This activity is linked to counseling and testing (HCT), condoms and other prevention, OVC and adult basic

care and support (BCS). In COP 08, Africare will begin PMTCT services with the establishment of two

PMTCT sites in Lagos state. Services will be provided to 1500 pregnant women who will be counseled and

tested and will receive their results at the two proposed sites. Following National guidelines HAART eligible

pregnant women will be referred to a nearby treatment center while those who are not HAART eligible will

receive Zidovudine or Combivir prophylaxis at 28 and 34/36weeks, respectively. All HIV exposed infants at

birth will receive single dose Nevirapine (sd-NVP) and a 6-week course of AZT which will be dispensed at

labor and delivery. Infant diagnosis and follow-up services will be optimized through integration in existing

child welfare and immunization clinics, with linkages to the Massey Street Children's Hospital program in

Lagos.

Africare currently provides facility and community based HCT, BCS and TB/HIV services at 16 sites in

Rivers and Lagos states, 7 of which provide HCT services to pregnant women. Specifically, at General

Hospital Shomolu in Lagos with over 120 new ANC bookings a month and positivity rate of 3.7%, 50% of

the HCT clients are pregnant women and 40% of all positives at this site are from the ANC. In COP08

services will be expanded to provide OVC, SI and sexual prevention support as well as PMTCT. 1500

pregnant women will receive testing and counseling services and will receive their results via PMTCT at the

two sites which will also have comprehensive care and support services for families. These sites are a

primary and a secondary health center which are also linked into a care network with a treatment facility

where HAART eligible pregnant women will be referred.

The funding to begin PMTCT services is expected to significantly improve the quality of services that clients

are currently receiving by ensuring onsite PMTCT service delivery, integration of this with Africare's existing

BCS, HCT, family planning, OVC services, and maternal and OVC support group activities, providing a

holistic family-centered continuum of care for these clients. In addition, further capacity building of the staff

at the site will ensure integration of much needed comprehensive HIV care for mothers and their babies into

existing health care services.

Programming during this inception year will emphasize provider initiated opt-out testing with group health

information, individual post test counseling with provision of same day results at ANC, labor and post

partum wards. Whole blood samples for women who test positive will be collected and sent for same day

CD4 count and Hb to ensure HAART eligible mothers are immediately identified and actively referred into

nearby treatment programs. Sd-NVP will be given on first contact to all positive clients to take home with

instructions for use.

In addition, testing of partners and children of the index client, TB screening of HIV infected pregnant

women with referral for treatment where needed, ARV prophylaxis for HIV infected women and newborns,

maternal nutrition and infant feeding counseling and infant follow-up will be supported. National PMTCT and

HIV and infant feeding guidelines will be followed in counseling mothers on infant feeding options and

AFASS criteria for replacement feeding will be emphasized. Infant follow-up will be optimized through the co

-location and co-scheduling of mothers support group activities with infant follow-up clinics,

immunization/post natal clinic days, and provision of maternal basic care and support services at all times

on site. Mother support groups will be formed to facilitate support from more experienced "Champion"

mothers to newer mothers around appropriate options for delivery, infant feeding, maternal nutritional

counseling and support, and disclosure support, and will serve to reduce the effects of stigmatization. These

champion mothers will receive training and onsite supervision. Mothers would also be strongly discouraged

from engaging in mixed feeding. These activities will be linked actively into the existing OVC program and

young kids clubs to optimize sustainable infant follow-up. Co-trimoxazole prophylaxis will be provided onsite

as part of the OVC basic care and support continuum from age 6 weeks until final HIV status is known, and

for all HIV infected children.

The program will support identification of fathers for participation in PMTCT through the support of couples

counseling, increasing male involvement through the use of "love invitation letters", and formation of male

support groups integrated into existing community support groups. Women and their partners will receive

educational materials brochures, pamphlets, and other materials during ANC visits in accordance with the

existing National PMTCT IEC tools. In partnership with Gospel Communications, movies focusing on

PMTCT will be aired during the visits. They will also focus on promoting early identification of HIV and early

initiation of ARVs for HIV-infected pregnant women and their newborns.

Africare will build capacity at the facilities to provide and strengthen integrated PMTCT and family planning

services linked with onsite BCS and OVC services. Lab staff will be trained to perform manual CD4+ counts

at the secondary health care facility, and 30 health care workers will be trained using the National PMTCT

curriculum to provide the full complement of PMTCT services. 20 of these health care workers will also be

trained on HIV and infant feeding, making medical injections safer and early infant diagnosis. Additionally,

counselors and nurses will be trained on family planning counseling, maternal nutrition, and early infant

diagnosis. Champion Mother counselors will be trained on an ongoing basis to provide mother support

group leadership. Health facility staff will be trained on the use of CD4, and determining HAART eligibility for

pregnant women depending on the CD4 count will be strengthened.

Direct supervision of the PMTCT program at inception would be provided by the Africare Project Director

alongside the HIV advisor currently on staff. A PMTCT advisor will subsequently be hired for the project.

He/She will provide support and supervision for the facility based staff, youth corpers (NYSC), project

monitoring team, patient care teams, and referral networks.

Project staff will provide onsite mentorship and supervision of staff to ensure quality of PMTCT care. The

project will provide training and onsite mentorship of counselors to increase skills in couples counseling and

integration of partners into PMTCT-related decision making. Nigerian National PMTCT manuals, guidelines,

SOPs, registers and job aids will be provided throughout the facilities and will be available for referral and

use in the ANC, labor wards and post natal clinics.

Particular emphasis will be laid on data collection and reporting. Staff capacity to work with data collection,

compilation and evaluation will be strengthened through training and follow-up at all points of service

delivery, with regular hands-on onsite mentoring and supportive supervision on capturing National PMTCT

indicators, completion of registers and proper data entry using the National PMTCT MIS tool. Staff will be

taught to interpret and integrate data from all the onsite HCT, OVC, Palliative care and PMTCT services,

Activity Narrative: ensuring smooth referrals into other onsite programs. Staff will be further trained to use data to improve

quality of care and to highlight areas for improvement.

A patient management team and a project monitoring team will be established at each facility. The project

team will consist of leadership from all units of the hospital who will provide support for the entire hospital-

wide project including the administrative support and supervision of the other program areas. The patient

management team will consist of direct patient care providers to focus on clinical issues as they arise in the

PMTCT clinic and to provide continuing medical education. Strong referral networks will be established,

aimed at strengthening linkages between the PMTCT services and other care services within the facility,

between separate facilities and with the communities they serve. The referral network coordinators will meet

monthly with management and clinical staff responsible for the ANC and PMTCT clinics, support group

leadership, referral treatment clinics, local and international NGOs, and other donor projects. It is envisaged

that these networks will also encourage rapid testing for syphilis and, if possible, gonorrhea, along with

single dose, directly observed treatment as appropriate.

Partnering with the NYSC, Africare will support the training of 2 additional youth corps members in each

facility (a physician to provide support for the PMTCT clinics and a public health specialist to focus on

developing and strengthening the linkages between program components) to work alongside the facility

based staff. Africare will also partner with two already identified Traditional Birth Attendants (TBAs) in the

communities where HCT outreach is already taking place and whose pregnant HIV positive patients will be

referred to the primary or secondary health facilities for delivery.

Mothers will receive delivery kits to further encourage them to deliver in the facilities. Each kit will contain

gloves, sanitary pads, cotton wool, cord clamp, delivery mat, gentian violet, methylated spirit and clean

surgical blades. Defaulter mothers who do not return for subsequent visits will be followed-up by the TBAs

in the communities working with the mother support groups and referral network coordinators. The facilities

will also be supported with delivery kits consisting of gloves, aprons, bleach, disinfectant, cotton wool,

pinard stethoscopes and tape rules.

ACTIVITY DESCRIPTION:

Africare will be a new partner in the program area of Abstinence/Be Faithful (AB) in COP08. Africare will

implement its AB programming activities in line with the overall PEPFAR Nigeria goal of providing a

comprehensive package of prevention services to individuals reached (thereby improving the effectiveness

of this messaging) through a balanced portfolio of prevention activities including condoms and other

prevention. Through the involvement of Africare as a new partner in this activity, PEPFAR Nigeria will

further its development of an integrated comprehensive prevention portfolio. Africare's goal for its new

activities in the AB program is to contribute to a reduction in HIV prevalence among youths, particularly in

the most at risk age group of 15-24 year olds, and to promote mutual fidelity among married adults. The

2005 ANC survey in Nigeria indicates that among age cohorts in Nigeria, the 20-29 year old age group has

the highest HIV prevalence (4.9% compared to a national prevalence of 4.4%). In addition, the 2005

National HIV/AIDS and Reproductive Health Survey (NARHS) demonstrated a low risk perception (28%)

among the general population and significant reports of transactional sex (11%) among young women aged

15-29 years. This age cohort for both men and women represents the working age group in Nigeria; it is

expected that a combination of prevention messaging approaches will ensure they are effectively reached

with prevention interventions.

In COP08 as a new program activity Africare will implement Abstinence/Be Faithful programming coupled

with condoms and other prevention program services (funded under C&OP) where appropriate. Priority

populations to be targeted by AFRICARE will be Police, Incarcerated persons, transport workers, oil

industry workers and in and out of school youths. These target groups will be reached with a minimum of

three strategies derived from the recommended minimum package inclusive of community awareness

campaigns, peer education models, and school based activities. Prevention activities will be provided

throughout Africare's PEPFAR program utilizing linkages to all AFRICARE's facility based, community

based, and home based activities. The goal of the program is to be focused on the communities targeted

and to saturate those communities with messages conveyed in multiple forums. The targets counted will be

those individuals that will have received AB messaging: (1) on a regular basis and (2) via the three

strategies Africare will employ. The target for this intensive AB messaging campaign is 1,000 individuals. In

addition, age appropriate abstinence only messaging and secondary abstinence messaging will be

conveyed to 500 children and adolescents, particularly focused on in-school youths and orphans and

vulnerable children receiving home based support. An estimated 1,000 individuals will be reached with AB

prevention activities and 500 individuals will be reached with abstinence only messaging in the first year in

25 sites (13 facility-based sites, 4 stand alone HCT sites, 4 workplaces, and 4 schools) plus outreach into

the surrounding communities. A total of 30 people will be trained, including but not limited to teachers,

religious leaders, students, and peer educators.

A complete prevention package of materials utilizing both AB and COP programming will be distributed at

all HCT sites and at all points of service in health care facilities where Africare is working. This will include

AB IEC materials and condoms. Africare will target communities where these registered clients live for

community and school based AB messaging in order to continue to reinforce messages provided in the

facility setting. As a component of the community based programming and school based programming AB

messaging will be integrated into sports activities. Activities highlighting role models and drama

presentations will be organized for in and out of school youth. The peer education model will be used to

organize formal peer groups that will then actively develop AB messaging campaigns for their peers.

Examples are the formation of school clubs and Motor Park HIV/AIDS Committees.

Africare will work with the USG PEPFAR team in developing an appropriate methodology for measuring

achievements in AB programming. Africare will have a project officer dedicated to oversight and guidance to

prevention activities under AB and COP programs.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

The funding in this activity area will contribute to the overall PEPFAR goals of preventing further infections

and reducing HIV rates in Nigeria. It will also help to lay the foundation for more sustainable programs.

LINKS TO OTHER ACTIVITIES:

This activity will be integrated with Counseling and Testing (6642.08), Basic Care and Support (6493.08),

Other Prevention (15667.08), TB/HIV (9879.08), OVC (15666.08) and Strategic Information (15668.08).

POPULATIONS BEING TARGETED:

The focus population for this activity will be youth (in/out of school youths), TB DOTS patients, the police,

incarcerated persons, oil workers, and transport workers. It will also target community/religious leaders,

teachers and parents.

EMPHASIS AREAS:

Project activities will increase gender equity in young adults. Stigma and discrimination of PLWHA is also

high in project areas. Activities will support mobilization and information messaging targeted at reducing

stigma and discrimination in project communities of PLWHA.

ACTIVITY NARRATIVE:

In COP08 Africare will provide community outreach to individuals identified as high risk for HIV and direct

them to counseling and testing while promoting prevention through activities other than abstinence and be

faithful messages. This activity will focus on condom use promotion in most at risk populations and referral

to Africare supported and/or other local HCT sites. Condoms and other prevention activities will be provided

in 23 sites (13 facility-based sites, 4 stand alone HCT sites, 4 workplaces, and 2 brothels). The activities will

target 4,286 most at risk persons (MARPs) which include clients/patients at health care facilities, TB

patients, PLWHA, incarcerated populations, youth, police, transport workers, oil workers, and commercial

sex workers in Rivers and Lagos states.

Africare will implement its condom and other prevention (COP) programming activities in line with the

overall PEPFAR Nigeria goal of providing a comprehensive package of prevention services to individuals

reached (thereby improving the effectiveness of this messaging) through a balanced portfolio of prevention

activities which will also include abstinence and be faithful activities. In COP08 Africare will implement this

activity at both the facility and community levels utilizing a combination of multiple strategies in this

implementation. Strategies to be employed in this program include community outreaches, peer education

models, and workplace programming drawn for the recommended minimum package. Each target counted

will be those individuals reached on a regular basis and via at least three strategies that Africare will

employ.

Community outreach will target most at risk individuals with the purpose of preventing geographical spread.

Trained health care workers, counselors and peer educators will be encouraged to provide education on

condom use and to distribute condoms to infected individuals. For HIV negative individuals, trained health

care workers, counselors and peer educators will provide education on HIV/AIDS transmission, risks, and

risk reduction strategies including condom use. Prevention with positives will be included in care services

and will involve activities such as HCT for family members and sex partners, counseling for discordant

couples, counseling on healthy lifestyles and positive living, prevention messages and IEC materials on

disclosure.

The first year of funding will include an inventory and review of condom and other prevention activities that

are currently being implemented in the communities where Africare is working, providing Africare with the

knowledge of current gaps to address and available strengths for linkages. These activities will include

condom distribution, education on condom use, and referral/provision of STI diagnosis and treatment

through syndromic management. As a component of the community outreach strategy, Africare will support

drama presentations and conduct road shows on a regular basis in the targeted communities. This strategy

will be closely linked to the peer education model strategy as community groups will be organized (ex.,

Motor Park HIV/AIDS Committee) and will help guide the development of community events. Peer

educators will also work one-on-one with community members to provide education on condom use and to

distribute condoms. In the prison community where Africare is working, it will raise the sensitive issue of

sexual activity in the prison setting with prison authorities and discuss possible avenues of addressing this.

Africare's condoms and other prevention workplace strategy will focus on oil workers and brothel-based

commercial sex workers. In these populations Africare will introduce a prevention education program which

encourages 100% condom use. Free condoms will be given to brothels, and sex workers will be advised to

insist on condom use with each client. Using peer education approach, Africare will select peer facilitators

from each brothel and train them to provide HIV prevention messages to their peers on a daily basis. The

key messages will include correct and consistent condom use in all sex acts, prompt and complete

treatment of STIs and testing for HIV. Advocacy with brothel owners will be to support the women in

enforcing a 100% condom use policy in their establishments. Workplace strategies focused on oil workers

will also include training of peer educators to promote condom use. In addition, Africare will work with oil

company management to identify strategic centralized mechanisms to reach their employees with COP

messaging and condom distribution. Oil workers will be reached not only through their workplace activities

but also through the brothel based activities as this population utilizes brothels.

Africare will train 100 peer educators, community group members, health care workers, counselors and

volunteers in appropriate provision of condom and other prevention services. Peer educators and

community group members will be trained on the use of advocacy tool kits that provide IEC materials,

condoms and job aids. They will also be taught participatory monitoring and evaluation to enable them to

monitor their progress against project objectives. Health care workers, counselors and home based care

volunteers will be trained on condom use and syndromic STI diagnosis and treatment.

Condoms will be procured from Society for Family Health (SFH) for all Africare sites. The provision of

condoms will be accompanied by individual and/or group counseling and demonstrations on their proper

use. Information Education Communication materials tailored to address the unique risks that individuals

from high risk groups face and the correct and consistent use of condoms will also be provided through the

community groups, peer groups, and in all Africare-supported health care sites.

CONTRIBUTION TO OVERALL PROGRAM AREA:

Africare's activities in condoms and other prevention are in line with the PEPFAR vision of enhancing

indigenous capacity to provide integrated HIV/AIDS services from the community to the national level, and

in this process to strengthen the health care system and local development partners.

These prevention activities are consistent with PEPFAR's five year goals for Nigeria, which plan to prevent

1,145,545 new infections through a number of prevention strategies including (but not limited to) condoms

and other prevention to specific high risk groups.

In order to be maximally effective, the prevention messages developed at different sites will be tightly

targeted to the various high risk groups that they serve. Furthermore, these activities are in line with the

PEPFAR 5 year strategy which seeks to scale up prevention services, build capacity for long term

prevention programs and target outreach to promote correct and consistent use of condoms with MARPs to

reduce the risk of HIV infection for these populations with the purpose of preventing geographical spread.

The continuation of Africare-supported services in HCT, care and support, and TB/HIV as well as STI

management will help facilitate the scale up of the overall program and increase utilization of these

Activity Narrative: services.

LINKS TO OTHER ACTIVITIES:

This activity relates to Counseling and Testing (#6642.08), Orphans and Vulnerable Children (15666.08),

Basic Care and Support (#6493.08), AB (#15680.08), TB/HIV (#9879.08), and Strategic Information

(#15668.08). Prevention for positives counseling to include condom use will be an important component of

posttest counseling in the STI clinics and in follow up care and support activities. This service will also

complement HCT services for those who ultimately test HIV negative. Through this program as well as

basic care and support, Africare will ensure access to STI treatment.

POPULATIONS BEING TARGETED:

The focus population for this activity will be out of school youths, HCT clients, TB DOTS patients, oil

workers, commercial sex workers, and transport workers. It will also target community leaders, brothel

owners and oil company management.

KEY LEGISLATIVE ISSUES ADDRESSED:

Project activities will increase gender equity in women, particularly commercial sex workers. Stigma and

discrimination of PLWHA is also high in project areas. Activities will support mobilization and information

messaging targeted at reducing stigma and discrimination in project communities of PLWHA.

EMPHASIS AREAS:

This activity includes an emphasis on human capacity development and local organization capacity building.

ACTIVITY DESCRIPTION:

In COP 08, Africare will continue care and support services which commenced in COP05 in two states,

Lagos and Rivers, and were provided through 15 service outlets in COP07. In COP08 Africare will increase

its provision of care and support activities to 21 sites (4 community based sites, and 17 facility based sites)

and will expand into Bayelsa state. TB/HIV services will be available onsite at 12 of the 17 health facilities.

Through community outreach care activities, services are also provided at identified primary health facilities

with the support of volunteer health workers. Community interventions will further be strengthened and

home based nursing care services will be provided by Africare in partnership with at least 5 CBOs and

FBOs (Rhema Care Partners, Lazarus Care Mission International, Initiative for African Youth Development,

Daughters of Charity and Society for Women and AIDS in Africa, Nigeria) that specialize in community

health services. Using National Palliative Care Guidelines and guidance from the USG technical working

group Africare will provide quality care services to 2,390 PLWHA and to 4,780 PABAs for a total of 7,170

clients receiving care services.

Care and support services will be offered to ensure that 20% effort is laboratory (CD4 counts, hematology,

chemistry), 30% is OI management with prophylaxis/treatment, and 50% is Home Based Care (HBC).

Africare will use its partnerships with 5 organizations (FBOs/CBOs) to link PLWHA identified through

community mobilization and HCT with psychosocial services, basic clinical follow-up and HBC. Africare will

provide at least one clinical service (laboratory, OI prophylaxis & management, HBC, nutritional

assessment/therapy) and at least two other services in the psychosocial, spiritual or preventive domains to

all PLWHA depending on their needs. Africare's care and support services in COP08 will include: basic

nursing care; assessment of signs and symptoms including pain; pain care medications like paracetamol;

nutritional assessment; adherence counseling; prevention for positives; facilitating support groups;

bereavement services; depression assessment; spiritual counseling with social support (transportation,

communication and referrals); and patient training and education in self-care. All PLWHAs are provided with

cotrimoxazole upon initial HIV diagnosis and maintained on it pending the initial CD4 count result. Each

PLWHA will receive a preventive care package of water guard, water vessel, ITN, multivitamins, soap,

condoms, and prevention IEC materials. IEC materials will be reproduced in local languages on ABC

messaging and basic infection control. Activities on prevention with positives include HCT of family

members and sex partners, counseling for discordant couples, prevention messages on disclosure, and

prevention education on abstinence/be faithful and condoms as appropriate. Africare will also support

integration of syndromic management of STIs and risk reduction interventions into care for HIV-infected

clients. All enrolled into care will receive risk assessment and behavioral counseling to achieve risk

reduction. Patient education to promote positive living, self-care, and support adherence will be provided.

Support group activities also include training on proper nutrition with food demonstrations and education on

economic empowerment activities.

The home based care providers will work with care givers of PLWHA and will be assigned or linked to a

team of medical staff in the hospitals that report to the team's physician. The project will also work with

community groups and members, with the full involvement of PLWHA to form or join existing support

groups. PLWHAs are visited by home based care volunteers on at least a monthly basis. Those that are

identified as needing additional medical assistance receive either immediate referral to a medical facility or

follow-up visits by a home based care medical provider. Home based care volunteers will have Home

Based Care kits containing items such as ORS, water guard, bleach, cotton wool, gloves, soap, calamine

lotion, vaseline, and genitian violet for use when visiting clients. HBC kits outfitted for health care workers

will also contain additional items such as aprons, bandages, analgesics, antidiarrheals, and antimalarials.

Referral for advanced laboratory diagnostics and clinical management is made to USG or GON supported

facilities. With the integration of TB/HIV program activities into HCT activities, HIV+ clients will be screened

and referred for TB diagnosis and/or treatment.

Through the partnerships Africare develops with CBOs/FBOs a full complement of trained counselors,

nurses, and PLWHA support group members will be mobilized. USG/GON palliative care and HBC curricula

will be adapted to train 34 volunteers, HBC workers and health care workers. The capacity of mobile

counselors will be built to do symptomatic screening for STIs, TB and other OIs in homes and make

referrals for advanced management of TB and OIs. The capacity building of health care providers will

ensure continuity and spill over beyond Africare catchment areas and project close out. Africare will adapt

USG developed data tools to track activities and follow up patients at project sites. SOPs and providers'

manuals will be given to all service providers to ensure quality service delivery.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

Africare's care and support component will contribute to the PEPFAR care and support overall goal of

mitigating the impact of HIV on 1,750,000 individuals infected and affected by HIV and AIDS through

compassionate care of 2,150 PLWHA and 3,000 PABAs. This activity will also contribute to the

sustainability of the program through capacity building of 5 partner institutions and 30 health care providers

and promoting community involvement. Fifteen service outlets will be targeted for provision of HIV related

palliative care services. The integrated approach will encourage increased use of HCT services by ensuring

that clients who test HIV+ receive necessary care. Likewise, TB diagnosis/treatment of TB co-infected

PLWHA in collaboration with NTBLCP will create the opportunity for receiving timely diagnosis for TB and

proper treatment of OIs. The outreach program will ensure that care services reach underserved

communities for linkages and referrals in particular in the Delta region of the country. The networks and

linkages established with CBOs/FBOs, state and local authorities will ensure the continuum of care in the

communities.

LINKS TO OTHER ACTIVITIES:

Africare's Palliative Care activity is related to Counseling and Testing (6642.08) as the entry point to care

and support, as well as AB (15680.08), condoms and other prevention (15667.08), OVC (15666.08), SI

(15668.08) and TB/HIV (9879.08). All served HIV+ clients needing advanced care will be referred to USG

supported, GON and private ART sites. Clients will also have access to Africare's TB/HIV program and

prevention activities. Households with HIV positive children, orphaned children, and/or vulnerable children

will be linked to Africare's OVC program. Networks and linkages are established with CBOs/FBOs, state

and local authorities through this program. It will avail PLWHAs a complete package from the point of

testing through treatment and between the project sites/health facilities to their homes.

POPULATIONS BEING TARGETED:

Activity Narrative: Africare's care and support activities will target PLWHA and their families, volunteers, care givers, and

health care providers along with policy makers at the local and state government levels.

COVERAGE AREAS:

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. These states

include Rivers and Lagos states.

EMPHASIS AREAS:

Emphasis areas include in-service training that contributes to human capacity development. Emphasis

areas also include: commodity procurement, community mobilization, development of

networks/linkages/referral systems, training and quality assurance. Project activities will also increase

gender equity in programming through HIV care and support targeting adults, especially women of child

bearing age and men who do not routinely present to health care facilities. Stigma and discrimination of

PLWHA is also high in project areas. Activities will support mobilization and palliative care programs

targeted at reducing stigma and discrimination in project communities and encourage care and support of

PLWHA.

ACTIVITY DESCRIPTION:

In COP07 Africare supported eight TB/HIV sites in two states (Lagos and Rivers) in collaboration with the

National TB and Leprosy Control Program (NTBLCP). In COP08, activities will be expanded to include four

additional TB DOTS sites for a total of 10 supported sites. Africare will continue to offer TB/HIV services in

Lagos and Rivers states, and will expand to Bayelsa state. Through its care and support and OVC

programs, Africare will provide HIV related palliative care to 7,170 adults and 2,000 children, including

PABAs. It is estimated that approximately 850 HIV+ clients attending HIV palliative care services will receive

treatment for TB disease. The HCT program will be integrated into the TB/HIV program; that is, clients for

TB diagnosis will be referred for HIV testing and vice-versa. The project will provide HCT to 5,000 people

presenting to TB DOTS sites, of which it is expected that 500 will ultimately be diagnosed with TB. Through

Africare's HCT program newly diagnosed HIV positive clients will be identified. It is expected that 3,000 will

receive TB screening. The focus of the program is on ensuring adequate and prompt linkage of TB patients

and their household contacts to HIV counseling, testing, care and treatment services, to ensure that all HIV

patients are screened for TB, and to enable all HIV-infected patients with TB to access services at DOTS

clinics.

In COP07, the project procured necessary laboratory equipment such as microscopes and chambers for

sputum smear preparations and trained DOTS staff. In COP08, Africare will employ the same procedures

for bringing on the four additional TB DOTS sites. Africare will upgrade facilities through infrastructure

support such as basic renovations, upgrading equipment and procuring supplies and consumables (e.g.

sputum containers) as needed. NTBLCP will ensure that drugs and reagents are made available at the

sites; Africare will work with sites to identify the etiology of TB drug stock-outs if and when this should occur.

This will facilitate improvements to the TB drug logistics system at the local, regional, and national level.

Mobile clinics at the motor parks and other public places will target MARPs such as truck drivers, mobile

populations, incarcerated populations, commercial sex workers, and oil workers for HCT and subsequent

TB screening in HIV positives. The project will work with Primary Health Centers, which will serve as

Outreach Point of Service (OPS) Centers where clinic days will be used for HCT as well as TB screening

and referrals made for laboratory diagnosis. TB clients with HIV will be linked to the project's care and

support services which include clinical and laboratory diagnosis, home based care, and psychosocial and

spiritual support. Clients that are due for HIV treatment will be referred to ART sites in the network. The

project will use IEC materials, health workers, volunteers, care givers and peer educators to educate

beneficiaries on basic TB infection control such as basic hygiene, ventilation, and drug adherence. The TB

DOTS sites will be supported to provide holistic patient care according to National and IMAI guidelines.

At the health facility and community levels, infection control education will be emphasized. Nosocomial

transmission of TB will be mitigated through attention to principles of TB infection control, including

administrative and environmental control measures such as clinic design, good ventilation, appropriate

patient triage, staff training, and enforcement of basic hygiene and proper sputum disposal. Patient and staff

education on infection control measures will be routinely carried out to ensure program success.

Africare will train its staff and health care providers within the health facilities, who will in turn train mobile

counselors and volunteers using an approved national training curriculum. A total of 48 care providers will

be trained and educated to screen for TB among HIV+ clients. Training of medical staff from Africare and

facilities will include x-ray diagnostic skills; and training laboratory staff will include good sputum specimen

collection and laboratory AFB sputum smear diagnosis to enhance diagnostic capabilities. Good laboratory

practices ensured through the implementation of the national guidelines for External Quality Assessment.

With the use of updated data tools, Africare's M&E staff will track activities at project sites. Africare will build

the capacity of health care providers and CBOs/FBOs to ensure sustainability after the project close out. All

providers will be given manuals/SOPs adapted from existing national guidelines to assist them in service

provision. Sites will also be assisted to put in place and/or improve defaulter tracking mechanisms.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

Africare's TB/HIV program in Lagos and Rivers states will build the capacity of the health facilities on

TB/HIV management. The integration of TB diagnosis into the HCT services will afford HIV+ clients the

chance of knowing their TB status early. Conversely, increased availability of diagnostic counseling and

testing services in medical settings will assist to identify the number of clients with TB/HIV who are potential

candidates for HIV treatment and care services. The TB treatment program by NTBLCP will strengthen the

project's palliative care program. Training of mobile counselors and volunteers on screening for TB will

assist early diagnosis of TB. The outreach programs will also ensure that services reach the underserved in

the communities. This activity will also contribute to the national plan of early diagnosis of TB/HIV and

referral/linkages to care.

LINKS TO OTHER ACTIVITIES:

Africare's TB/HIV program is also related to Basic Care and Support (6493.08), Counseling and Testing

(6642.08), Other Prevention (15667.08), AB (15680.08), OVC (15666.08), and Strategic Information

(15668.08). TB patients that are HIV+ will be counseled on prevention for positives messaging while those

that are HIV- will be given prevention messages as well. The project will ensure that clients for TB diagnosis

are referred for HCT and those that are HIV+ enroll in the project's care and support program. The home

based care program for clients will provide basic care kits, prophylaxis for minor ailments, spiritual

counseling and other support. Clients will also be referred to ART sites for treatment. The HVTB program

will assist in strengthening the capacity and practices in health facilities to screen, diagnose and treat HIV-

infected patients for TB which is an essential component of quality care in HIV programs. The networks and

linkages established with CBOs/FBOs, state and local authorities will close gaps in the provision of services

to the communities. This will help reduce new infections.

POPULATIONS BEING TARGETED:

The HVTB activities target specifically HIV+ clients and those that may be at risk of infection such as their

family members. Activities will target young people, adults, pregnant women, truck drivers/mobile

populations and other most at risk populations. Project activity will test for TB among care givers and family

members of TB/HIV patients and will provide them with information on TB case management. Medical staff

in the health facilities and volunteers from partner organizations would be trained on TB management

especially among PLWHA. Similar training will also be made available to the support groups, local groups

and care givers of PLWHA in project communities.

Activity Narrative:

EMPHASIS AREAS:

Activity's emphasis will be on training of project staff, health workers, volunteers, CBOs/FBOs, other

partners and care givers on TB/HIV management and caring for people with TB/HIV. Other emphasis areas

include renovation, SI and local capacity development.

Africare's TB-HIV program will help increase gender equity in programming by ensuring that equitable

number of men and women participate in program activities. Stigma and discrimination of PLWHA is high in

project communities leading to problems of disclosure by those infected, either to partners or family

members. Activities will support programs targeted at reducing stigma and discrimination in the project

communities, which will encourage care and support for PLWHA. Activities will use strategies that address

other social norms of women's and men's behavior in the communities that increase their vulnerability to

impact of HIV and TB. Such strategies include the involvement of men as peer educators, counselors and

support group members.

ACTIVITY DESCRIPTION:

In COP08 Africare will expand its portfolio to include OVC activities - providing preventive care packages to

HIV infected children, to families with an HIV infected parent/caregiver and/or to orphans due to HIV/AIDS.

Africare will provide the full spectrum of OVC services to 2,000 OVC clients, including HIV+ children,

children orphaned by HIV, and caregivers. These services will be provided at 15 project sites in Lagos and

Rivers States. Africare will ensure the success of the program through hiring an OVC program specialist in

COP08. In its OVC programming, Africare will focus on providing health services, nutrition, psychosocial

support, and education to OVCs that it serves.

The activities which will be available through Africare's OVC program include health care related services.

OVCs will have access to appropriate TB diagnostics and linkage with DOTS programs described under

TB/HIV, instruction for parents/caregivers in appropriate water purification and provision of water guard,

provision of insecticide treated bed nets (ITNs). Referrals to USG or GoN supported facilities will be made

for the diagnosis and management of common opportunistic infections, the provision of cotrimoxazole

prophylaxis, and symptom management including provision of pediatric formulations of

antidiarrheals/analgesics/ antipyretics/ antimalarials.

Preventive care packages will be procured from Society for Family Health (SFH) for distribution to identified

OVCs. Prevention messaging will be provided at a level appropriate for children and caregivers.

Access to food and nutrition support will also be provided to OVCs. Africare will conduct nutritional

assessments, provide counseling, provide education/training including food demonstration on appropriate

food choices, and provide multivitamins/minerals. In COP08 Africare will also explore linkages to CBOs and

FBOs as well as traditional community OVC providers for ongoing food and nutrition resource support. In

addition, Africare will refer malnourished children for therapeutic feeding programs where available. In

partnership with the USG, Africare will network with other PEPFAR IPs and through the USG with Clinton

Foundation on the possibility of developing a community therapeutic care program for nutrition services in

the communities it serves.

In COP08, direct educational support for children will also be provided. This will include: school fees, school

uniforms, books, shoes, and/or incidental fees. Africare, through its prevention program, will also conduct

school based peer education and peer education plus programs. OVCs in the targeted schools will receive

age appropriate prevention messaging and education through interactive programming such as drama clubs

and sports.

Psychosocial support including disclosure management, grief and loss, stigma and discrimination issues,

etc. will be provided to all identified OVC. In COP08 Africare will include in its training program topics

specific to the care and treatment of OVCs. This will include training on psychosocial support for children

focused on counseling of children to include child development, disclosure of the diagnosis, grief and loss,

and adherence to medications. Other training activities will address opportunistic infections, including early

suspicion of TB, nutritional assessment, and appropriate prevention messaging for children. 30

community/home based care providers will be targeted for training, who will in turn step down the training to

the caregivers that they will serve.

Through referrals to CBOs and FBOs Africare will assist OVCs in obtaining access to other core OVC

program services such as shelter and care, protection, vocational training, and economic

opportunities/strengthening. A tracking form that is based on the Child Status Index will be utilized to

monitor each child's needs and service provision.

COVERAGE AREA:

The states where activities will be include Lagos and Rivers states

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

This activity provides services which are a high priority for the 2-7-10 EP strategy by providing a range of

services for all identified HIV+ children, families with an HIV infected parent/caregiver or children orphaned

by HIV/AIDS. The services are consistent with the National Plan of Action for OVC in Nigeria and Standard

Operational Guideline for OVC services. Capacity development at the site level and consistency with

national guidelines will ensure sustainability. Africare staff will contribute to the development of a National

OVC training curriculum, identified as a priority by the FMOH.

LINKS TO OTHER ACTIVITIES:

This activity is linked to Counseling and Testing (6642.08), TB/HIV (9879.08), AB (15680.08), COP

(15667.08), Care and Support (6493.08) and Strategic Information (15668.08). HCT services will be

available to OVC in HIV affected families. All HIV positive children are monitored and referred for ARV

therapy when indicated. Where services are co-located with TB DOTS centers Africare staff will work with

sites to ensure coordinated systems are in place. Data reporting services supported by Africare will be

available at all sites. Home based care programs will be implemented by a number of indigenous CBOs and

FBOs under the guidance of Africare.

POPULATIONS BEING TARGETED:

OVC services are offered to HIV positive children, children orphaned from HIV, caregivers of OVC/PLWAs

and HIV/AIDS affected families. Health care workers in the public and private sector are targeted for

training. Community groups including CBOs and FBOs will be targeted for training as well.

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 and educational services. 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 human capacity development for sustainability. Minor emphasis

will be on commodities and procurement.

ACTIVITY DESCRIPTION:

In COP07, Africare provided HCT services at 15 service outlets (4 stand alone sites, 11 facility integrated

sites) in 2 states (Lagos and Rivers). The facility-based testing is fully integrated whereby HCT points of

service are available in the general outpatient departments, the inpatient wards, and the ANC settings. For

testing done at ANC points of service, Africare provides referrals for pregnant women testing HIV positive to

PMTCT programs. The 4 stand alone sites are at motor parks where long distance truck drivers congregate

and are in close proximity to brothels and markets. In addition, Africare provides outreach HCT services at a

prison, in markets and in other motor parks. In COP08 HCT services will be continued at these 15 service

outlets and 4 additional outlets will be added for a total of 19. Africare will continue to offer HCT services in

Lagos and Rivers states and will expand to Bayelsa state. HCT will also be occurring in TB DOTS sites

under the TB/HIV program area; refer to this narrative for details. In COP08 Africare will provide HCT and

give results to 18,500 clients.

The project uses the provider initiated and opt-out models for maximum uptake of HCT services at the

healthcare facilities. Africare's community and mobile HCT programming targets most at risk populations

(MARPs) such as long distance truck drivers, commercial sex workers, oil workers, incarcerated persons,

and in and out of school youth. Africare partners with community based organizations (CBOs) and faith

based organizations (FBOs) to carry out community HCT activities utilizing volunteers from these

organizations. Africare's HCT program is closely linked with its prevention services, including prevention for

positives which encourages HCT for family members and sex partners; healthy lifestyles and positive living;

and provides prevention messages and IEC materials on disclosure. The program encourages (through

mobilization and advocacy) couples counseling and testing, particularly for discordant couples. In addition,

the activities promote disclosure to partners and family members. Other prevention services provided in the

HCT setting in COP08 will include STI syndromic management and treatment. Clients that test HIV positive

will be referred to the project's care and support program; those subsequently identified as needing

treatment will be referred to USG/GON supported sites providing ART services. All individuals presenting to

HCT sites, even those who ultimately opt-out or decline results, will be reached with balanced ABC

messaging and offered condoms.

HIV testing will be carried out using the National Testing Algorithm. An ongoing QA program, which consists

of quarterly proficiency testing and blinded rechecking, will be continued during COP08. Africare will work

with the USG laboratory technical working group to maintain an effective QA program. Client satisfaction

questionnaires are utilized to evaluate counseling provided.

Thirty-five health care providers, laboratorians, counselors and volunteers will be trained to provide HCT

services to clients at facilities and within the community, using a national training curriculum. These groups

will also be trained to screen for signs and symptoms of TB and other OIs in order to appropriately make

referrals for laboratory diagnosis. Additional training will be in STI syndromic management and treatment.

There will be refresher trainings for previously trained counselors on updated national guidelines on HCT.

All trained HCT providers will receive SOPs as reference materials. The capacity building of health workers,

CBOs, FBOs and volunteers, will ensure sustainability after the project close out.

Test kits will be procured using the Supply Chain Management System. Test kits and other consumables

will be stored centrally by Africare's Country Office in Abuja and distributed to the sites based on projected

needs with proper LMIS and inventory management by designated staff. Condoms will be sourced from

Society for Family Health for provision along with HCT activities. BCC/IEC materials appropriate for its

clientele are adapted and reproduced by the project. Africare's M&E staff will track activities at project sites.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

Africare's HCT program, through its advocacy and mobilization activities, is expected to increase the

number of people accessing HIV testing services. Increased availability of diagnostic counseling and testing

services at health facilities plus in the communities will assist in identifying the number of clients with HIV

infection who are potential candidates for treatment and palliative care services. HCT activities targeting

pregnant women at outpatient departments, primary health care centers and antenatal clinics will contribute

to other activities such as the PMTCT program. The networks and linkages established with CBOs/FBOs,

state and local health facilities will close existing gaps in the provision of services to the communities. The

referrals for treatment will help link clients to treatment programs provided by PEPFAR, GON and other

agencies. Africare will build the capacity of partner FBOs/CBOs on program management to ensure

sustainability.

LINKS TO OTHER ACTIVITIES:

Africare's HCT program is related to AB (15680.08), condom & other prevention (15667.08), OVC

(15666.08), basic care & support (6493.08), TB/HIV (9879.08) and Strategic Information (15668.08)

programs. The HCT program will strengthen the HIV prevention and palliative care programs in the states

and improve utilization of Africare's and/or other USG supported care and treatment services in these

states. All clients are linked to HIV prevention services with ABC and other prevention as appropriate.

Those that are HIV+ or have TB/HIV will also be referred to the project's care services. Clients identified at

the antenatal clinics will be referred to PMTCT programs.

POPULATIONS BEING TARGETED:

Africare's HCT activities are targeting MARPS (including truck drivers, mobile populations, commercial sex

workers, oil workers, incarcerated persons, in and out-of-school youth), couples, and PLWHA family

members. Project activities will make counseling and testing available to the care givers and family

members of PLWHA. Training on HIV programs will be made available to medical staff, community groups

and other relevant organizations.

EMPHASIS AREAS:

Africare's HCT activities' will be focusing on building networks/linkages/referral systems. In addition,

Africare will focus on training, human resources, quality assurance/supportive supervision, logistics,

commodity procurement and infrastructure. Networks will be formed with government agencies, NGOs, and

other groups for support in mobilization activities to generate clients for HIV testing. Staff of health facilities

and volunteers of partner organizations will be trained to conduct quality counseling and testing. Africare

staff along with partners will carry out quality assurance in project sites and provide supervision.

Activity Narrative: The project activities will also increase gender equity in programming through HIV counseling and testing

targeting adults, especially women of child bearing age and men who do not routinely present to health care

facilities. Stigma and discrimination of PLWHA is also high in project areas. Activities will support

mobilization and palliative care programs targeted at reducing stigma and discrimination in project

communities and encourage care and support of PLWHA.

ACTIVITY DESCRIPTION

In COP08 Africare will begin activities under the Strategic Information (SI) program area. Africare will be

supporting the SI activities that will occur for a total of 36 entities (17 facility-based sites, 4 stand alone HCT

sites, 10 community sites, 5 NGOs) in 3 states (Bayelsa, Lagos and Rivers). Africare staff and the staff of

the NGOs that partner with Africare for activities at a variety of these sites will be involved in these site-level

SI activities. Africare will strengthen SI under the "One M&E Framework" by supporting standardized HIV

indicator reporting systems at program sites and registering sites in the national M&E system. Data

collection and indicator reporting will be harmonized and one reporting system will be used in accordance

with the national guidelines and indicators. Africare will work with USG and GON to include Africare-

supported facilities in the National Public Health data system launched in 2007 (Voxiva platform) where

applicable. Africare will be an active participant on the USG SI working group supporting PEPFAR in

Nigeria.

Funding will be used to provide information technology (IT) infrastructure for data aggregation and reporting.

Effective use of paper-based and electronic data systems will be promoted in clinical settings to enhance

the enrollment, follow-up, assessment, and referral/linkages to other Africare-supported services (e.g., TB,

STI, home-based care, HCT, etc.) and to services outside of Africare's programs (e.g., ART services) for all

Africare clients.

Africare's data quality assurance program will involve several components. Each state team (Rivers and

Lagos) will have an M&E focal person who will report back to the M&E staff in the central office in Abuja.

The state-based staff will also work with sites to ensure that they are reporting appropriately to state level

data collection authorities as part of the national system. National registers and data collection tools will be

used at all service delivery points. Africare will ensure that copies of registers are available and in use at

sites and will provide supportive supervision to site staff to ensure they are being used correctly. State-

based Africare staff will conduct regular monitoring and supervisory visits to all sites. They will liaise with

state level M&E authorities regarding site level reporting and monitoring; state M&E officers will be invited to

participate in monitoring activities in order to build relationships and capacity within the states. During

routine monitoring visits data collection tools will be reviewed for completeness and accuracy and on-site

technical assistance will be provided. Randomly selected individual patient records will be reviewed across

tools as one method of assessing accuracy. For sites identified as having problems with data reporting

requirements, SI staff will involve the site in developing a corrective plan that may include follow-up through

additional visits, mentoring and more regular communication/reporting via other routes (phone, email).

Africare SI staff will liaise with the USG SI staff as they develop and implement their DQA activities to

ensure completeness and harmonization with PEPFAR and GON reporting requirements.

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. Africare will

also work with on-site administrators and staff to improve their knowledge and understanding of the data

from their sites so that they will be involved in decision-making, thus promoting sustainability of the

program.

Building site staff capacity to monitor key metrics in an ongoing way is an important strategy for promoting

sustainability. Emergency Plan (EP) funding will be used to train 60 Africare M&E staff, CBOs, FBOs, health

care workers, counselors, and facility-based data focal persons on data collection, data use and reporting.

Facility based data focal persons are hired through the hospital or health center personnel system to

promote sustainability. Training to 60 home based care providers, peer educators, and community groups

will be done by CBOs and FBOs through step down training. A total of 120 persons will be trained in data

collection and monitoring and evaluation activities appropriate to their level of service provision.

CONTRIBUTIONS TO OVERALL PROGRAM AREA

Strengthening SI will enable timely, transparent, and quality data reporting of 2008 EP targets for Nigeria.

Concurrently, through collaboration with the GON, Africare will work to establish one standardized system to

monitor the National HIV program. Targeted evaluations that could guide decisions in improving program

implementation and scale-up and will be discussed, defined and coordinated with the USG team in-country.

Africare will work to promote effective use of patient data by care providers to ensure best practices in HIV

prevention and care.

LINKS TO OTHER ACTIVITIES

SI activities are cross-cutting and relate to condoms and other prevention (15667.08), abstinence and be

faithful messaging (15680.08), adult basic care and support (6493.08), TB/HIV (9879.08), OVC (15666.08),

and counseling and testing (6642.08). 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, counselors, facility-based data focal persons home based care

providers, peer educators, and community groups in best practices of information use and reporting. HMIS

and program evaluations target the general population and people affected by HIV/AIDS receiving services

supported by the Africare.

EMPHASIS AREAS

This activity emphasizes human capacity development and SI.