The Ariel Glaser Pediatric AIDS Foundation (Ariel) is a local organization funded by PEPFAR to support HIV prevention, care and Tx programs in Mozambique. Ariel has taken over technical assistance (TA) and support to all sites districts previously supported by EGPAF in Maputo Province. With FY12 funding Ariel will expand to Cabo Delgado as TA partner at previously supported EGPAF sites. The goal is to increase access to quality HIV prevention, care and treatment using evidence-based approaches. In particular Ariel will provide support to health facility staff through in-service trainings, supportive supervision, case reviews, patient follow up and tracking and implementation of quality improvement (QI) activities and contribute to PARTNERSHIP FRAMEWORK GOALS by: 1) Scaling up counseling and testing, PMTCT and ARV treatment; 2) Promoting community mobilization and linking of facility and community based care 3) Supporting QI.

GHI focus areas addressed are: expanded access and uptake of quality MNCH services.

Ariel is a new organization and no expenditure analysis has been conducted to date. Ariel will participate in future expenditure analyses. The USG views this new agreement as a stepping stone towards transitioning programs to local partners. However, recognizing that Ariel has no prior experience in managing programs in this area, a phased approach to transition has been adopted. An M&E system captures standard data related to quantity, quality and impact of HIV clinical services, systems strengthening activities, financial accountability and administrative management

In Year 1 Ariel did not purchase any vehicles. Pipeline analysis was not possible at the time this budget was developed as Ariel only received year 1 funding for this mechanism in late Sept. 2011.

In FY 12, Ariel partner will continue to support the Ministry of Health in implementing HIV related services in Mapuo Province and Cabo Delgado.

Capacity building will be the main focus to ensure integration, high quality of services, early access to care and retention in care.

The partner will also leverage existing resources, promoting cost efficiencies and sustainability of the Care and support programs. It will also ensure that health facilities coordinate with community partners on bi directional linkages.

To ensure that Pre-ART and ART patients are retained in care, funds provided to the TBD partner will be used for:

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 standardized manner. The objective is to ensure that all patients in care, either pre-ART and ART benefit from a comprehensive set of intervention such as diagnosis of opportunistic infections (OIs), provision of cotrimoxazole prophylaxis, TB screening, INH prophylaxis, STI diagnosis and syndromic management, nutrition assessment and counseling (NAC), psychosocial support, adherence support, positive prevention and other services that will contribute to link to and retain patients in 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, Malária and other HIV related complications and promote a culture of hand washing and use of safe drinking water among patients.

To ensure that HIV services are delivered, including bidirectional community- clinical linkages, funds provided to the TBD partner will be used for:

1) 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, provision of condoms and risk reduction counseling); 2) Partner testing and referral);3) STI screening, treatment and partner treatment or referral ;4) Family Planning assessment and referral);5) Adherence assessment and referral for counseling;6) Support assessment and (if referral (ie: home-based care, support groups, post-test-clubs);7)Alcohol use assessment and counseling

2) Provincial trainings and supervision to improve the syndromic management of STIs.

3) Scale up of the `screen and treat` cervical cancer program.

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

5) Implementation of universal access of peer educators (PE) support. At central level, ICAP will support the standardization of PE role across all partners, harmonization of the national strategy, curricula development, and reproduction of manuals, guidelines, and tools

All USG-supported treatment partners, including ARIEL, 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 ARIEL 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 ARIEL 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 ARIEL 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) ARIEL in Maputo Province and Cabo Delgado will assess the need to support or hire a TB/HIV focal person.

5) Motorcycles will be purchased to support supportive supervision to peripheral health facilities, community based DOTs volunteers/activists and to trace defaulters and contacts of TB.

6) Print and disseminate IEC 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.

During FY12 Ariel will support Pediatric HIV care services in Maputo Province and Cabo Delgado.

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.

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;

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

Ariel has been asked to place 1 M&E Advisor in Maputo province and Cabo Delgado as part of their overall support to clinical services in these Provinces.

While strengthening systems for M&E and Health Information Systems (HIS) remains a priority, the model of providing assistance is currently under review in a joint process by USG and MOH. During FY12, these discussions should provide updated guidance on the most effective model for providing technical assistance that results in greater MOH ownership and capacity (e.g. via seconded technical advisor or another model of technical assistance.) The overall objectives of this technical assistance continues to be to strengthen MOH systems at provincial level

*To coordinate routine activities related to M&E and HIS at the Provincial Directorate of Health, giving priority to endemic diseases, including HIV.

*To reinforce and support the implementation of the decentralization of HIV services including related routine data collection systems.

*To strengthen MOH leadership in the supervision and management of data to ensure the quality of data at the district and site level, help to strengthen the flow of data to the district, provincial, and central levels.

*To support the Provincial Directorate of Health in the analysis and dissemination of data (for example, to the site level, Ministry of Health, and partners.)

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

Ariel supports Ministry of Health (MOH) priorities outlined in the Human Resources National Development Plan (2008-2015) and is coordinating with other PEPFAR implementing partners and other donors in the provinces of Maputo province and Cabo Delgado. In 2012 will continue to support in the following activities:

Given the urgent need for increasing the number of qualified health care workers at all levels, PEPFAR funds are used each year to pay the entire course expenses associated with training for clinical officers, general nurses, MCH nurses, laboratory technicians, and pharmacy technicians from both basic and middle level training programs at the provincial Health Institutes. The goal of this activity is to increase the production of healthcare workers and decrease the numbers who drop out of training due to financial constraints. The partner will provide annual support to health training institutes in their province areas through the Provincial Health Directorate (DPS) per the needs identified by the province.

Based on the laboratory program model of support, in FY12 partners will continue to provide support to supply chain management of medicines and reagents at the periphery by supporting the position of a pharmaceutical supply chain advisor for the province. This advisor will work with the DPS and DDS to incorporate pharmacy supervision visits into joint integrated supervisions visits; coordinate with the provincial advisors in other areas, CMAM, MoH laboratory section, and SCMS around bottlenecks or problems with essential commodities, including laboratory reagents; help coordinate and support trainings in collaboration with the DPS an CMAM.

Laboratory services are integral service component to support optimal care and treatment to HIV patients. FY12 funds will continue to support Laboratory Technical Advisors based at the DPSs. The laboratory advisor will liaise with and coordinate activities with NGOs and partners, MoH, SCMS, APHL, and others. The advisor will identify weaknesses in laboratory processes, procedures, and logistics, propose adequate strategies for improvement, and contribute to a plan towards building capacities at provincial and district levels.

Minor renovations and infrastructure. FY12 funds will support rehabilitation of existing infrastructure to accommodate the decentralization process. Partners will have funds to support minor rehabilitation to facility and district pharmacies, including paint, ventilation or air conditioning systems, racking and other material/infrastructure requirements for improved storage conditions for medicines.

Supply chain & commodities support. Partners will receive OHSS funds to provide additional support to the supply chain system below provincial level, in collaboration with SCMS and SIAPS. Partners will provide general support to strengthening quality of pharmaceutical management services, including ARV dispensing services through improved monitoring of the MMIA system, monitoring pharmacies and adherence to standard operating procedures, and participation in joint supervision visits with the DPS/DDS. Partners will also support the expansion of the logistics management information system (SIMAM) to additional districts.

Prevention of medical transmission of HIV is addressed through the MOH Infection Prevention and Control program, which goal is to reduce the risk of transmission of HIV and other blood borne pathogens at health facilities. Activities include: compliance with Infection Prevention and Control/Injection safety (IPC/IS) standards; reinforce of biomedical waste management; Post Exposure Prophylaxis (PEP) to HIV and work place safety. The program started in 2004 with PEPFAR technical and financial support. Since 2010 USG/PEPFAR supported Clinical partners are requested to mainstream IPC/IS activities at their sites.

In alignment with PEPFAR FY 2012 goals, Ariel will continue to reinforce IPC implementation including: compliance with IPC standards and guidelines; adequate sharps and other infectious waste disposal; PEP scale-up and M&E; dissemination and implementation of the National waste management plan. In FY12 Ariel will pilot a model waste management approach using autoclaves in 1 facility (Ndlavela health Center in Maputo province), with support of JHPIEGO and in close coordination with CDC Mozambique and support of CDC HQ International medical waste Program manager.

FY 12 Key activities include: 1) Strengthen and expand implementation of PEP services 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 Ariel will participate in the provincial planning and district technical working groups and in monitoring implementation of the activities with the DPS and other existing partners in their geographic area.

Ariel 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.

Ariel 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

Ariel will also be instrumental in the regional CT campaigns planned for FY12 as demand creation activities will be carried out in Maputo province and cabo del Gado. 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 Ariel 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 Ariel's 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, Ariel's 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

Ariel 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.

Positive Prevention

GOALS AND OBJECTIVES

Positive Prevention (PP) is the name given in Mozambique to those interventions that specifically target people living with HIV and AIDS (PLHIV) in order to promote their well-being and to prevent onward transmission, including sexual transmission or mother-to-child transmission. These program goals contribute to the following Partnership Framework (PF) goals: Goal 1: By reducing sexual transmission of HIV and improving access through increased geographic coverage and improved facility-community linkages for HIV services. PEPFAR Mozambique activities are currently focused on scaling up PP in clinical service settings in a fully integrated manner. The goal is to ensure that all PLHIV seen in clinical settings receive 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).

GEOGRAPHIC LOCATIONS AND TARGETS

Ariel partner will work in Maputo Proince and Cabo Delgado and the PP activities will target PLHIV in Pre-ART and ART. The target population projected for 2012 is &by Province. This province is high/medium/low prevalence area.

USE OF EXPENDITURE/COSTING DATA

For PP program theres not yet Expenditure Analysis information. The minimum package of PP interventions, according to Ministry of Health, will allow the health providers to deliver, in a comprehensive and systematic way, some of interventions that already are being done by the health providers with HIV patients, but not in a consistent and systematic way. PP program will improve the quality of care to the HIV patients in Pre-ART and ART and will help to document and monitor this intervention when the reporting tool will be developed and implemented.

SYSTEM STRENGHTENING AND CAPACITY BUILDING

The Provincial and District Ministry of Health capacity will increase through PP training, supportive supervision, technical and managerial support; and improving HIV services integration.

?? will have a dedicated person / technical counterpart for prevention by province/a focal person for PP activities to coordinate and ensure successful implementation and monitoring of PP activities; will focus e.g. integration of PP services in existing HIV activities, and expansion in geographical and technical scope through training of health providers, monitoring the PP indicator, supportive supervisions and reproduction of training materials / dissemination (job aides, leaflets, etc) in coordination with lead TA partner.

MONITORING AND EVALUATION PLANS

PP program will improve the quality of care to the HIV patients. However, the monitoring plan is not yet in place. There is an issue to document and monitor this intervention. The national PP technical working group headed by Ministry of Health is working on it as well as developing a National PP Strategy which will include a clear guidance on how to roll-out the PP intervention at facility and community level as well how to monitor the PP indicator.

ARIEL FOUNDATION 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 ARIEL FOUNDATION 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:

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 as well as male involvement.

Additionally, ARIEL FOUNDATION 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.

Ariel supports adult ART services in Maputo Province and Cabo Delgado.

Priority areas are treatment scale-up; ART retention; ART Quality assurance; program linkages and integration especially with CT, TB, PMTCT, nutrition, pre-ART services, and prevention with positives.

FY 12 Ariel targets are 34 028 patients on ART

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.

Adherence strategies include: Patient support groups, Pre- and post-ART adherence counseling, decentralized drug distribution and family centered care and treatment services.

The strategies that will be employed to address these challenges are:

Intensification of testing and recruitment strategies

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

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

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

Gender distribution of access to treatment shows that currently about 66% of patients on ART are female. there are also comparatively more females testing 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.

The following are systems strengthening and capacity building activities supported by Ariel

1) DPS sub agreements to finance staff priority activities

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

3) Hiring provincial Clinical Advisors for Maputo Province, .

5) Join Ariel/DPS supervision visits that are linked to Continuous Quality improvement (CQI) program activities.

6) Participation in development and implementation of a national QI system. Ariel participates in the periodic HIVQUAL program activities

In FY12 clinical services management responsibility in Maputo Province and Cabo Delgado shall transfer from EGPAF to Ariel Foundation, EGPAF shall provide managerial capacity building to DPS, districts and to Ariel foundation.

Clinical outcomes are tracked routinely on paper and electronically. Monthly reports are submitted to MoH. Ariel 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 funds will be provided to Ariel to support Pediatric ART services in Maputo Province and Cabo Delgado.

Scale-up of pediatric HIV is a national priority that will be supported including ensuring implementation of new guidelines within the province, districts and sites. the TBD partner 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%.

Pediatric treatment targets for FY12: 3318 children on ART.

Activities to expand pediatric enrollments and access to diagnostic services include:

1) improving patient flow and specimen referrals to increase access to EID

2) POC CD4 testing

3) implementation of continuous quality improvement programs

4) early initiation of treatment

5) An active case finding model

6) Improved linkages between services (i.e.: TB, MCH, inpatient wards etc)

7) Increased community awareness of the importance of testing children and accessing care early

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

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

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

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

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

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