appointment every six month and also improve linkages to care and support services, prevent the occurrence of OIs such as diarrhea, Malaria and other HIV related complications and promote a culture of hand washing and use of safe drinking water among patients.

3) Integration 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)condoms (assessment of sexual activity and provision of condoms (and lubricant) and risk reduction counseling);) Partner testing (assessment of partner status and partner testing provision or referral);v 3) STI (assessment for STIs and (if indicated) treatment/partner treatment provision or referral (including TB); 4) Family Planning (assessment of FP/PMTCT needs and (if indicated) family planning services provision or referral); 5) Adherence(assessment of adherence and (if indicated) support or referral for adherence counseling; 6) Support(assessment of need and (if indicated) refer or enroll PLHIV in community-based program such as home-based care, support groups, post-test-clubs); 7)Alcohol (use, assessment and counseling).

4) Provincial trainings and supervision to improve the syndromic management of STIs (includes reproduction of tools and algorithms).

5) Scale up of the `screen and treat` cervical cancer program (includes training, supervision, tools and equipment).

6) Train nurses and medical agents in OIs (new guidelines) to ensure appropriate and early diagnosis of and provision of cotrimoxazole prophylaxis.

7) Revitalize the management of Kaposi Sarcoma (includes organization of treatment teams, training, referral systems, data collection and reporting; and job aids).

8) Implementation of universal access of peer educators (PE) support.

Medical male circumcision (MC) reduces female to male HIV transmission by approximately 60% and is recommended by WHO and UNAIDS as part of a comprehensive HIV prevention program in high HIV prevalence countries such as Mozambique. Following the successful completion of a national demonstration project, the Mozambican MOH has demonstrated increasing support for MC as an HIV prevention strategy and expressed an interest in a targeted scale-up of MC services in provinces with high HIV prevalence and low circumcision rates, including Zambezia.

In FY12, Columbia will fund and support three integrated MC and minor surgical sites in strategic, high volume facilities in Zambezia Province. Exact sites will be identified with MOH and CDC. Working in collaboration with the MOH, NAC, USG and other key partners, Columbia will implement safe MC services within an integrated framework designed to enhance minor surgical capacity at the identified three sites. Specific activities will include providing surgical equipment/supplies, training, development of educational materials, and ensuring that appropriate quality assurance mechanisms are established. MC services are not a stand-alone intervention, but part of a comprehensive prevention strategy, which includes: the provision of HIV testing and counseling services; treatment for STIs; the promotion of safer sex practices; the provision of male and female condoms and promotion of their correct and consistent use; and linkages and referrals to prevention interventions and other social support services.

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/ARE activities at their sites.

In alignment with PEPFAR FY 2012 goals, Columbia will continue to reinforce IPC implementation in Zambezia province, 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.

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 autoclaves

As part of provincial team Columbia will continue to participate in the provincial planning and district technical working groups and in monitoring the implementation of the activities with DPS and other existing partners in the province.

Columbia 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.

Columbia 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 couples

Columbia will also be instrumental in the regional CT campaigns planned for FY12 as demand creation activities will be carried out in Zambezia. 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 ICAP 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 Columbia Universitys 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, Coluimbias 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 EVALUATION

Columbia 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

Columbia 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 Columbia 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 transmission

a. 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 disclousre 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, Columbia 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.

Columbia supports adult ART services in Zambezia through this funding mechanism.

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.

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 strategies that will be employed to address key implemenation challenges are:

Intensification of couple counselling and testing and recruitment strategies to include family members of index cases (spuoses and children)

Universal ART for TB/HIV co-infected patients

Implementation of the 350 cells/mm3 CD4 count threshold

Test and treat strategy for all HIV-infected pregnant women accessing antenatal care at ART sites, irrespective of CD4 count

Mobile clinics to bring services closer to patients living in rural isolated areas

Scale-up of Community Adherence and Support Groups

Community drug distribution

Standardizing and universalizing peer educators in all PEPFAR supported health facilities

Standardized quality improvement program

Scale-up of POC CD4 count technology

Implementation of a pre-ART package

Additional task-shifting to include nursing cadres and medical assistants

Columbia will be the technical assistance partner for the implementation, monitoring and evaluation of all of the above listed activities.

On-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 are also strategies that will be implemented to improve retention and early access to care.

The following are systems strengthening and capacity building activities supported by Columbia:

1) DPS sub agreements to finance staff priority activities

2) Task shifting ART to nurses, middle-level health and mentoring of providers

3) Hire provincial Clinical Advisors for Maputo City and Inhambane province.

4) Joint Columbia/DPS supervision visits that are linked to Continuous Quality improvement (CQI) program activities.

5) Participate in development and implementation of a national QI system. Columbia participates in the periodic HIVQUAL program activities

In FY12 clinical Columbia shall provide managerial capacity building to DPS, districts and to CCS as well as

provide site-level clinical technical assistance.

Clinical outcomes are tracked routinely on paper and electronically. Monthly reports are submitted to MoH. Columbia 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 Columbia will support Pediatric ART services in Zambezia province.

Scale-up of pediatric HIV is a national priority that Columbia will support MoH work towards including ensuring implementation of new guidelines within the province, districts and sites. Columbia 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- 1622 new patients and 3143 ever on treatment and FY13 2478 new patients and 5706 ever on treatment.

Activities to expand pediatric enrollments and access to diagnostic services include improving patient flow and specimen referrals to increase access to EID, CD4 testing; implementation of continuous quality improvement programs; early initiation of treatment.

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.

Columbia has implemented a few adolescent ART activities such as support groups and youth friendly services. The USG will develop a comprehensive strategy on adolescent ART which will be implemented by clinical partners.

Adherence and retention strategies are provision of psychosocial support, improve quality of care giver counseling, support groups, and community follow up.

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