ACTIVITY DESCRIPTION This activity also relates to activities in Care and Support (#6770), Orphans and Vulnerable Children (#6771), ARV Services (#6766), and Laboratory infrastructure (#6767). Utilizing a network model with basic PMTCT care centers linked to secondary and tertiary hospitals able to provide more complex PMTCT care and laboratory testing, 79,000 women will receive PMTCT counseling and testing and receive their results and 63 PMTCT sites will be supported. This represents a doubling in the number of PMTCT sites between COP 06 and 07. As PMTCT services are focused on the primary health center level, the average number of pregnant women per facility has decreased from 1500 to 1200. "Opt out" counseling and testing (C&T), with same day test results, will be provided to all pregnant women presenting for ANC including labor and delivery. All women are provided post-test counseling services on prevention of HIV infection including the risks of MTCT. Partner testing is offered as part of counseling through referral to on-site VCT centers and counseling includes a focus on strategies for negative women to remain negative. This provides an opportunity to interrupt heterosexual transmission. Master trainers for VCT will be utilized to train Labor and Delivery staff in the use of a simple rapid screening test such as the Abbott Determine for women who present for delivery without previously being seen at the hospital for antenatal care. As a result of these C&T activities, an anticipated 4,300 HIV+ pregnant women will be provided with a complete course of antiretroviral prophylaxis. Women will have access to ACTION supported laboratory services including CD4 measurement without charge. This will be available on-site or within the network through specimen transport. Women requiring HAART for their own health care will be linked to a network ARV center. For the anticipated 2/3 of women not requiring HAART, the current WHO recommended short course ARV option will be provided which includes ZDV from 28 weeks, intra-partum NVP, and a 7 day ZDV/3TC post-partum "tail". Infant prophylaxis will consist of single dose NVP with ZDV for 6 weeks. All HIV+ women will be linked post-partum to a HIV/ARV point of service, which will utilize a family centered care delivery model whenever feasible, co-locating adult and pediatric care. HIV+ women will be counseled pre- and post-natally regarding exclusive breast feeding with early weaning or exclusive BMS using the WHO UNICEF curriculum adapted for Nigeria. Consistent with national policies on importation of infant formula and recent concerns regarding mortality/morbidity among infants receiving BMS, ACTION will support BMS only if provided by the FMOH/NACA as part of a national program. Efforts will be focused on the provision of safe weaning nutritional supplements as part of OVC programming. HIV+ women will be linked to support groups within network which will provide both education and ongoing support around infant feeding choices. Co-trimoxazole suspension is provided to all exposed infants pending a negative virologic diagnosis. Eight Regional laboratory centers for DNA PCR have been or will be established by ACTION. Testing of infants will be carried out using dried blood spot specimen collection. Action will train a total of 276 HCWs in the provision of PMTCT services. This will include 216 HCWs across 63 sites and 20 TBAs in PMTCT regional trainings. These trainings will utilize the national PMTCT training curriculum. Including TBAs in regional trainings is an effort to reach women who do not access hospital/health center based services for antenatal care or delivery; the national training curriculum will be adapted for the TBA level when appropriate. In addition, counselors will be trained utilizing the infant feeding counseling curriculum recently harmonized with ACTION support. A major priority of the FMOH is capacity development and technical assistance to ensure that regional PCR facilities are developed throughout the country. ACTION will support this by conducting 4 Master Trainings in DNA PCR for laboratory scientists. Forty laboratory scientists will be trained who will train 5 other laboratory staff for an indirect target of 200 trained. ACTION will support PMTCT services at 63 sites, expanding from 32. Sites are located in states chosen based upon high prevalence in the most recent 2005 antenatal HIV sero-survey and geo-political distribution. They include: Anambra, Edo, FCT, Nasarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Delta, Lagos, Sokoto, Jigawa, Plateau, Kaduna, Ogun, Osun, Imo, Katsina, Gombe, Kwara, and Akwa Ibom. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity will provide counseling and testing services to 79,000 pregnant women, and provide ARV prophylaxis to 4,300 mother and infants pairs. This will contribute to the PEPFAR country specific goals of preventing 1,145,545 new HIV infections in Nigeria by 2009. With 63 operational sites, the PMTCT activity is in line with the desire of the GoN to have 1,200 PMTCT sites operational by 2008 and the USG's target of having 80% PMTCT coverage for antenatal clinics across the country LINKS TO OTHER ACTIVITIES This activity is linked to Care and Support (#6770), Orphans and Vulnerable Children (#6771), ARV Services (#6766), and Laboratory infrastructure (#6767). Prevention for positives counseling will be integrated within

PMTCT care for HIV+ women. The basic package of care provided to all HIV+ patients will be available to HIV+ pregnant women. Women requiring HAART for their own health care will be linked to within network ARV services. ACTION laboratory staff will ensure that HIV testing provided within the PMTCT context is of high quality by incorporating PMTCT sites into the laboratory QA program. ACTION will collaborate with UNICEF in the support of PMTCT services at some sites, leveraging resources without duplication and creating a more sustainable service support structure. POPULATIONS BEING TARGETED This activity targets pregnant women who will be offered HIV counseling and testing, HIV+ pregnant women who will be offered ARV prophylaxis and infant feeding counseling, and HIV+ infants who will be offered ARV prophylaxis and infant HIV diagnostic testing. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses the key legislative issue of "Gender" since treatment will be provided to women and will focus on family centric issues including male involvement in PMTCT programming. EMPHASIS AREAS The major emphasis area for this activity is "Training" as nearly all supported personnel are technical experts who focus on this at the central and site level. In addition, considerable resources are devoted to training costs. A secondary emphasis area is "Commodity Procurement" as ARVs for prophylaxis and laboratory reagents for infant diagnosis will be procured. Another secondary emphasis area is "Development of Network/Linkages/Referral Systems" as networks of care will be supported which are critical to ensuring quality of care at the primary health center level, identifying women in need of HAART through CD4 testing, and ensuring access to HAART if needed within the network. This strategy of identifying the women most at risk for perinatal transmission and offering them the most intensive intervention is critical to maximizing reduction of MTCT and scale-ability while ensuring quality

Reprogramming 9/07: These funds are to restart the ART treatment partner collaboration with NBTS and SBFAF to link hospitals to the NBTS blood screening system to ensure that all units of blood are screened appropriately and that the flow of donated blood to NBTS from hospitals is started to take advantage of the excess capacity at NBTS facilities.

This activity was suspended at the direction of the OGAC Prevention TWG.

ACTIVITY DESCRIPTION: This activity also relates to activities in Counseling and Testing (6772), Medical Transmission Injection Safety (3.3.04), and Laboratory Infrastructure (6767) .

ACTION will support capacity development for Blood Safety (training and equipment), screening for HIV, universal precautions, good laboratory practice, waste management, and QA/QC for serological testing at 32 sites.

The first component of this activity is capacity development for Blood Safety (training and equipment). This will entail personnel and institutional capacity development aimed at improving the quality of blood safety services at site levels. The Personnel capacity development will involve trainings in universal precaution, good laboratory practice, laboratory safety, and use of rapid HIV test kits. The institutional capacity development component will only cover the provision of basic needs for the collection of blood and HIV serologic testing to ensure that all blood meant for transfusion is HIV free.

In line with the GON national training guideline and curriculum for HIV testing for blood transfusion safety, ACTION will conduct centralized training of trainers so that a minimum of 2 laboratory scientists per site will be trained (64 Master Trainers). These Master Trainers will in turn train all the Laboratory staff at their sites, including all laboratory staff that handles blood transfusion. The site trainings will be conducted under the supervision of the ACTION Program Officer for Blood Safety. Thus, an additional 4 laboratory staff per site (128 additional laboratory staff for a total direct training target of 192).

This activity will promote the principles of Universal Safety Precautions, like the reduction of unnecessary transfusions, exposure to blood, accidental injury/contamination as well as the provision of essential consumables and services that protect the health worker from contacting blood borne infections such as HIV. These universal precaution materials include personal protective equipment such as hand gloves and laboratory coats and other consumables (methylated spirit, hypochlorite solutions, antibacterial soaps, etc) which will be provided to the sites. Other equipment to be provided will include centrifuge, thermometer, pipettes, and rapid test kits. In addition, each site will have in place a Post-Exposure Prophylaxis (PEP) access in case the need arises (described under ARV Services narrative).

Screening for HIV will be consistent with the national testing algorithm for blood screening and to test for all units of blood used for emergency services. Expectedly, a total number of 16,000 units of blood will be required for urgent transfusion at the 32 sites. Assuming an average of 3 voluntary donors may need to be screened for every unit of blood collected and transfused, 48,000 donors may be screened. All screening services will be linked to pre and post test counseling services at each site.

Proper waste management will be encouraged through the use of Bio-Hazard bags, suitable sharps containers, and the use of incinerators. In order to maintain high quality laboratory results, ACTION will include the blood bank in its laboratory QA/QC program that involves on-site quarterly monitoring and retraining as well as selective retesting and proficiency panels.

This activity will provide support for 32 service outlets, train 192 individuals in counseling and testing/blood safety protocol, and provide HIV screening for 48,000 individuals. The 32 sites will be located in the following states: Anambra, Edo, FCT, Nassarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Rivers, Delta, and Lagos

CONTRIBUTIONS TO OVERALL PROGRAM AREA: Activities in this program area will support PEPFAR and GON goals to avert new infections through ensuring that all blood transfused are HIV free and also reduce risk of

transmission of HIV by instituting safe blood activities at all sites.

LINKS TO OTHER ACTIVITIES: This activity is linked to 3.3.09 (C&T) as directed donors screening positive will be linked to VCT services for counseling and confirmatory testing. This activity is also linked to 3.3.04 (Medical Transmission Injection Safety) as universal precaution supplies and safe disposal containers and training will be provided.

POPULATIONS BEING TARGETED: The target population is laboratory workers at public facilities who will be the focus of capacity development.

KEY LEGISLATIVE ISSUES ADDRESSED: N/A

EMPHASIS AREAS: The major emphasis area for this activity is "Training" as capacity development for sustainability is a key focus. A Minor emphasis area for this activity is "Quality Assurance, Quality Improvement, and Supportive Supervision" as an ongoing QA program will be an important activity.

ACTIVITY DESCRIPTION ACTION will provide Safe Injection support to 46 sites and will train 220 staff. A Medical Program Officer will be dedicated to this program area. Health care workers targeted for services include physicians, nurses and aids, laboratory workers, and waste handlers.

ACTION will carry out training at the site level for maximum penetration and economy which will focus on universal precautions, behavior change around techniques for proper handling and disposal of syringes and sharps, and waste management. A standard curriculum and SOP will be provided to each site to encourage sustainability. Safe disposal supplies including sharps containers and universal precaution supplies including standard gloves, eye shields, boots for the surgical theater, and elbow length gloves for intrauterine procedures will be provided to sites.

Procurement will be supported by other implementing partners including John Snow Incorporated (JSI)/Making Medical Injection Safer (MMIS) in addition to ACTION. Commodities and disposables will be warehoused by ACTION. They will be provided to sites based upon a pull system using a site level inventory control system linked to the ACTION warehouse logistics management information system. The current system can be easily harmonized with a national or PEPFAR wide logistics management information system and inventory control system once implemented.

ACTION staff will implement ongoing quality assessment of implementation by direct observation and by training a local site staff member to monitor compliance in harmony with hospital policies to be developed as part of a sustainability strategy. ACTION has also developed an SOP, training curriculum, and IEC materials for post-exposure prophylaxis procedures at sites which are described under ARV services.

ACTION will support 46 sites where HIV care and/or PMTCT services are provided and these sites will be targeted for Medical Transmission services. Sites are located in states chosen based upon high prevalence in the most recent 2005 antenatal HIV sero-survey and geo-political distribution. They include: Anambra, Edo, FCT, Nassarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Rivers, Delta, and Lagos

CONTRIBUTIONS TO OVERALL PROGRAM AREA: This activity will contribute to the reduction of medical transmission of HIV and other blood-borne diseases by following universal precaution measures, as well as proper waste management. It will likely improve the quality of health care and reduce barriers to comprehensive medical care by addressing concerns of health workers and other hospital staff. Overall this will contribute to the prevention of 1,145,545 new HIV infections by 2010 in Nigeria and to the PEPFAR global achievement of 2,7,10 goals.

LINKS TO OTHER ACTIVITIES: This activity is linked to 3.3.01 (PMTCT) and 3.3.11 (HIV AIDS Treatment services) and 3.3.12 (Laboratory Infrastructure) as health care workers providing those services will be targeted for training under this program area.

POPULATIONS BEING TARGETED: Doctors, nurses, laboratory scientists, other health care workers and waste handlers are targeted for training and services in the public sector.

KEY LEGISLATIVE ISSUES ADDRESSED: This activity addresses the key legislative issue of Stigma and Discrimination as the services will reduce stigma and discrimination associated with HIV status in the health care facility setting.

EMPHASIS AREAS: The major emphasis area for this activity is "Training" as nearly all supported personnel are technical experts who focus on development of training materials and SOPs and the provision of training at the site level. A secondary emphasis area is "Commodity Procurement" as supplies for safe disposal will be procured and supplied.

ACTIVITY DESCRIPTION ACTION will provide Condoms and Other Prevention Activities targeting 60,000 HIV+ adults and youth and 45,000 HIV- most at risk persons (MARPS). Prevention counseling for HIV+ will take place in the clinic or support group context and include promotion/instruction regarding correct and consistent condom use if acceptable to the client and coupled with information education communications (IEC) about abstinence and mutual faithfulness. In collaboration with counseling and testing (C&T) sites, a special focus will be placed upon sexually active discordant couples or couples with unknown HIV status. Collaboration with Persons Living with HIV AIDS (PLWHA) support groups will ensure that IEC materials and counseling messages are culturally acceptable. Group counseling will be carried out in PLWHA support group meetings to discuss and promote HIV prevention behaviors including avoidance of sexually transmitted infections (STIs), recognition and seeking early treatment for symptoms of STIs, and addressing alcohol and illicit drug use. ACTION will expand prevention services for those testing HIV- at C&T services targeting MARPS. ACTION will continue to provide mobile "moonlight" C&T targeting locales where transactional sex and intergenerational sex is common using 2 specially equipped vans. Under COP06, the sero-prevalence among clients accessing this service was 10%. ACTION will enhance services for clients testing HIV- in the mobile C&T setting. In addition, ACTION will be providing VCT services in collaboration with experienced CBOs along the Benin-Lagos transport corridor, targeting truck drivers and those who engage in transactional sex at overnight motor parks. This will be based upon a successful model developed along the Mambasa-Kampala corridor in Kenya-Uganda. A 20% sero-prevalence is anticipated. Services for persons testing HIV- at both mobile C&T sites and motor park sites will be enhanced to include: syndromic sexuaIly transmitted infection (STI) management, targeted condom promotion and distribution coupled with information about abstinence and mutual faithfulness, behavioral change communication, and risk reduction education using peer educators. 45,000 HIV- persons will be served in the mobile C&T setting and 18,595 HIV- persons will be served in the motor park setting. A dedicated program officer will be hired by ACTION to oversee this activity. Site level trainings for medical, nursing, counseling staff, peer educators, and PLWHAs will be carried out by ACTION program staff and CBO subcontractors using a role play based curriculum. 50 site level trainings will train 8-10 persons each. General training will include counseling to reduce risk of transmission to others including condom use and training for health care workers will include syndromic STI management. Program staff will work with sites to ensure appropriate linkage to STI care is available to HIV+ clients. As part of strengthening the capacity of PLWHAs, 3 central Training of Trainers will be conducted to train 60 Master Trainers, with an effort to include PLWHAs. Each Master Trainer will train 20 others who will provide counseling to 50 HIV+ clients and/or partners. Thus, direct training targets are 500 and indirect targets are 1,200 trained and 60,000 clients counseled. ACTION currently supports HIV/ART care at 16 sites and will develop 35 additional sites under COP07 for a total of 55 sites. Sites are located in states chosen based upon high prevalence in the most recent 2005 antenatal HIV sero-survey and geo-political distribution. They include: Anambra, Edo, FCT, Nasarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Delta, Lagos, Sokoto, Jigawa, Plateau, Kaduna, Ogun, Osun, Imo, Katsina, Gombe, Kwara, and Akwa Ibom. CONTRIBUTIONS TO OVERALL PROGRAM AREA: As transmission from known HIV+ persons contributes to HIV transmission, this activity will support the Nigerian Federal Ministry of Health (FMOH) and EP goal of reducing new HIV infections and thus decreasing the overall disease burden of HIV in Nigeria. Targeted efforts to promote correct and consistent condom use with MARPs can reduce the risk of HIV infection for these populations. LINKS TO OTHER ACTIVITIES: This activity also relates to activities in care and support (#6770), ARV services (#6766) and VCT (#6736). Prevention for positives counseling will be an important component of post-test counseling of HIV+ persons as part of C&T services and HIV+ persons will be linked to care and treatment services. The service is included in the basic package of care for all HIV+ persons. Prevention for positives counseling will be incorporated in counseling for persons receiving ARV treatment. This service will complement C&T services for those who ultimately test HIV-. POPULATIONS BEING TARGETED This activity focuses upon people living with HIV/AIDS and their partners/spouses (HIV/AIDS-affected families). Targeted populations also include most at-risk populations such as commercial sex workers and their clients and mobile populations such as truck drivers. Doctors, nurses, other health care workers in the public sector as well as PLWHAs are targeted for training. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses the key legislative issue of "Gender" since services will be provided equitably to women and data will be collected to demonstrate this. This activity also addresses the legislative issue of "Stigma and

Discrimination", since HIV counseling reduces stigma associated with HIV status through education. EMPHASIS AREAS The major emphasis area for this activity is "Training" as nearly all supported personnel are technical experts who focus on this at the central and site level. In addition, considerable resources are devoted to training costs. A secondary emphasis area is "Information, Education, and Communication" as IEC materials and training curricula will be developed, adapted, and distributed.

Reprogramming 9/07: $600,000 in reprogrammed FY07 funds advanced for COP08 targets, funding to be reduced accordingly from the COP08 budget submission for BC&S.

ACTIVITY DESCRIPTION: This activity also relates to activities in counseling and testing (#6772), Condoms and Other Prevention (#9210), HIV/AIDS Treatment Services (#6766), OVC (#6771), TB/HIV (#6765), and HVLab (#6767). ACTION will provide comprehensive care to 51,405 HIV+ adults. The basic care package which will be available to all HIV+ adults includes: access to appropriate TB diagnostics and linkage with DOTS programs described under TB/HIV, instruction in appropriate water purification and provision of Water-Guard, provision of ITNs, linkage to psychosocial support through participation in PLWHA support groups and individual counseling operational at all points of service, provision of TMP/SMX prophylaxis for all those with CD4 absolute count < 350 cells/ml3, pain and symptom management, and access to community home based care services. A standard formulary will be provided to sites to treat common opportunistic infections. The function of PLWHA support groups will be strengthened by a PLWHA ACTION Program Officer with a counseling background who will work with support groups to improve educational and support programs and linkage to the point of service and community. Laboratory monitoring including CD4 counts, hemogram, clinical chemistry, pregnancy testing if indicated, and malaria smears are supported and funded under this program area for those not requiring ARV treatment. All clients have direct access to HIV medical care. Community home based care will be provided in the catchment areas surrounding the 24 clinical hub sites ACTION supports. This will be implemented by a supervising community home based care nurse and health extension workers and volunteers. This activity will be linked to the primary prevention and VCT programs emphasizing the "home-based" prevention linkage to ensure that family members at risk are tested and counseled, a strategy that supports family engagement in home-based care and support. A number of models will be utilized depending upon the site preference including supplementing site staffing with dedicated home based care staff or developing an agreement with a local NGO/CBO/FBO to provide this service. Extension workers will be preferentially recruited from the PLWHA support group membership. Home based care will be provided to an average of 200 patients per site for a total of 4,800 patients served. Home based care will be linked to the patient's medical care source as the supervising community home based care nurse will work under the medical direction of the site physician. Training essential for program success will target nurses, aids, counselors and PLWHA/community volunteers will be carried out by ACTION program staff at the site level to maximize coverage. The total training target is 324. ACTION will collaborate with other IPs so that a standard training curricula is utilized and standard provider manuals are distributed. Training curricula focusing on pediatric care will be developed, and this is described under OVC activities. ACTION currently supports ARV services at 16 sites and will develop 8 additional sites under COP07 for a total of 24 full service sites. Full service sites will be affiliated with 20 additional primary health center ARV sites so that routine care of stable patients can be moved to the community level. These primary health center sites already have established referral relationships with existing ARV sites at the secondary or tertiary level and will be strengthened under COP07 to provide ARV and Care and Support services in a more accessible location. Sites are located in states chosen based upon high prevalence in the most recent 2005 antenatal HIV sero-survey and geo-political distribution. They include: Anambra, Edo, FCT, Nasarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Delta, Lagos, Sokoto, Jigawa, Plateau, Kaduna, Ogun, Osun, Imo, Katsina, Gombe, Kwara, and Akwa Ibom. CONTRIBUTIONS TO OVERALL PROGRAM AREA: This activity provides services which are a high priority for the 2:7:10 Emergency Plan strategy by providing a basic package of care for all HIV+ adults. The services are consistent with the draft Guidelines for Palliative Care in Nigeria and the USG Palliative Care Policy as well as the Nigerian Guidelines for Antiretroviral Therapy which stress home based care, symptom management, and OI prophylaxis. Capacity development at the site level and consistency with national guidelines will ensure sustainability. ACTION staff will contribute to development of a national palliative care training curriculum, identified as a priority by the FMOH. LINKS TO OTHER ACTIVITIES: This activity is linked to C&T (#6772), Condoms and Other Prevention (#9210, HIV/AIDS Treatment Services (#6766), OVC (#6771), TB/HIV (#6765), and HVLab (#6767). VCT targeting most at risk populations is established proximate to points of service. All patients are monitored and linked to ARV therapy when indicated. Care and Support services such as psychosocial support and symptom management promotes ARV adherence. Services will be integrated with prevention for positives activities including counseling and condom

availability. Services are co-located with TB DOTS centers and ACTION staff work with sites to ensure coordination systems are in place. High quality laboratory services supported by an ACTION facilitated laboratory QA program are available at sites. Home based care programs will be implemented by a number of indigenous NGOs, CBOs, FBOs. Sub-agreements will be coordinated with other Emergency Plan IPs to ensure non-overlap of funding and services. POPULATIONS BEING TARGETED: Services are offered to adults living with HIV/AIDS. Sites have been chosen to maximize linkage with national TB program DOTS sites and provide services for HIV+ pregnant women identified through PMTCT. Doctors, nurses, other health workers (public sector) as well as people living with HIV/AIDS and caregivers of PLWHAs are targeted for training. Volunteers participate in providing home based care services. KEY LEGISLATIVE ISSUES ADDRESSED: This activity also addresses the key legislative issue of "Gender" since services will be provided equitably to women and data will be collected to demonstrate this. The activity also addresses the key legislative area of "Stigma and Discrimination" as training of health care workers and community volunteers will reduce stigma. EMPHASIS AREAS: The major emphasis area for this activity is "Training" as capacity development for sustainability is a key focus. Minor emphasis areas for this activity include "Commodity Procurement" and "Logistics" as pharmaceuticals and supplies are provided to sites and secondary partners to facilitate service provision.

Reprogramming 9/07: $566,700 in reprogrammed FY07 funds advanced for COP08 technical assistance training targets, funding to be reduced accordingly from the COP08 budget submission for TB/HIV.

ACTIVITY DESCRIPTION: This activity is also linked to VCT (6772) Basic Care and Support (6770), OVC (6771) and HIV/AIDS Treatment Services ((6766) ACTION will leverage significant TB laboratory and clinical expertise and build upon ongoing collaboration with the National TB and Leprosy Training Center (NTBLTC) in Zaria to focus on strengthening the integration of high quality TB and HIV care delivery in support of the national TB control strategy. At 34 points of service directly supported by ACTION, 11,431 newly presenting HIV+ patients or existing Care and Support patients developing symptoms will be screened for TB, 30% or 4592 will be linked to TB treatment, and 2,286 or 20% will receive preventive treatment. Two ACTION laboratory and medical program officers will be dedicated full-time to these activities. In addition, ACTION will collaborate with a Gate's funded international project at Johns Hopkins University to provide technical advice and pilot the Microscopic Observed Drug Sensitivity (MODS) assay. Improving the quality of smear microscopy and TB laboratory diagnosis will remain a major focus in COP07. Centralized training for 100 laboratory scientists and staff will be conducted jointly by ACTION and the NTBLTC in proper smear microscopy methodology. These personnel will also be trained in HIV diagnosis using HIV rapid test kits and linked to trained counselors so that a co-infected patient will be appropriately counseled and diagnosed at TB clinics. Microscopes and supplies will be provided to sites. An ongoing QA program will be conducted including: joint site visits with the FMOH or relevant State MOH for observation/retraining, selective review of completed smear examinations, and proficiency testing with "unknown" slides provided by the QA team. The ACTION M&E staff will work with sites to ensure that incident TB cases are properly reported to the FMOH. ACTION will continue to focus on improving laboratory detection of TB infection by supporting a cost effective innovative laboratory diagnostic approach and TB culture capacity at a minimum of three training sites to support national TB program priorities. One method is a rapid improved immuno-florescent technology that increases the sensitivity of detecting TB bacilli in direct sputum smear microscopy several fold piloted at NTBLTC in COP06. The second approach is the conventional culture system that allows the detection of the bacilli in a culture medium in an incubator over several weeks and provides drug sensitivity testing. 200 specimens per month will be tested. The microscopic observation drug susceptibility (MODS) assay will be piloted at these sites as a more scaleable alternative. ACTION will network with Global Fund in implementing these plans to avoid duplication of services to be developed under Global Fund. Integrated clinical management of HIV/TB co-infected patients at ACTION points of service will be strengthened. FMOH DOTS site expansion will be supported through training collaboration and minor renovations at sites to ensure 100% co-location with ARV sites. 48 physicians will be trained as Master Trainers in diagnosis and proper management of co-infection. They will return to sites to carry out site level training for indirect targets of 240 health workers trained. Patient record tools have been modified to prompt for TB screening indicators and site level training of health workers will focus on utilization of a symptom history focusing on chronic cough, fever, weight loss, or night sweats to prompt referral for TB evaluation. Chest X-rays will be supported for sputum negative patients being evaluated for TB or candidates for INH prophylaxis. HIVQUAL will be utilized as a clinical quality indicator and improvement strategy at sites. These efforts will increase TB screening, with a target of 11,431 new HIV patients screened and an anticipated 30% requiring TB treatment. INH prophylaxis will be provided for HIV+ patients with active TB excluded in accordance with national guidelines. Cotrimaxozole Preventive Therapy (CPT) will be provided to eligible TB/HIV patients. Nosocomial transmission of TB to HIV+ patients will be prevented through such measures and principles as basic hygiene, proper sputum disposal, and good cross ventilation at clinics. Facility co-location of TBHIV services is preferred to clinic co-location. The national guidelines on infection control on co-located sites will be implemented in all our sites. In addition to the training collaboration with the NTBLTC, ACTION currently supports integrated TB HIV services at 16 sites and will develop 18 additional sites under COP07 for a total of 34 sites. Sites will be established at the secondary and primary health center levels with linkages to tertiary centers to provide accessibility of services to patients. Sites are located in states chosen based upon high prevalence in the most recent 2005 antenatal HIV sero-survey and geo-political distribution. They include: Anambra, Edo, FCT, Nasarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Delta, Lagos, Sokoto, Jigawa, Plateau, Kaduna, Ogun, Osun, Imo, Katsina,

Gombe, Kwara, and Akwa Ibom. CONTRIBUTIONS TO OVERALL PROGRAM AREA: Training and support to improve the quality and integration of TB HIV services are consistent with FMOH and EP priorities. The aims are an expansion of TB DOTS points of service with collocation of DOTS/ARV services, an increased number of HIV patients screened and treated for TB, and use of preventive therapy driven by best evidence. An overarching focus on technical capacity development will ensure sustainability. Smear microscopy QA will be carried out collaboratively with the FMOH and State MOH to promote sustainability through capacity development and integration into the health sector system. Prior support and collaboration with the NTBLTC has included infrastructure upgrades to create a national clinical and laboratory TB training facility, development of curricula and carrying out trainings to facilitate HIV testing at all DOTS points of service improving the quality of TB diagnosis and management among HIV+ patients, and upgrading of the NTBLTC diagnostic laboratory and clinical care facilities. COP07 activities will focus on sustainability of the national training program and this national model facility for laboratory diagnosis and clinical care with a decreasing dependence upon ACTION technical expertise and a focus on the training of a cadre of Master Trainers. LINKS TO OTHER ACTIVITIES: This activity is also linked to VCT (6772), BC&S(6770), OVC (6771) and HTXS (6766). The collaboration with the NTBLTC will also include training to ensure that VCT is available at all DOTS points of service. Linkage to TB diagnosis and treatment is an important component of all Care and Support services. Linkage to ARV services and proper management of patients requiring ARV and TB medications is a major program area focus. Zankli Hospital is a private facility which has a significant TB lab infrastructure. As a public private partnership, ACTION will provide training and collaborate in the piloting of TB diagnostic methods. POPULATIONS BEING TARGETED: ARV services are offered to HIV positive infants/children and adults living with HIV/AIDS. Doctors, nurses, and laboratory workers are targeted for training in both the public and private sectors. KEY LEGISLATIVE ISSUES ADDRESSED: This activity focuses on "Wrap Arounds - Other", as the activity relies upon non-EP funding related to TB and promotes linkage with HIV specific funded programs to ensure that comprehensive services are available to HIV/TB co-infected persons.

Reprogramming 9/07: $500,000 in reprogrammed FY07 funds advanced for COP08 technical assistance training targets, funding to be reduced accordingly from the COP08 budget submission for TB/HIV.

ACTIVITY DESCRIPTION This activity is also related to Counseling and Testing (#6772), HIV/AIDS Treatment Services (#6766), TB/HIV (#6765), and Lab (#6767) services. Focusing on ensuring that a comprehensive package of care is provided for HIV-infected children, ACTION will provide OVC services to 7,203 children at a minimum of 22 sites. ACTION will strengthen the coordination of PMTCT, ART and OVC services for seamless movement of HIV+ children across the various services. Access to free laboratory monitoring for HIV+ children not requiring ARV treatment is funded in this program area including: CD4 measurement, hematology, chemistry, and malaria smear. The basic care package which will be available to all HIV+ children receiving services includes: access to appropriate TB diagnostics and linkage with GON sponsored DOTS programs described under TB/HIV, instruction for parents/caregivers in appropriate water purification and provision of Water-Guard, provision of ITNs, provision of trimethoprim/sulfamethoxazole prophylaxis, symptom management including provision of pediatric formulations of antidiarrheals/analgesics/antipyretics. In addition, a standard formulary will be provided to sites to treat common opportunistic infections. Access to food and nutrition support is a major need for HIV+ children. ACTION will provide comprehensive nutritional support for OVCs, especially those on ART, including assessment, counseling, supplementation and multivitamins/minerals. Linkages with community NGOs and faith based organizations as well as traditional community OVC providers will be established for food and nutrition resource support. Through these linkages, access to other core OVC program services including: shelter and care, protection, psychosocial support, education/vocational training, economic opportunities/strengthening will also be provided. A tracking form will be utilized to ensure that each child has access to these key core program services. In addition, ACTION will pilot provision of Kwashi-pap and other appropriate but scaleable nutritional interventions for children as part of the basic care package. ACTION has worked in COP06 to strengthen psychosocial support for children by improving the quality of counseling available for children at points of service through conducting a training focused on counseling of children to include child development, disclosure of the diagnosis, grief and loss, and adherence to medications. Focusing on sustainability under COP07, this training will be modified as a TOT for 10 very experienced counselors selected to ensure regional distribution. Each of these Trainers will be expected to train 25 other counselors for an indirect target of 250. Community home based care for children is in need of extensive development in Nigeria. ACTION is working in COP06 with the GON, other IPs, and community resources to develop and pilot a pediatric HBC training. This will be scaled up to all points of HBC service so that 2000 children of the 7,203 total target receive pediatric specific HBC. Training of 348 health workers and community outreach workers will be conducted primarily at the site level to ensure maximum coverage in the most cost effective manner. An additional 10 will be trained in the pediatric counseling TOT described above for a total direct training target of 358. Sites are located in states chosen based upon high prevalence in the most recent 2005 antenatal HIV sero-survey and on geo-political distribution. They include: Anambra, Edo, FCT, Nasarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Delta, Lagos, Sokoto, Jigawa, Plateau, Kaduna, Ogun, Osun, Imo, Katsina, Gombe, Kwara, and Akwa Ibom. CONTRIBUTIONS TO OVERALL PROGRAM AREA This activity provides services which are a high priority for the 2:7:10 EP strategy by providing a basic package of care for all HIV+ children. The services are consistent with the draft Guidelines for Palliative Care in Nigeria as well as the Nigerian Guidelines for Antiretroviral Therapy which stress home based care, symptom management, and OI prophylaxis. Capacity development at the site level and consistency with national guidelines will ensure sustainability. ACTION staff will contribute to development of a national palliative care training curriculum ensuring inclusion of pediatric care, identified as a priority by the FMOH. LINKS TO OTHER ACTIVITIES This activity is linked to #6772 (Counseling and Testing), #6766 (HIV/AIDS Treatment Services), #6765 (TB/HIV), and #6767 (Lab). VCT services will be available to HIV affected family members in need of HIV testing. All patients are monitored and linked to ARV therapy when indicated. OVC services such as psychosocial support for families and symptom management promotes ARV adherence. Services are co-located with TB DOTS centers and ACTION staff work with sites to ensure coordination systems are in place. High quality laboratory services supported by an ACTION facilitated laboratory QA program are available at sites. Home based care programs will be implemented by a number of

indigenous NGOs, CBOs, FBOs. Sub-agreements will be coordinated with other EP IPs to ensure non-overlap of funding and services. POPULATIONS BEING TARGETED OVC services are offered to HIV positive infants and children, children orphaned from HIV, caregivers of OVCs/PLWAs and HIV/AIDS affected families. Doctors, nurses and other health workers in the public and private sector are targeted for training. Community groups including CBOs, NGOs and FBO will be targeted for training, linkages and identifying OVCs. KEY LEGISLATIVE ISSUES ADDRESSED This activity addresses the key legislative area of "Wrap Arounds" as activities will strengthen/develop linkages between HIV/AIDS services and other sectors for food resources. The activity also addresses the key legislative area of "Stigma and Discrimination" as training of health care workers and community volunteers will reduce stigma. EMPHASIS AREAS The major emphasis area for this activity is "Commodity Procurement" as laboratory reagents for monitoring of ARV patients are supported. Secondary emphasis area include "Training" and "Human Resources" as capacity development for sustainability is a key focus and considerable resources are devoted to training costs as much of our community linkages is through partners. In addition, "Community Mobilization/Participation" is an emphasis as community involvement in identification of and treatment for OVCs is essential. Likewise, "Development of Network/Linkages/Referral Systems" to ensure the referral of HIV+ persons from VCT to ARV/HIV care points of service will be an important focus

Reprogramming 9/07: $655,000 in reprogrammed FY07 funds advanced for COP08 technical assistance training targets, funding to be reduced accordingly from the COP08 budget submission for TB/HIV.

ACTIVITY DESCRIPTION This activity relates to C&OP (#9210), C&S (#6770), Treatment Services (#6766), OVC (#6771), TB (#6765) and Lab (#6767). ACTION will provide C&T services for 130,000 people. C&T centers are supported at 63 points of service (POS) which will provide ARV, Palliative Care, and/or PMTCT. Collaborating with indigenous NGOs, an additional 12 C&T only POS focusing on testing most at risk persons using a mobile strategy will be supported for a total of 75 C&T centers. A national training curriculum and the national "Heart to Heart" branding logo will be utilized and partner testing is encouraged. Counseling and IEC materials focus on abstinence, be faithful, and consistent and correct condom use (ABC). In addition, IEC materials will include information promoting "couple counseling". Unlimited condoms, supplied by other donors and provided to all IPs through Society for Family Health will be available at C&T centers at no charge. Existing site staff will be used as counselors. At high throughput centers, temporary additional staff support may be provided, but sites must agree to include funding for any new position in the next fiscal year site budget. The use of the national curriculum and branding will further promote sustainability. Using established C&T SOPs and a standardized GON endorsed training curriculum, new counselors will be trained either centrally or at the site level, and refresher courses for existing counselors will be conducted. ACTION will train 183 counselors in the provision of C&T. This includes 40 Master Trainers from TB Directly Observed Therapy (DOTS) sites in support of national priorities. (Total direct training target 225.) Each of these DOTS site C&T Master Trainers will train 4 additional counselors for an indirect target of 160 additional trained. This will ensure high quality HIV C&T services are provided to an average of 40 patients per DOTS site not included as ACTION C&T centers for an indirect target of 5000. The quality assurance strategy for counseling will include post-test client surveys and periodic refresher training. Hospital-based C&T services will ensure that services are available to all high risk individuals within the institution and the catchments area. C&T services will be available at TB DOTS and chest clinic POS and accessible to the general outpatient clinic where STI patients are seen. C&T staff will round regularly on the wards and identify inpatients in need of HIV testing with the medical staff. Each of the IHV-N referral hospital POS has a network of affiliated regional primary health centers. C&T services will be offered at these affiliated primary health centers on a regular basis so that services are more accessible. Additional strategies such as equipping home-based care teams with C&T capacity to implement "home-based" testing and prevention outreach will be evaluated to target high risk discordant couples. NGOs that service substance abuse populations in selected locales will augment targeting of this hard to reach high risk group. HIV testing will be carried out by counselors using the nationally approved non-cold chain dependent algorithm with results available immediately. The current algorithm is: Determine and StatPak (parallel) then Genie II as tiebreaker. Whenever feasible, client witnessed testing will be carried out to encourage client confidence in the result. Lab program officers will assist with training and a QA program will be in place to ensure quality. Laboratory program officers are dedicated to QA described under Laboratory Infrastructure. Test kits and disposables for testing will be warehoused by ACTION. They will be provided to sites based on a pull system using a site level inventory control system linked to the ACTION warehouse logistics management information system. The current system can be easily harmonized with the national test kit logistics management information system and inventory control system once implemented. Post test counseling includes prevention for positives counseling with active encouragement of abstinence or consistent and correct condom use. Counselors are trained to counsel clients concerning disclosure to spouse and sexual partners and encourage disclosure while exploring and addressing potential negative consequences. Also, we will seek out training opportunities for counselors on "couples counseling". Counselors at the site level provide adherence counseling in ARV clinics in addition to C&T services. This eases the referral and linkages for newly-diagnosed clients. Newly-identified HIV+ clients at free standing or community based C&T centers will be linked to a HIV care center in the network. Post test counseling for those testing negative will focus on prevention using the ABC approach, and partner testing will be encouraged. Based on risk assessment, a follow-up testing interval will be recommended. The M&E system will be primarily ledger based to maximize time devoted to service provision and facilitate services at primary health center and community mobile settings. Aggregate data will be summarized and reported to the ACTION regional M&E

program officer monthly. A referral tracking system for HIV+ clients has been developed. C&T services will be provided at 75 sites in the following states: Anambra, Edo, FCT, Nasarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Delta, Lagos, Sokoto, Jigawa, Plateau, Kaduna, Ogun, Osun, Imo, Katsina, Gombe, Kwara, and Akwa Ibom. This activity supports the national C&T scale up plan by promoting the accessibility of C&T services using an FMOH approved training curriculum and procedures. C&T services are essential to identify HIV+ people to meet national prevention goals and the national ARV/HIV care scale up goals. C&T services will target most at risk persons to maximize this impact. The activity will support the FMOH and EP goal of having high quality HIV testing available at all DOTS sites. This activity is linked to 3.3.05 (C&OP), 3.3.06 (BC&S), 3.3.11 (HTXS), 3.3.08 (OVC), 3.3.07 (TB) and 3.3.12 (Lab). Prevention for positives counseling will be integrated within post test counseling for HIV+ persons. Access to C&S services and ARV services within the network of care will be provided. Other at risk family members including vulnerable children will be identified through C&T and referred to services. A major emphasis is placed on ensuring that C&T services are provided at TB DOTS centers. In appropriate settings, testing will be carried out by staff who are not trained laboratory scientists. Where this is the case, ACTION laboratory staff will train and work with these staff to ensure that HIV testing provided within the C&T context is of high quality by incorporating C&T sites into the laboratory QA program. This activity serves children and youth and adults in the general population who will offered HIV counseling and testing. However, most at risk persons including: commercial sex workers, discordant couples, mobile populations, and partners/clients of commercial sex workers, and TB patients will be specifically targeted. Other health care workers and community volunteers will be targeted for training. This activity addresses the key legislative issue of "Stigma and Discrimination", since HIV counseling reduces stigma associated with HIV status through education. The major emphasis area for this activity is "Training" as nearly all supported personnel are technical experts who focus on this at the central and site level. In addition, considerable resources are devoted to training costs. A secondary emphasis area is "Development of Network/Linkages/Referral Systems" as ensuring the referral of HIV+ persons from C&T to ARV/HIV care POS will be an important focus.

Reprogramming 9/07: $1.3 million in FY07 funding toward COP08 targets from reprogramming to be reduced from COP08 funding levels in country prior to COP submission.

ACTIVITY DESCRIPTION: ARV drugs will be procured so that ARV treatment can be provided for 37,044 adults (13,044 new) and 3,458 children (1,328 new) at 44 clinical sites throughout Nigeria. The first component of this activity includes forecasting and procurement of ARV drugs. It is estimated that 90% of patients begun on EP-provided ARVs will be adults and the remaining 10% will be children. Overall, it is assumed that 10% of both adults and children begun on ARVs during prior years will ultimately require 2nd line treatment under COP07. ACTION will follow Nigerian ARV Guidelines in the provision of ARV regimens. The regimen mix has been forecasted based on current utilization and balancing best clinical evidence with scale-ability. PEPFAR approved generic formulations will be utilized whenever available. For all regimens, a 3 month buffer stock is maintained to minimize the likelihood of problems with drug supplies. IHV staff will develop ARV projections, while procurement and shipping of ARVs has been subcontracted to IDA Foundation (total cost procurement/shipping fees excluding drug costs $885,258). IDA inspects drugs for authenticity and tests selected batches prior to accepting for shipping. IDA certifies packaging and storage conditions during shipping and provides insurance to the point of delivery at the frontier. Drug procurement will follow USG regulation, National Treatment Guidelines, and comply with requirements for NAFDAC registration or waiver. Some sites (approximately 10 sites) may have access to high quality first line adult ARVs provided by the FMOH financed by the Global Fund. Collaborating with the FMOH at sites to leverage this alternative ARV source could increase the number of adults accessing ARV services to as high as 16,000. In this scenario, ACTION will ensure access to alternative first line and second line ARVs, pediatric formulations, and wrap around services including lab monitoring. Coordination with the FMOH to plan site targets will ensure a single comprehensive HIV care program although there may be multiple ARV sources. The second component of this activity includes expediting of commodities through the port of entry, storage, distribution, and management of commodities. This includes site assessment of pharmacies and storage facilities with corrective recommendations. Needed site renovations for proper security and storage conditions in pharmacy stores will be undertaken by ACTION. Training of site pharmacists for drug commodity management using a computer or card-based inventory control system at the site level and training in proper drug storage will be carried out. Storage and distribution of ARVs, maintenance of a site level commodities management system, and instruction in site staff regarding the system, has been subcontracted to Axios Foundation (total cost $1,600,000). Axios documents proper storage conditions at the central warehouse and site level. ACTION currently supports ARV drug provision at 16 sites and will provide ARVs at 28 additional sites under COP07 for a total of 24 full service and 20 primary health center and DOTS satellite sites. States include: Anambra, Edo, FCT, Nasarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Delta, Lagos, Sokoto, Jigawa, Plateau, Kaduna, Ogun, Osun, Imo, Katsina, Gombe, Kwara, and Akwa Ibom. As expansion of ARV drug services is prioritized to rural areas, we will strengthen existing referral channels and support network coordinating mechanisms. CONTRIBUTIONS TO OVERALL PROGRAM AREA: This activity supports the scale up of ARV treatment in Nigeria, a major priority for the FMOH.

Reprogramming 9/07: $700,000 in FY07 funding toward COP08 targets from reprogramming to be reduced from COP08 funding levels in country prior to COP submission.

ACTIVITY DESCRIPTION: This activity also relates to activities in Antiretroviral services (#6766), Counseling and Testing (#6772), Condoms and Other Prevention (#9210), Orphans and Vulnerable Children (#6771), Care & Support (#6770), TB/HIV (#6765), and Lab (#6767). ACTION will provide Antiretroviral (ARV) services including laboratory monitoring to 40,502 individuals, including 37,044 adults (13,044 new) and 3,458 children (1,328 new). ACTION will capitalize upon in-country ARV treatment expertise to ensure high quality of care. Physicians, nurses and pharmacists at the 16 existing points of service have been trained in adult and pediatric ARV care utilizing a curriculum developed jointly by IHV-N and Family Health International. Two hundred and nine staff will be trained including 20 Master Trainers. The 20 Master Trainers will each train 10 physicians for 200 indirect targets. However, bedside teaching is a fundamental component of ongoing medical education. Central to this paradigm is the Nigeria posting of IHV/UMD faculty adult and pediatric HIV care specialists. In addition, a "preceptor program" brings volunteer physicians with extensive AIDS treatment experience from other US and European institutions to be posted at sites for 1-3 months to participate in "on the job" training and establishment of the "case conference" format of instruction. Through the mentoring program site physicians will become HIV experts and ensure the long-range sustainability of the program. ACTION has developed an adherence counseling training curriculum which has been shared with other PEPFAR countries as a model curriculum. In addition, we have collaborated with Axios to develop an integrated pharmacist training curriculum focusing on both patient counseling and commodity management. These curricula will be utilized to train 48 site counselors and pharmacists. Strong PLWHA support groups are a valuable adherence support strategy. These are supported and offered IEC materials focusing on adherence and ART education by site and ACTION staff. Some sites may have access to high quality first line adult ARVs provided by the government of Nigeria (GON) financed by the Global Fund and other sources. Collaborating with the GON at sites to leverage this alternative ARV source could increase the number of adults accessing ARV services to a minimum of 16,000 new adult ARV enrollees. In this scenario, ACTION will ensure access to alternative first line and second line ARVs, pediatric formulations, and wrap around services including lab monitoring. Coordination with the FMOH to plan site targets will ensure a single comprehensive HIV care program although there may be multiple ARV sources. Collaboratively with the USG and GON, ACTION will carry out site program review visits. ACTION will develop or adapt with the USG and GON a Quality Indicator (QI) tool for use in the ARV care setting. Implementation of a site QI assessment system and support for Master Trainings will support site and network self-management for sustainability. ACTION will continue to participate in the USG coordinated Clinical Working Group to address ongoing treatment related topics and ensure harmonization with other IPs and the GON. ACTION currently supports ARV services at 16 sites and will develop 28 additional sites under COP07 for a total of 24 full service and 20 primary health center and DOTS satellite sites. Pediatric ARV care will be provided at all 24 full service sites and selected primary health center and DOTS satellite sites. Sites are located in states chosen based upon high prevalence in the most recent 2005 antenatal HIV sero-survey and geo-political distribution. They include: Anambra, Edo, FCT, Nasarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Delta, Lagos, Sokoto, Jigawa, Plateau, Kaduna, Ogun, Osun, Imo, Katsina, Gombe, Kwara, and Akwa Ibom. CONTRIBUTIONS TO OVERALL PROGRAM AREA: Harmonization of the ARV program around drug sourcing and QI, including selected primary health centers as ARV points of service, and expanding the role of nurses and health care workers will support the scale up of ARV care which is a high priority for both the PEPFAR and the GON. As expansion of ARV drug services is prioritized to rural areas and DOTS sites, we will strengthen existing referral channels and support network coordinating mechanisms. New primary health center and DOTS sites will be managed using 3 different models: 5 sites will have a physician and a laboratory assistant from nearby tertiary sites provide care on selected days; 10 will be primary health centers which are nurse managed (nurse training is described under Policy); and 5 will be mobile vans with physician/lab assistant staffing. These primary health centers affiliated with existing ARV sites will be developed so that stable ARV patients can receive their care closer to home, while being referred back up within network should a complication occur in the future. Selected primary health centers are currently providing PMTCT services in a similar network fashion and this experience

will provide relevant lessons learned. The role of nurses in Nigeria could be greatly expanded to improve the capacity at the site level to provide ARV care. ACTION has recruited a nursing faculty member with ARV treatment expertise who is resident in Nigeria. She is charged with conducting site level training of nurses focusing on improving fund of HIV knowledge, developing triage / patient assessment skills in the context of chronic HIV care, improving patient education skills and will spearhead the Nurse Training and Certification Curriculum development described under Policy. This will address a key FMOH and OGAC priority to improve access to care. Quality evaluation is another key priority. M&E data will be used to plan targeted interventions. An example is evaluation of ARV TB linkage at two sites, which demonstrated that only 30% of patients with symptoms such as chronic cough suggestive of TB were evaluated and resulted in training and modification of medical record tools. LINKS TO OTHER ACTIVITIES: This activity is linked to activities in Counseling and Testing (#6772), Condoms and Other Prevention (#9210), Orphans and Vulnerable Children (#6771), Care & Support (#6770), TB/HIV (#6765), and Lab (#6767). VCT targeting most at risk populations is established proximate to ARV points of service. All ARV patients are offered a care package including TMP-SMX, ITNs, Water Guard, malaria diagnosis and treatment, pain/symptom medications, referral and psychosocial support including linkage to on-site support groups.. Home based care programs provide linkage between medical home and the community. ARV services will be integrated with prevention for positives activities including counseling and condom availability. ARV sites are co-located with TB DOTS centers and ACTION staff work with sites to ensure coordination systems are in place. High quality laboratory services supported by an ACTION facilitated laboratory QA program are available at full service sites with manual laboratory methods or specimen transport systems to be established for primary health center satellites. POPULATIONS BEING TARGETED: ARV services are offered to HIV positive infants, children and adults living with HIV/AIDS. Sites have been chosen to maximize linkage with national TB program DOTS sites and facilitate access to HAART for pregnant women who require this for their own health care. Doctors, nurses, and pharmacists are targeted for training in both the public and private sectors. Health workers in the private sector will be targeted by offering a dedicated central ARV training for private hospitals and practices.

Reprogramming 9/07: $350,000 in FY07 funding toward COP08 targets from reprogramming to be reduced from COP08 funding levels in country prior to COP submission.

This activity also relates to activities in PMTCT (6768) OVC (6771) and HIV Treatment Services (6766). Tests for opportunistic infections and training in these techniques will strengthen Care and Support (6770), C&T (6772) and HIV/TB (6765).

ACTION will continue to support ART, Care and Support, PMTCT, and VCT programs by building a laboratory infrastructure and training personnel to accurately diagnose, stage and monitor patients. ACTION will continue to monitor PEPFAR supported laboratories through its aggressive QA/QC activities to ensure high quality of lab results; while upgrading the lab infrastructure at new sites to support PEPFAR related activities. Based upon revised guidelines for simplified laboratory monitoring and HIV rapid testing, chemistry panel, hemogram, and CD4 measurement counted as single tests each, a minimum of 658,214 laboratory tests will be performed in COP07

The proposed expansion to secondary/primary sites, an integrated tiered referral laboratory network with mentoring by trained laboratory personnel in existing tertiary sites will be established. 4 regional virology labs, staffed by two laboratory scientists each, spread over the South, Central and North Nigeria will support infant DNA diagnosis of HIV using whole blood and Dried Blood Spots (DBS) shipped from ACTION sites and other IPs), viral load for selected patients, and centralized training. With the tiered referral lab network and the need to ship blood samples and DBS to regional virology labs, ACTION will develop detailed Standard Operating Procedures (SOPs) with clear guidelines for shipment of these samples. ACTION will also expand its lab capability to diagnose additional OIs such as Cryptococcus and common STIs.

Each new point of service will receive adequate infrastructure upgrades to ensure stable electricity and water, and must adhere strictly to developed SOPs. Secondary/primary sites will have the capacity to diagnose HIV using GON approved serological algorithm, and in some cases estimate CD4 T cells using the manual method. However more automated or sophisticated analysis will be performed at neighboring full service laboratory under this integrated tiered laboratory network.

As previously, training of laboratory personnel from new sites will include a centralized training for focal laboratory personnel and key lab staff followed by a more customized on site training in lab safety, Good Laboratory Practices (GLP), HIV diagnosis, pediatric diagnosis, viral load estimation, CD4 staging of adults and infants, hematology, blood chemistry, record keeping and storage. 290 laboratory staff will be trained with an estimated cost of $800-$1000 per person for a 1 week central training. On-site refresher trainings will occur during QA/QC monitoring and will reinforce GLP and proficiency, while centralized refresher trainings will be more in-depth, and will include new technologies. The centralized refresher training sessions will also provide a forum to address challenges experienced by sites and to reinforce networking among sites. With facilitation from the CDC, ACTION has already interacted with The Association of Public Health Laboratories (APHL) for the provision of lab equipment and supplies. APHL also has the capacity to provided in-country technical assistance on lab management and quality assurance. Therefore ACTION proposes to collaborate with APHL to train master trainers in lab management who will then train others. Each regional training lab will have at least one master trainer in lab management. Additional laboratory training focused on TB diagnosis is described under TB/HIV.

To maintain high quality lab results, ACTION has an aggressive QA/QC program that involves 2 trained staff that are dedicated to on-site quarterly monitoring, retraining, proficiency testing in all lab assays. This has proved invaluable in improving the quality of results and maintaining high lab standards at sites. ACTION intends to continue with this program at old sites and expand it to new sites. Additional staff will be trained to support the expansion in sites. Developed documents and expertise will be shared with all IPs and with the Government of Nigeria at the regular Laboratory Working Group meeting coordinated by USG-Nigeria. In addition, ACTION's regional virology labs will participate in the DBS proficiency program run by CDC Atlanta.

ACTION will support a minimum total of 46 labs (9 tertiary, 14 secondary, and 23 primary) expanding by 23 labs (2 tertiary, 8 secondary and 13 primary labs). Thirty-three labs will have the capacity to perform HIV diagnosis and CD4 assessment in support of HIV care and PMTCT. ACTION will support an additional 13 laboratories, some of which will be more limited in scope of service in order to support points of service focusing on PMTCT and C&T as well. Capacity for CD4 measurement will be developed at these additional labs under COP07. Automated chemistry, and hematology capability will be located in tertiary or secondary facilities (4 of these will be regional training/reference laboratories). All labs will be supported with regular QA activities. Labs are located in the following States: Anambra, Edo, FCT, Nassarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Rivers, Delta, and Lagos.

The inclusion of laboratories and trained lab personnel from the secondary/primary health centers and an effective integrated tiered referral laboratory network and QA/QC program as described above, will allow for the provision of ART services at all tiers of health care facilities, and rapid scale up.

Training laboratories established by ACTION have been extensively utilized by the FMOH and other IPs, for capacity development to meet national ARV scale up, PMTCT, and TB priorities. An example is recent purchase of automated CD4 equipment by the FMOH. The ACTION training laboratory provided and will continue to provide centralized training for laboratory staff from non-EP supported ARV sites in the proper use of this equipment and serve as a resource for other IP and GON sponsored training. An anticipated 300 indirect targets are anticipated. ACTION will focus on capacity development for sustainability under COP07, training a minimum of 30 Master Trainers who will each train 5 other laboratory scientists for an indirect target of 150.

With the establishment of high quality regional virology laboratories, infant diagnosis of HIV will be more proficient thereby strengthening 6768 (PMTCT), 6771 (OVC) and 6766 (HIV Treatment Services). Tests for opportunistic infections and training in these techniques will strengthen 6770 (Care and Support).

Regional training and Virology laboratories established by ACTION will continue to support other IPs in training, pediatric diagnosis; viral load and rapid scale up, augmenting their ability to implement and scale up PMTCT and HIV Treatment. ACTION will train laboratory personnel and healthcare providers from TB labs of other IPs and the FMOH DOT centers, strengthening both C&T (6772) and HIV/TB (6765). Under ACTION's Public Private Partnership, industrial health care providers and private clinics will benefit from ACTION's training and QA/QC program.

These activities will provide essential laboratory services to people living with HIV/AIDS, HIV positive pregnant women, HIV positive infants, and HIV positive children. Laboratory workers from both the public and private sectors will benefit from the Lab Training centers and developed SOPs and training curriculum.

ACTIVITY DESCRIPTION This activity relates to PMTCT (#6768), Blood Safety (#6769), Condoms and Other Prevention (#9210), Adult Basic Care and Support (#6770), TB-HIV (#6765), OVC (#6771), ARV Services (#6766), and Laboratory Infrastructure (#6767). ACTION will strengthen Strategic Information (SI) under the "One M&E framework" by supporting standardized HIV care and ART program reporting system and Health Management Information System (HMIS)/Patient Management Monitoring (PMM) at existing sites, establishing SI support in new sites, supporting a network/linkage/referral system, providing 73 local organizations Technical Assistance (TA) on SI activities, and training 300 individuals in Monitoring and Evaluation (M&E), surveillance, and HMIS. For ART sites where there is other donor support, data collection and indicator reporting will be harmonized and one reporting system will be used in accordance with the national guidelines and indicators. Emergency Plan (EP) funding will be used to train health care providers and medical data personnel on data collection, data use and reporting. It also will be used to provide Information Technology (IT) infrastructure and CAREWare at each ART site. Effective use of paper-based and electronic data will be promoted in clinical, laboratory, pharmacy settings to enhance the enrollment, follow-up, assessment, and referral/linkages to other services (e.g. TB, STI, home-based care, etc.) for all clients in HIV care. Evaluations using data collected through facility-based services and community-based services will be performed to provide evidence-based decisions for program quality, impact, and effectiveness. Continuous quality improvement (QI) (e.g. HIVQUAL) will be implemented in coordination with USG. This will provide readily available quality metrics and individual patient data to site staff which will enhance site staff investment in the M&E process. Additionally, our SI team will continue to be active participants on the SI working group established and coordinated by USG-Nigeria. Building site staff capacity to monitor key metrics in an ongoing way is an important strategy for promoting sustainability. Additional means of developing site-based tools to promote accurate laboratory data reporting to support patient care and treatment is vital to QI and where possible clinical data to support patient care at the site such as through CAREWare will be emphasized. National PMTCT data tools will be used at all PMTCT service delivery points. Since 2000, with support from CDC, ACTION assisted the Federal Ministry of Health (FMOH) in developing and implementing the National PMTCT Monitoring Information System (PMTCT MIS) in Nigeria. ACTION will continue to technically support the FMOH as needed in software maintenance of the national system and continue to work with FMOH on a mechanism to align the PMTCT MIS and PMM systems effectively to improve follow-up and continued care for HIV-infected women and their exposed infants. Standard VCT data collection tools will be used at all VCT service delivery points to enhance identification of positive clients and sero-discordant couples/partners and timely referral to treatment, prevention, and care. Site level M&E staff are hired through the hospital or health center personnel system. While sites are asked to provide for M&E staffing, temporary staffing support is available to new sites, who must agree at program initiation to list these staff in the budget request for the institution for the next fiscal year. Dedicated M&E program staff are posted at ACTION regional offices to focus on site level quality control/quality assurance. SI will be provided to the Nigerian National AIDS surveillance and information system as well as state and local governments. ACTION is engaged in providing TA to the State ACTION Committees on AIDS (SACAs) and State Ministries of Health (SMOH) in the implementation of the Nigerian National M&E System (NNRIMS). Each ACTION state level point of service has a representative to the SACA. State level data for the NNRIMS is reported by the SACA to the National Agency for the Control of AIDS on AIDS (NACA). There are 44 ART sites total (28 new sites in COP07), 73 VCT sites (49 new), 63 PMTCT sites (31 new). Sites are located in: Anambra, Edo, FCT, Nasarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Delta, Lagos, Sokoto, Jigawa, Plateau, Kaduna, Ogun, Osun, Imo, Katsina, Gombe, Kwara, and Akwa Ibom.

CONTRIBUTIONS TO OVERALL PROGRAM AREA Strengthening SI will enable timely, transparent, and quality data reporting of substantial portions of 2007 EP targets for Nigeria and will concurrently through collaboration with the Government of Nigeria (GON) establish one standardized system to monitor the National HIV care and ART program. Planned targeted evaluations (TEs) will guide decisions in improving program implementation and scale-up and will be defined and coordinated with the USG team in-country. Of interest is evaluating barriers to care and access to care for HIV positives identified and referred through VCT. ACTION will work to promote effective use of patient data by care providers to ensure best practices of HIV care. These activities will contribute to improved use of information strategically at all levels. This activity also contributes to

Nigeria's 5-Year National Strategic Framework's (2005-2009) emphases on documenting best practices on ART, VCT, PMTCT, OVC, etc., on information linkages between sites and services, on one standardized reporting framework, and on program evaluations through increased involvement of local evaluation officers. LINKS TO OTHER ACTIVITIES SI activities are cross-cutting and relate to 3.3.01 (PMTCT), 3.3.03 (blood safety), 3.3.05 (condoms and other prevention), 3.3.06 (adult basic care and support), 3.3.07 (TB-HIV), 3.3.08 (OVC), 3.3.11 (ARV services), and 3.3.12 (laboratory infrastructure). Linkages between these program activities/areas will be strengthened to improve efficiency and effectiveness of services in order to catalyze the formation of networks of care. POPULATIONS BEING TARGETED This activity targets health care providers in best practices of information use and reporting. Provision of TA targets host country government workers. HMIS and program evaluations target general population and people affected by HIV/AIDS receiving services supported by the ACTION Project. KEY LEGISLATIVE ISSUES ADDRESSED This activity will look at gender equity trends within service sites by collecting data to show breakdown of women and men receiving prevention activities, treatment, and care services and by analyzing VCT client data to assess service uptake among couples/partners. EMPHASIS AREAS This activity includes major emphasis on Monitoring, Evaluation or Reporting. Secondary areas of emphasis include: HMIS, IT Communication Infrastructure, TE, and Local Organization Capacity Development.

ACTIVITY DESCRIPTION:

This activity relates to activities in ARV Services, Basic Care and Support, OVC, HCT, PMTCT and Other Prevention. ACTION will support the efforts of the Nigerian Government FMOH in strengthening the skills of nurses for National response to the HIV/AIDS epidemic in the country in line with the Health Sector National Strategic Framework for HIV/AIDS (NSF). This is in consideration of the fact that nurses constitute the highest number of health care workers in Nigeria and spend the highest amount of manpower hours with patients but there has not been a very specific program to address the weak skills that exist country wide. If adequately trained and empowered to utilize learned skills, nurses could render more appropriate care for PLWHAs and contribute meaningfully to mitigating impact of HIV/AIDS as well as to sustaining the efforts conducted under the Emergency Plan. As the number of patients accessing ART services continues to increase without exponential increase in the number of doctors, especially in primary and secondary sites, doctors are overworked and patient access to care is still not optimal. With proper training, nurses will be better utilized to address the personnel challenges being faced by ART sites. This activity is aimed at establishing a HIV care nurse fellowship training program to address the weaknesses that exist in the skill levels of nursing professionals in Nigeria.

ACTION will develop a South - South collaboration with another African Country with similar experiences e.g. Zimbabwe, Zambia, South Africa or Uganda and utilize lessons learned to develop a standardized but comprehensive nursing curriculum and provider manuals. This will be done in collaboration with the USG team, FMOH, Nursing and Midwifery Council of Nigeria and other stakeholders. ACTION will implement in collaboration with other IPs a training program for nurses in practice using this curriculum with a focus on specific skills sets and knowledge needs as identified through the experiences of the IPs in the field. This will incorporate the GON adopted IMAI/IMCI approach to HIV/AIDS care with emphasis on such skills as: aseptic technique; injection safety; universal precautions; nursing triage; nursing assessment and follow up of stable patients with prescription re-authorization; monitoring for adverse effects and treatment efficacy; adherence/general counseling; linkages with community care and other services; palliative care and treatment of minor ailments including OIs like thrush, malaria, diarrhea etc. using standing orders developed and approved by supervising physicians. In addition, their skills will be enhanced to provide counseling for prevention, HCT, disclosure/partner notification & other support services thereby creating sustainability since these nurses will continue to work at the sites. Because these skills are transferable, their ability to manage and care for patients with other disease conditions will be enhanced.

Three TOTs which wiill include didactic, practicum and test taking sessions will be conducted to develop a cadre of 45 trainers who will then carry out training for as many nurses as funding will allow nationwide. Each Master Trainer will train 10 nurses thereby indirectly supporting 450 nurses. Both trainers and trainees will be certified and earn continuing education credits which the Nursing and Midwifery Council will be encouraged to consider as a requirement for license renewal (to instigate a culture of professional development for Nigerian nurses). Management structure and logistics for the training program will be through USG funding to LMS.

ACTION currently supports ARV services at 16 sites and will develop 8 additional sites under COP07 for a total of 24 full service sites. Full service sites will be affiliated with 20 additional primary health center ARV sites so that routine care of stable patients can be moved to the community level. These primary health center sites already have established referral relationships with existing ARV sites at the secondary or tertiary level and will be strengthened under COP07 to provide ARV in a more accessible location. Most of these sites are staffed by Nurses. ACTION anticipates that at least 10 out of these 20 primary health centers will be developed as "nurse managed" ART sites with oversight from the affiliated hubs. These are ideal settings where this training could be piloted. Sites are located in states chosen based upon high prevalence in the most recent 2005 antenatal HIV sero-survey and geo-political distribution. They include: Anambra, Edo, FCT, Nasarawa, Kogi, Niger, Kano, Cross Rivers, Bauchi, Benue, Delta, Lagos, Sokoto, Jigawa, Plateau, Kaduna, Ogun, Osun, Imo, Katsina, Gombe, Kwara, and Akwa Ibom.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

Curriculum development will lead to Capacity development at the site level and will be consistent with national guidelines to ensure sustainability. ACTION staff will ensure that there is a step down training with trainees from various hospitals using the Training Centers in Benin, Kano , Jos and Abuja. The GON and other IPs will also utilize the curriculum and other trainers developed to further step down the trainings across the country.

LINKS TO OTHER ACTIVITIES: C&T, ART Services, Basic C&S, VCT, PMTCT, OVC and Other Prevention

KEY LEGISLATIVE ISSUES ADDRESSED: This activity addresses the key legislative issue of "Twinning" as a South to South partnership with another African country will be utilized to develop the curriculum.

EMPHASIS AREAS: The major emphasis area for this activity is "Training" as capacity development for sustainability is a key focus. Minor emphasis areas include "developing a training curriculum and modules" and provision of additional "training resources" for trainers and trainees for step down training in hospitals. An additional emphasis area is "Human Resources" as manpower shortfalls to address HIV care needs will be addressed.