With existing funding FGH in COP12 will implement HIV program activities in Zambezia province. The program goal is to increase access to quality HIV prevention, care and treatment using evidence based approaches which directly contributes to PF goals 1-5 in the following ways: 1) Scale up service delivery of Counseling and testing, PMTCT and ARV treatment; 2) Community mobilization and linking of facility and community based care 3) Increase Provincial and District Ministry of Health capacity; 4) Supporting quality assurance and quality improvement activities

The FGH project will directly contribute to two of Mozambiques GHI strategy focal areas; expanded access and uptake of quality MNCH services by supporting PMTCT and pediatric HIV services and strengthened governance in the health sector by supporting provincial and district planning, logistics management and sub agreements

Cross cutting programs include: 1) Food and Nutrition, including community links to improve nutrition through basic nutritional education and counseling and the promotion of locally appropriate, nutritious foods; 2) Gender addressing male norms and behaviors, increasing gender equity in HIV/AIDS activities and services and womens legal rights and protection; 3) Positive prevention and Pre-ART services; 4) Most at risk populations and 5) Health care worker / workplace program by supporting facility-level WPP to boost awareness and understanding of HIV and AIDS related issues of the personnel of the health sector and their families and 6)Local capacity development.

Because this is an end of program, no vehicles will be purchased in FY12.

FGH in 2012 will continue to support the Provincial Center for Health information with the goal to improve the DPS and USG partners M&E systems.

In FY 12, the FGH will continue to support the Ministry of Health through the Provincial Health Directorate (DPS) of Zambezia as well as the District Health Directorates (SDSMAS) in this province.

The focus will be capacity-building to improve program management and delivery of services

In Zambezia FGH will intensify its support to ensure high quality services for patients in care (pre-ART and ART patients), improve the retention rates, strengthen referral systems within health facilities and the community.

The main activities are:

1) Roll out 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 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) Integration of 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)Condom provision and education; 2) Partner testing and referral; 3) STI management and partner testing; 4) Family Planning; 5) Adherence assessment and support;6) Assessment of support needs and referral (i.e: home-based care, support groups, post-test-clubs); 7)Alcohol use, assessment and counseling

3) Provincial trainings and supervision to improve syndromic management of STIs

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

5) Train nurses and medical agents in OIs (new guidelines) to ensure appropriate and early diagnosis of and provision of CTX prophylaxis

6) Implementation of universal access of peer educators (PE) support

7) Capacity building to the DPS,DDSMAS and local organizations to manage and implement quality HIV/AIDS Prevention, Care, and Treatment related sub agreements

8) Expand Performance Base Financing to all districts of Gaza and Nampula

FGH works in collaboration with the DPS and DDSs in Zambezia province to improve TB related services As a result of this partnership, there has been significant improvement in the integration of TB and HIV services at the health center level. These achievements are due to:

1) Implementation of the 3 "is" : intensive case finding(ICF); izoniazid preventive treatment (IPT), and infection control (IC)

2) Training of clinicians on TB/HIV co-infection and management of MDR-TB.

2) Strengthening of the referral system

In 2012 FGH will continue to strengthen the identification, treatment and management of TB in adults and children and to strengthen other TB/HIV-related activities.

The priorities will be to:

1) Increase TB detection rates and TB cure rates;

2) Scalling up the implementation of the 3 "is" : intensive case finding(ICF); izoniazid preventive treatment (IPT), and infection control (IC)Strengthen PICT;

3) Support Routine provision of CTX ;

4) IImpementation of universal access to ART regardless of the CD4 count

5) Strengthen the referral system and linkages with other services Consultation for Child at Risk (CCR), Counseling and Testing for Health (ATS), PMTCT and ART and inpatient wards;

6) Moreover FGH will continue to expand the implementation of one stop model to additional sites.

7) Strengthen laboratory diagnostic services through training of new and existing laboratory technicians on smear microscopy techniques and establish a referral system for the regional laboratory for performing TB culture and DST.

8) Continue assist in the implementation of administrative, environmental and personal protection measures in both HIV and TB facility and will support training of staff in TB infection control.

FGH will strengthen the TB surveillance and M&E systems in collaboration with DPS.

FGH will continue to support LEPRA to strengthen their successful community-based TB programs. These programs are intended to:

a) Increase TB case detection and cure rate by increasing TB literacy and adherence support by establishing a system of defaulter tracing carried out by private providers of health care services, community leaders, community health workers and volunteers

b) Strengthen the M&E system that ensures proper recording of the activities, reporting to the appropriate level and conducting supportive supervisions.

During FY12 FGH 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 FGH 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;

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

MOH has placed increasing focus on strengthening human and technical resources at the provincial level to improve the coordination and delivery of services in the province. In FY 2008, MOH developed a standard set of technical advisor positions to be placed at the Provincial level; these four positions included advisors in Clinical Care, Laboratory, Pharmacy, and Monitoring and Evaluation (M&E).

USG was asked to assist with the funding and recruitment of these positions at the provincial level. The primary partner responsible for providing technical assistance in the area of clinical services in a province will also be responsible for the recruitment and support of the four technical advisor positions, including this Monitoring and Evaluation Technical Advisor position. Recruitment has begun for these positions; USG will support training of these Advisors through another USG supported partner (South to South collaboration with Brazil).

The role of the M&E Provincial Advisor is to provide support in the coordination of routine activities related to monitoring and evaluation at the Provincial Directorate of Health, giving priority to endemic diseases, including HIV. This advisor will help to reinforce and support the implementation of the decentralization of HIV services including related data collection systems. S/he will provide 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. Additionally this person will support the Provincial Directorate of Health in the analysis and dissemination of data (for example, to the site level, Ministry of Health, and partners.) This person will sit within the Provincial Department of Planning and Cooperation at the Provincial Directorate of Health.

The goal of the injection safety program is to reduce the risk of transmission of HIV and other blood borne pathogens among health care personnel at health facilities. In FY 20112FGH will support MOH efforts to expand and institutionalize infection prevention and control (IPC) programs.

FGH will assist in the mainstreaming of relevant activities into the routine functioning of health facilities where USG activities are supported. In coordination with national guidance and in collaboration with a central level technical assistance partner also supported by USG, IPC efforts will be expanded and institutionalized in the following areas:

1) Implementation of standard operating procedures regarding sharps and other infectious waste disposal / IPC

2) Ensure that all health facility staff receives updated training and supervision in injection safety / IPC/ PEP

3) Dissemination of written procedures for handling and disposal of sharps and infectious waste

4) Improved availability and use of personal protective equipment, including technical assistance at DDS/DPS level to improve management of stock levels and resupply of necessary items through existing MOH channels

5) Support for availability of PEP to health care workers

6) Appropriate data collection and reporting/record keeping, including PEP

7) Other activities include supportive supervision/empowerment of health workers with knowledge and tools to protect themselves and patients; demand creation for safe conditions in the workplace with all health facility staff cadres; increasing IPC awareness including hand hygiene and universal precautions; and consideration of strategies aimed at both the community and HCW to reduce unnecessary injections.

USG clinical services partners will pursue these activities in collaboration and coordination with a single central-level technical assistance partner, which will also specifically support the development and implementation of IPC/ injection safety measures at national level.

HMIN activities are linked to workplace programs. Implementation and supervision of activities will be conducted through an integrated approach in close collaboration with DDS and DPS.

FGH/Vanderbilt 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.

FGH 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

FGH 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 FGH 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, FGHs 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

FGH 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.

FGH will support three distinct areas within the other sexual prevention portfolio. These activities will be carried out in coordination with support from the care and treatment portfolio and injection safety.

Key Activities:

(1) Mainstreaming of positive prevention (PP) activities:

(2) Management of sexually transmitted infections (STI): FGH will support the management of STIs at provincial, district and health facility level (18 sites in 12 districts) in order to reduce the burden of STIs as well as HIV infections attributable to STI co-infection. Additional focus will be on most-at-risk populations (MARPs). Key activities will include basic STI care; training and job aids; infrastructure support (equipment, privacy); Coordinate and support mechanisms to ensure availability of all medications necessary for following Mozambiques 2006 STI Syndromic Management Guidelines in the pharmacies; and M&E.

(3) Health care worker / workplace program (WPP): FGH will support facility-level WPP to boost awareness and understanding of HIV and AIDS related issues of the personnel of the health sector and their families.

Additionally, this IM receives Central GBVI funds.

Priorities in FY 2012are coordination with MOH and scale up of PMTCT services within an integrated MCH system an emphasis in supporting roll out of revised WHO guidelines on ARV prophylaxis and infant feeding as approved by MoH. Vanderbilt objectives include improved quality through clinical mentoring and other quality improvement strategies; access to a comprehensive package including psychosocial support; and improved nutrition support for reduced vertical transmission, including supporting staff (nutritionists, SMI nurses) fully dedicated to this area. Vanderbilt activities will align with MOH through district-, and provincial-level support, technical assistance, training, quality improvement, and monitoring and evaluation (M&E). The district-based approach and collaboration at provincial level, including subcontracts or grants from Vanderbilt to provincial and district public health departments, will increase Vanderbilt responsiveness, including support for overall systems strengthening and positioning for transition. Community platforms will be strengthened to increase demand for PMTCT services.

The major allocation of effort (at least 60%) will be towards scale up, including training, supervision, and technical assistance, in line with the goal of 80% PMTCT coverage by 2014.

Key activities:

1) Expansion: Support for sites without PMTCT services, and enhanced support for low-performing sites receiving partner or MOH support; increased community demand for services

2) 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.

3) ARVs for PMTCT: Focus on more effective regimens and ART initiation support the MoH roll out of revised WHO guidelines for ARV prophylaxis and infant feeding

4) Cotrimoxazole prophylaxis: Focus on improving coverage for pregnant women

5) Early infant diagnosis

6) Support for prevention of unintended pregnancies among HIV-infected women

7) Support groups and community involvement based on national model Mães para Mães support groups

8) Information, education, communication: Dissemination of materials developed by a central / lead partner

9) Safe infant nutrition interventions integrated into routine services, including counseling and distribution of commodities in close collaboration with central / lead nutrition technical assistance and procurement partner

10) M&E: support for reproduction and roll out of revised registers

11) PMTCT clinical mentoring based on national model

11) Linkages to system strengthening, including infrastructure projects for PMTCT as required

12) Mainstream infection prevention control in PMTCT settings; support workplace programs including PEP.

FGH supports adult ART services in 12 districts of Zambezia province

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 also comparatively more females testing HIV positive than men. Continued efforts to promote family centred approaches to treatment and care will be implemented to ensure gender equity in access to service.

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

Intensification of testing and recruitment strategies including couple counselling and testing.

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 (in Zambezia)

Scale-up of Community Adherence and Support Groups

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. The peer educator program will be standardized in all sites in FY12.

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.

During FY12 FGH will support Pediatric ART services in Zambezia Province

Scale-up of pediatric HIV is a national priority that FGH will support MoH work towards including ensuring implementation of new guidelines within supported provinces, districts and sites. FGH 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- xx new patients and yy ever on treatment and FY13 xx new patients and yy ever on treatment.

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.