ACTIVITY DESCRIPTION:

In COP07, APIN supported PMTCT services at 32 sites. COP08 funding will support a comprehensive

PMTCT program in line with the revised National PMTCT Guidelines (2007), at 36 service outlets in 9 states

(Benue, Borno, Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). "Opt-out" counseling and testing

(HCT) with same day test results will be provided to all pregnant women presenting for ANC including labor

and delivery. The current level of PMTCT opt-out testing and counseling uptake from women presenting for

ANC or delivery is 90%. All women are provided posttest counseling services on prevention of HIV infection

including the risks of MTCT. They are encouraged to bring partners and family members for HCT. The

program has a target of providing HCT with 70,000 receiving results. A full course of ARV PMTCT

prophylaxis will be provided to approximately 5,475 women. All ART ineligible women will be enrolled into

long term palliative care following the completion of ART prophylaxis. Palliative care services include onsite

enrollment or referrals for family planning services. In addition, for all women, PMTCT services are

integrated into a system of OB/GYN services designed to promote maternal and child health. 2,190 ART-

eligible HIV-infected women will be provided with ART treatment for their own disease following the National

PMTCT Guidelines (2005). As a result, APIN+ will provide basic care and ART prophylaxis to 5,475 HIV-

exposed infants. Children who remain uninfected following the completion of ART prophylaxis will be

provided with care services under OVC activities. Infant follow-up care linked with PMTCT activities

includes Early Infant Diagnosis (EID), nutritional support, growth monitoring, cotrimoxizole prophylaxis and

other preventative care services.

ART sites will provide downward referrals to secondary and primary sites for continuity of care. Counseling

on infant feeding options begins in the antenatal period following the National PMTCT and Infant Feeding

guidelines. Infant feeding counseling will be performed in an unbiased manner and women will be supported

in their choice of method. Clients will also be counseled on the beneficial effect of couple/partner

HCT/disclosure on adherence to infant feeding choice. A follow-up team consisting of counselors and a

support group of PLWHAs will assist in home and community tracking of positive mothers to provide

nutritional support and ascertain infant diagnosis. Infants at all sites are diagnosed and monitored for ART

eligibility by HIV DNA PCR and CD4 testing respectively, which are performed at tertiary care sites. APIN

will actively participate in the National Early Infant Diagnosis Initiative and scale-up by providing DNA PCR

testing of dried blood spots (DBS) at APIN supported laboratories. The source of DBS samples will include

APIN and non-APIN supported PMTCT sites. Through implementation of the 2007 National PMTCT

Guidelines, APIN+ aims to reduce MTCT substantially from the current 10-12% rate. This funding will

support the ANC, labs, ARV prophylaxis intervention to mothers and babies (not HAART), and personnel

involved in PMTCT.

In addition to program monitoring through electronic data capture, during COP08 APIN+ will develop and

implement a QA/QC program. The program will utilize electronic data captured through the SI activities to

measure the quality of services provided and associated patient outcomes.

A regular training program will be established at all sites to train and retrain health personnel (430) involved

in the PMTCT program in the National PMTCT curriculum. Indirect targets include training Traditional Birth

Attendants (TBAs) (using an adapted curriculum) in local areas near sites in PMTCT counseling, training

PMTCT counselors in the National PMTCT program, providing technical assistance for the development of

the National Infant Feeding counseling manual, and providing a zonal training of trainers with this manual.

This training supports PMTCT efforts at all National PMTCT centers; APIN proposes that all pregnant

women tested and receiving results at National PMTCT sites are indirect targets.

APIN will partner with other IPs in the implementation of the PEPFAR-Nigeria LGA coverage strategy in the

program areas of PMTCT and TB/HIV, designed to ensure the provision of PMTCT and TB/HIV services in

at least one health facility in every local government area (LGA) of 6 identified states. Per patient costs

reflect the expansion to at least 8 new sites and scale up as a part of this LGA coverage strategy in Plateau

and Lagos states. Under the coverage strategy, these facilities are all linked with primary health facilities

which provide HCT and referrals for PMTCT services for HIV infected mothers. Harvard will leverage

UNICEF support in capacity building/training in identifying new PMTCT sites in its scale up plans.

CONTRIBUTIONS TO OVERALL PROGRAM AREA

Through the PMTCT program, APIN will provide HCT with test results to 70,000 pregnant women.

Additionally, treatment and prophylaxis will be provided to 5,475 pregnant women. Implementation of the

National PMTCT Guidelines in 36 sites (old and new) contributes to the PEPFAR goal of expanding ART

and PMTCT services. Site numbers have increased by adding secondary and primary level sites in the

radius of APIN+ tertiary care institutions which will continue to build the network capacity and coverage in of

target states. Counseling will encourage mothers to bring their partners and family members for testing, to

reach discordant couples and expand the reach of HCT, based on the PEPFAR 5-year strategy. This

program is implemented in geographically networked sites to optimize training efforts and provide

collaborative clinic/lab services as needed. APIN+ will train and retrain 430 health care personnel from the

PMTCT sites, including doctors, nurses, and counselors. Training will build capacity at local sites to

implement PMTCT programs and provide essential treatment support to pregnant women with HIV/AIDS.

Capacity building efforts are aimed at future expansions of PMTCT programs. Quality assurance and

control will be carried out through personnel training, data collection from sites for monitoring and evaluation

and supervisory visits from key program management staff, which may include representatives from the

USG and GON.

LINKS TO OTHER ACTIVITIES

This activity is also linked to counseling and testing (5424.08), OVC (5415.08), ARV Services (6715.08), AB

(15652.08), condoms/other prevention (9216.08), blood safety (6489.08), injection safety (6818.08) and SI

(#3.3.13). Pregnant women who present for HCT services will be provided with information about the

PMTCT program and referred to the PMTCT program if they are eligible for these services. ART treatment

services for infants and mothers will be provided through ART Services. Basic pediatric care and support,

including TB care, is provided for all infants and children through our OVC activities. All exposed infants

identified through PMTCT services will be linked to these OVC services. Pregnant women are at high risk

for requiring blood transfusion. Personnel involved in patient care will be trained in universal precautions as

a part of injection safety activities. Additionally, these activities are linked to SI, which provides support for

monitoring and evaluation of the PMTCT activities and QA/QC initiatives.

Activity Narrative: POPULATIONS BEING TARGETED

In addition to providing PMTCT services for HIV infected pregnant women and girls on HAART for testing

and prophylaxis, this program also targets women who may not know their HIV status and may be at

greater risk for MTCT. Furthermore, it seeks to target infants, who are most at risk of becoming infected

from an HIV positive mother during the antepartum, intrapartum and postpartum periods. Through the

counseling and testing components, APIN seeks to target a broader group of adults by encouraging women

to bring their partners and family members in for HCT. Furthermore, training activities will train public and

private health care workers on the implementation of PMTCT protocols and HIV related laboratory testing.

KEY LEGISLATIVE ISSUES

The program will increase gender equity by specifically targeting pregnant women, girls and their male

partners for HCT and PMTCT prophylaxis. Data collection on PMTCT regimens provides a basis for

developing strategies to ensure that all pregnant women have access to needed and optimally effective

PMTCT services. This program addresses stigma and male norms and behaviors through the

encouragement of partner notification and bringing other family members in for HCT. Infant feeding

counseling, including on the appropriate use of exclusive breastfeeding or BMS where AFASS is available,

will be in line with the National PMTCT Guidelines. Referrals to Income Generating Activities (IGAs) will also

be provided to women as a part of palliative care and counseling activities.

EMPHASIS AREAS

This activity will place major emphasis on the development of networks through expansion into more local

areas through a network of secondary or primary PMTCT clinics with rural outreach to community

healthcare workers involved in home delivery, which are linked to tertiary health care facilities. In addition,

major emphasis will be placed on building organizational capacity in order to work towards sustainability of

PMTCT centers and further expansion of the Nigeria PMTCT program. These system strengthening

activities are led by local investigators at current PMTCT sites who participate in new site assessments,

overseeing QA/QC, capacity development and training for new PMTCT centers. Minor emphasis is placed

on performing targeted evaluations of PMTCT interventions, to estimate the rate of transmission with each

of the ART treatment and prophylaxis courses.

ACTIVITY NARRATIVE:

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

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(funded under that area). Through the involvement of APIN+ as a new partner in this activity

PEPFAR Nigeria will extend its reach with AB services as APIN+ will be active in 8 states (Benue, Borno,

Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe) by the end of COP08. Through its other program areas APIN+

has a large population of HIV+ adults, adolescents and children to which it is already providing services; this

group forms part of the core target population for AB messaging that is provided by APIN+ through its

prevention with positives activities funded under care. In addition, APIN+ will target activities to HIV negative

persons in its catchment areas in order to minimize their risk behaviors and contribute to an overall

reduction in HIV prevalence. A key age group for AB activities is youth/young adults aged 15-24 years as

this encompasses the highest prevalence age group. 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 reached with prevention interventions.

In COP08 APIN+ will implement this activity at both the facility and community levels to reach its target

group with a minimum of three interventions. APIN will ensure that each beneficiary is reached through

community awareness campaign, peer education models and peer education plus activities within the year.

Activities conducted at the local level by APIN+ will be reinforced through national level mass media

campaigns by other USG partners such as the successful Zip-Up campaign. APIN+ will target the general

population within catchment areas of current care and treatment services. AB messages promoting

abstinence, mutual fidelity and addressing issues of concurrent and multiple sexual partnerships will be

balanced with concurrent condoms and other prevention messaging where appropriate and will be

integrated with treatment and care services in current and proposed expansion sites totaling 40 sites (facility

based comprehensive care sites, PMTCT sites, and HCT sites with their surrounding communities) in 9

states. Targets to be counted will be those individuals that were reached on a regular basis with the three

strategies APIN+ will employ .The target for this intensive AB messaging campaign is 6,400 individuals. In

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

conveyed to 3,200 children and adolescents, particularly focused on those orphans and vulnerable children

receiving both facility and home based support. A total of 380 health care providers, counselors, and peer

educators will be trained to conduct effective prevention interventions inclusive of AB messaging.

APIN+ collaborates with a community based organization (CBO) and with PLWHA support groups at its

facilities and surrounding communities in other PEPFAR programming activities. These support groups and

this CBO will also serve as appropriate partners in the dissemination of ABC messaging to other PLWHA

utilizing the peer education model, and to wider audiences through the peer education plus model and

community awareness campaigns. To address stigma issues and in compliance with the GIPA principle,

approximately 10 PLWHA from the pool of those receiving treatment at facilities who are living openly and

positively will be trained using the peer education model on dissemination of ABC messaging. They will

serve as peer educators to extended family members and members of their support groups. These trained

PLWHA will in turn reach individual cohorts of at least 10 other persons from among their social peers. With

36 treatment facilities (including PMTCT sites), this will serve as an effective tool for reaching individuals in

at least as many communities with balanced ABC messages.

A community awareness strategy will also be employed to serve the catchment areas of the hospital

facilities which will be linked with community mobilization efforts promoting HCT. During static and mobile

HCT services, counselors will be disseminating balanced ABC messages to recipient communities and

clients through focused group discussions and interpersonal communication. With an HCT target of 78,500

clients getting counseled, tested and receiving their results, a minimum of this many clients will receive

balanced ABC messaging through this approach. The key messages that will be conveyed are delay in

sexual debut, secondary abstinence, mutual fidelity, prompt and complete treatment of all STIs and

promotion of need to ascertain HIV serostatus through HCT.

APIN+ will also implement the peer education model targeting job peers who are healthcare workers.

Healthcare workers at each site will be trained (the exact number will vary based on facility size) using

established National peer education curricula and each will be requested to form peer groups of

approximately 10 members from the healthcare worker community for dissemination of balanced ABC

messaging. It is anticipated that these healthcare workers will continually serve as conduits for age

appropriate prevention messaging not only for their work peers but also for their social peers and for all

clients with whom they come in contact.

A focus of the program in COP08 will be improvement of the integration of prevention activities into the HIV

care and treatment settings; specifically, healthcare providers and lay counselors in care and treatment

settings will be trained to appropriately deliver integrated ABC prevention messages and incorporate the

messages into routine clinic visits using IEC materials and job aids. An appropriate balance of abstinence,

be faithful, and correct/consistent condom use education will be tailored to the needs and social situation of

each individual client in its presentation. In addition to the integration of such services into the HIV-specific

treatment setting, prevention activities will be assimilated into other points of service in each health facility

(general outpatient clinics, emergency services, etc.), particularly into reproductive health services

including, family planning counseling, sexually transmitted infection management and counseling, and risk-

reduction counseling.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

APIN+ AB activities emphasize integration of prevention activities with treatment and care services. Use of

the community awareness campaigns, the peer educator model, and peer education plus activities

(community drama, dance events, etc.) allows dissemination of AB messaging, including integration with

condom messaging, from society-attributed sources of credible information - healthcare workers and

Activity Narrative: PLWHA. This program will contribute to the Global HIV/AIDS Strategy by reaching 6,400 people with AB

messaging and 3,200 people with abstinence only messaging in a comprehensive approach. The activities

will also address issues of stigma and discrimination through the education of individuals and communities

reached.

LINKS TO OTHER ACTIVITIES:

AB activities relate to HCT (5424.08), by increasing awareness of HIV. It also relates to care and support

activities (5369.08) through dissemination of information by home based care providers and ultimately by

decreasing demand on care services through decreased prevalence. Linkages also exist to condoms and

other prevention (9216.08) as a complementary prevention strategy and to OVC programming (5415.08) by

targeting orphans and vulnerable children.

POPULATIONS TARGETED:

Key populations targeted are the healthcare community in treatment facilities, PLWHA, youths and adults

accessing HCT services at either static or mobile within catchment areas of the treatment sites, support

group members and immediate families of PLWHA. Other target populations include discordant couples,

pregnant women and religious leaders.

EMPHASIS AREAS:

AB programming emphasizes local organization capacity building, human capacity development and efforts

to increase gender equity in HIV/AIDS programs.

AB activities promote a rights based approach to prevention among positives and other vulnerable

members of society and equal access to information and services. Reduction of stigma and discrimination

are also key to the program.

ACTIVITY DESCRIPTION:

This activity will support capacity development for blood safety (training and equipment), blood bank

screening for HIV and other TTIs, universal precautions and good lab practices, waste management, and

QA/QC for HIV serologic testing. The funding will support the building of infrastructure and capacity for high-

quality blood bank and transfusion practices, the support of counseling and laboratory personnel and their

training. Capacity for high-quality blood transfusion services at seven APIN+ supported ARV centers will be

increased through linkages between blood banks at these APIN+ sites and NBTS Zonal Centers. This

activity will support the infrastructure development, laboratory training, HIV counseling training and

replacement laboratory equipment to supported facilities.

In COP08, APIN+ will work closely with the National Blood Transfusion Service (NBTS) and Safe Blood for

Africa Foundation (SBFA) in all aspects of its blood safety program. APIN+ will support the NBTS in

implementing its primary objective of migrating fragmented hospital-based blood services to centralized

NBTS-based blood services nationwide. A key feature of this program is the development of a nationwide

voluntary donor recruitment system (VDRS). At APIN+ supported facilities NBTS will provide TA for blood

donation drives and SBFA will train nurses and medical laboratory scientists in recruitment strategies to

create repeat voluntary blood donors from the ranks of current family replacement donors. In this plan

APIN+ will be instrumental in working with hospital management and staff at all comprehensive sites to

participate in the NBTS blood services program, to create support of blood donor organizers, and to

strengthen health facility and community focused blood drive activities. Each of the 28 APIN+ sites that

have blood transfusion services will be technically supported so that HIV testing using the National testing

algorithm for HCT is conducted in the pre-donation setting. Data on patients provided with HCT through

these activities will be captured and analyzed through APIN+ SI activities. All donors will be prescreened

using the NBTS screening questionnaire and donors may be deferred based on their responses. APIN+ and

its supported facilities will establish and coordinate a regular QA/QC program to ensure that HCT testing in

the blood donor setting meets national and international standards. It is expected that these improvements

in the donor screening and blood collection practices will result in the safe collection of 15,000 units of

blood.

Linkages to NBTS Zonal Centers will occur through strengthening of ongoing collaborations. APIN+ works

in a range of secondary and tertiary facilities that do blood transfusions, some of which are already utilizing

a combination of ELISA and rapid testing for the four transfusion transmissible infections (TTIs) of HIV I and

II, hepatitis B, hepatitis C and syphilis and are resistant to moving their current blood screening practices to

NBTS. APIN+, NBTS and SBFA will continue to promote the benefits of NBTS-screening to the

management and hematology departments of these facilities, however they will not be chosen during

COP08 as NBTS-linked blood banks. APIN+ will facilitate the development of an NBTS/hospital blood

exchange program at seven health facilities that will be selected based on supportive management,

proximity to a zonal NBTS office, availability of blood banking facilities, laboratory infrastructure and other

resources. This linkage will include regular delivery of donated units of blood to NBTS for screening in

conjunction with a regular delivery of screened units of blood back to the facility. NBTS will pick up

unscreened blood units that these seven hospitals have appropriately collected and stored and will transport

these units back to NBTS centers where they will be screened for the four TTIs using ELISA techniques. In

addition to collecting unscreened units, NBTS will deliver to these seven hospitals their requested order of

screened units for blood banking and use at the facilities as well as a supply of blood bags for blood

collections. NBTS will also provide monthly feedback on rates of the four TTIs found by ELISA screening of

blood units collected by each facility. It is expected that through this NBTS blood banking system 3,500

units of blood will be sent to NBTS for screening.

APIN+ will identify appropriate staff for training by SBFA who, in turn, will utilize standardized training

modules that are approved by NBTS and appropriate to the various levels of trainees. APIN+ will refer a

total of 35 doctors, nurses, and lab workers at supported sites to SBFA for training related to blood safety.

In order to avoid double counting, these 35 targets are counted under the SBFA blood safety narrative.

APIN+ will in turn coordinate step down training of 350 staff from its supported sites in counseling, universal

precautions, good laboratory practices, and lab safety as related to blood transfusion practices. A focal

person within APIN+ will be identified for blood safety. QA/QC activities will include site M&E and personnel

trainings on proficiency in HIV testing, universal precautions, and good laboratory practices. All sites will be

provided with copies of the National Blood Policy, operational guidelines for blood transfusion, SOPs and

job aids to support blood safety activities.

This activity will promote the principles of Universal Safety Precautions, such as the reduction of

unnecessary transfusions, exposure to blood, accidental injury/contamination as well as the essential

consumables and services that protect health care workers from contracting infections, especially HIV.

These universal precaution materials will include personal protective equipment such as hand gloves,

laboratory coats, masks, and other essential consumables for each site. Additionally, each site will make

provisions for the referral of staff for access to post exposure prophylaxis (PEP) when needed. PEP will be

provided through ART drugs activities. Proper waste management will be encouraged at each site through

the use of biohazard bags, suitable sharps containers, and the use of incinerators.

CONTRIBUTION TO OVERALL PROGRAM AREA:

This activity will provide support for seven service outlets at tertiary health care facilities. Individuals will be

trained in counseling and testing and blood bank safety protocols and linkages will be created with the

National Blood Transfusion System. The emphasis on infrastructure building within this program is

consistent with the PEPFAR five-year goal of providing technical assistance for the development of site

specific blood safety policies, protocols and guidelines. Furthermore, it is consistent with the goal of

ensuring a safe, effective and nationally coordinated blood program that provides blood free of the four

TTIs.

LINKS TO OTHER ACTIVITIES:

This activity relates to activities in counseling and testing (5424.08). All blood donors will be screened with

donor questionnaires and provided with full HCT. The universal precaution processes put in place at the

blood bank screening centers will also enhance blood bank workers knowledge on best practices for high

quality HIV testing and the proper procedures for handling of blood specimens throughout the blood banking

protocol. These activities are also linked to our injection safety activities (6818.08) and laboratory

infrastructure (6716.08) through the promotion of universal safety precautions, good laboratory practices,

Activity Narrative: and proper waste management for biohazardous materials.

POPULATIONS BEING TARGETED:

This activity targets adults and particularly, blood donors, aged 18 and above. Additionally, it targets public

health care workers and laboratory workers for training in HIV testing techniques and proper universal

precautions in the handling of blood specimens.

EMPHASIS AREAS:

This activity emphasizes upgrading the infrastructure of participating hospitals and their laboratories and

blood banks through training and minor renovation to effectively link up with the NBTS and contribute to the

nationally coordinated blood banking system. In order to develop human capacity, there will also be

emphasis on in-service training of laboratory workers and public health personnel in the implementation of

recruitment of VNRD and safe blood activities. This will also be achieved through quality assurance and

supportive supervision of trained staff. Strategic information will be emphasized in the collection of data

surrounding transfusions done at the site level. Lastly, this program will develop the capacity of local

organizations (blood banks in hospitals) to participate in national blood safety activities. It is expected to

promote awareness about safe blood practices in the communities and indirectly increase the number of

volunteers available for blood donations.

ACTIVITY DESCRIPTION:

By the end of COP07, APIN+ will be conducting injection safety activities along with other PEPFAR

programs at 16 sites. In COP08, this will increase substantially to 28 sites in nine states (Benue, Borno,

Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). This activity provides the initiation of intensive training

program in injection safety practices for health care workers at 28 of the high volume APIN+ comprehensive

sites, including 11 tertiary and 17 secondary health care facilities. As HIV/AIDS care and treatment

programs are scaled up under the PEPFAR goals, it is critical that the capacity of partners be built to

provide such care in a medically safe environment. This includes education on appropriate practices to

diminish the risks of medical transmission. In HIV endemic settings, health care facilities need to discuss

and adopt policies that address the risks of HIV medical transmission and methods that can be used to

mitigate these risks. In this vein, at all APIN+/PEPFAR sites, a minimum package of safe injection activities

is provided, which includes needle disposal containers, vacutainers and basic educational materials for

staff. APIN+ also provides ongoing training efforts in universal precautions that have been a part of the

continuing education of health care workers. Through this ongoing training in universal precautions, staff

are encouraged to use personal protective equipment such as hand gloves, laboratory coats, vacutainers,

masks, and other essential consumables in order to protect themselves and other patients from exposure to

blood and other bodily fluids.

In COP08, a focus of the trainings provided will be scale up to facility saturation: reaching workers from

every section of the hospital facility. In order to build the human resource capacity of each site for these

activities, at least one workshop on injection safety procedures will be conducted and a total of 450 people

will be trained. APIN+ will collaborate with JSI/MMIS in the development of the training plan and delivery of

the training. For COP08, APIN+ will target healthcare workers (HCWs) at sites who were not provided with

training during COP07 and HCWs at expansion sites. To encourage sustainability of infection prevention

and control, including injection safety, at each site, a standard curriculum developed by JSI/MMIS and

approved by the GON will be utilized. Following the training, step down trainings will be conducted for other

health workers at these sites. Workers attending the workshop will include physicians, nurses, laboratory

workers, community health workers involved in Home Based Care (HBC), laundry workers and

administrative personnel. Site based waste managers and handlers will also be provided with training on

safe waste management techniques. At this workshop, we will review the protocol for safe needle handling,

and disposal. At the training workshop, we will review the policy for provision of Post Exposure Prophylaxis

(PEP) for personnel at APIN+ supported sites as a component of the injection safety policy. PEP will be

provided to employees through the ART drugs and services activities. The funding for this activity will also

support the procurement of color coded bin liners for segregation of infectious wastes and autoclave

containers at 28 APIN+/PEPFAR sites that were not provided with these in COP07. The procurement of this

equipment will be shipped and managed through the APIN+ central warehouse in Lagos. As a part of the

LGA coverage plan for Plateau State, secondary and tertiary health care facilities will be targeted for

training efforts. Trained personnel at these sites will then engage in step down trainings to build capacity in

this area for associated primary health care centers.

The funding will also support the distribution of educational brochure materials and posters on injections

safety for relevant locations at all 28 sites. APIN+ will collaborate with MMIS in the production and

distribution of these educational brochures. Sites will be provided job aids and IEC materials to encourage

behavior change and sustainability. Training activities for each of the 28 sites will be accompanied by the

sharing of safe injection standard operating procedures at each site. Supportive supervision will be

provided to all the sites with technical support from MMIS. In this manner, APIN will build networks among

sites to allow the continued roll out of training, services and best practices in a sustainable manner.

CONTRIBUTION 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 stigma and barriers to comprehensive medical care for PLWHAs by

addressing concerns of health workers and other hospital staff. As the overall program continues to scale-

up, there will be an increase in the number of patients at each of the sites with various needs other than

ART and the need to have well-trained staff in injection safety will be a necessity. The adoption of practices

and policies to address the risks of HIV medical transmission will be important for the overall practice of a

high quality comprehensive HIV/AIDS care and treatment program and prevention of new infections.

LINKS TO OTHER ACTIVITIES:

This activity also relates to activities in Laboratory Infrastructure (6716.08), Palliative Care (5369.08),

TB/HIV (3222.08), ART Services (6715.08) and OVC (5415.08). Health care workers involved in these

programs will benefit from the training program in injection safety and the adoption of a safe needle, needle

stick policy and PEP protocol, all which will improve the safety for workers involved in these other

programmatic activities.

POPULATIONS BEING TARGETED:

All levels of health care providers that handle needles and/or blood from patients will be involved in the

training efforts. In addition, heads of service and administrators need to be aware of the policies put in place

to limit medical transmission of HIV. Furthermore, these activities will indirectly target the general

population, who will be provided with safer injection practices, which are designed to prevent transmission

of HIV.

EMPHASIS AREAS:

Through these activities, an emphasis is placed on training of staff and capacity development of APIN

+/PEPFAR supported sites. This program will provide the basis for a workplace program through

professional medical associations that will ensure that the care and treatment of HIV/AIDS infected patients

and specimens are handled safely, with minimal risk to our healthcare providers.

Stigma and discrimination also occur in healthcare settings, and this has been reported in Nigeria. As

HIV/AIDS treatment and care programs have been initiated, the training of all levels of healthcare providers

in universal precautions and the risks of medical transmission have helped reduce the stigma and

discrimination that can occur in these settings due to fear of occupational hazard.

ACTIVITY DESCRIPTION

In COP07, Harvard/APIN+ supported 17 hospital networks in providing HIV/AIDS care and treatment via a

multidisciplinary, family-focused approach at the hospital and community level. In COP08, APIN+

programming will expand prevention efforts to 28 comprehensive APIN+ sites in 9 states (Benue, Borno,

Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe); these hospital networks and their associated satellite

sites and communities will serve as the platform for APIN+ prevention activities in the coming year.

APIN+ 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 APIN+ will implement this activity at

both the facility and community levels utilizing a combination of multiple strategies in this implementation,

including community outreach campaigns, peer education models, infection control activities, and STI

management/treatment. The goal of the program is to be focused on the communities targeted and to

saturate those communities with messages conveyed in multiple fora. Utilizing such a methodology, a large

number of people will be reached with messages received via one method or another, but the target group

will be those individuals that will have received condom/other prevention messaging: (1) on a regular basis

and (2) via at least three of the four strategies APIN+ will employ (community outreach campaigns, peer

education models, infection control activities, and STI management/treatment). The target for this intensive

COP activity campaign is 32,633 individuals.

In COP 08, all APIN+ supported treatment sites will integrate prevention counseling and services for people

living with HIV into HIV care and treatment clinics. Specifically, healthcare providers and lay counselors in

care and treatment settings will be trained to deliver prevention messages during routine clinic visits using

tools and job aids. Social peers will be utilized from PLWHA support groups. Prevention messages will

promote correct and consistent condom use and where appropriate will incorporate AB messaging for a

balanced approach. In conjunction with the delivery of prevention information, clients are provided with

syndromic management/treatment for STIs, referrals for preventative care and other wrap-around services

as necessary. High risk HIV negative individuals tested at STD clinics will be provided prevention messages

to reduce their likelihood of acquiring HIV.

Community outreach efforts and PLWHA support groups will be utilized and prevention interventions and

information will be included in their activities. These support groups provide key community linkages for

PMTCT, palliative care and ART services. Support group activities will include the dissemination of

prevention information for HIV-infected individuals (funded under BC&S) as well as community outreach to

high risk populations to encourage HCT and healthy behaviors including recommendations for partner

notification and condom use. For HIV negative individuals, trained counselors will provide education on

HIV/AIDS transmission, risks, and risk reduction strategies including HIV testing.

Several APIN+ sites target Most At Risk Populations (MARPs) including outpatient STI patients, border

traders, military personnel, fashion designers, young male market agents, and motor mechanics. A

prevention program for young male market agents has been established in the Ibadan marketplace and

implemented through the Association for Reproductive Family Health (ARFH) NGO. HaltAIDS, a community

based-NGO in the poor community of Tudun Wada in Jos, has an established community HCT center,

which currently provides prevention messages, condoms and HCT to 150 community members per month.

HCT in Victoria Island PHC clinic serves the Kuramo Village community where most residents are sex

workers and bar workers, resulting in greater than 60% HIV prevalence in this high risk population.

Following the destruction of the Kuramo site in 2006 APIN+ discussions with the Lagos State Government

have resulted in the government's agreement to reestablish the HCT clinic in the vicinity of Kuramo village

to serve the needs of that population. Prevention activities at these clinics will provide educational materials

based on the risks that this population faces and distribute condoms. In addition to comprehensive

counseling on HIV prevention and risk reduction, HIV-infected individuals identified through this activity are

referred for palliative care and evaluation for ART eligibility. An emphasis on high risk men through these

community based efforts will also enhance prevention efforts and facilitate access to their partners. This

funding will support the implementation of behavioral interventions for MARP at stand-alone HCT centers,

the development of educational prevention materials developed by ARFH and HALTAIDS and referral for

STD diagnosis and treatment. Where appropriate, APIN+ will build site capacity for STI syndromic

management.

APIN+ will implement the peer education model at healthcare facilities as well, targeting job peers who are

healthcare workers. Healthcare workers at each site will be trained, especially focusing on infection control

practices in the workplace. Health and allied care providers will be supported to adopt positive attitudes and

behaviors including safe practices to reduce their risks of exposure. Facilities will be assisted to implement

SOPs for post-exposure prophylaxis should exposure occur.

This funding will be also used to support the procurement and distribution of written prevention messages

and condoms. The materials will provide patients and clients with HIV prevention information using the

"ABC" model, including information about healthy behaviors, safer sexual practices, PMTCT, and condom

usage. Prevention messages will also include information about other STIs. Condoms will be offered to all

individuals at all sites and will be provided to APIN+ by the Society for Family Health (SFH).

Additional staffing and training of counselors will also be provided by this funding, including a dedicated

fulltime staff person. This activity will provide support for training of 380 individuals in condom promotion,

STD prevention and risk reduction.

CONTRIBUTION TO OVERALL PROGRAM AREA

These prevention activities are consistent with PEPFAR's 2008 goals for Nigeria, which aim to support a

number of prevention strategies as a comprehensive prevention package. In order to be maximally

effective, the prevention messages developed at different sites will be tightly targeted to various high risk

groups that they serve. Furthermore, these activities are consistent with the PEPFAR 5-year strategy, which

seeks to scale up prevention services, build capacity for long term prevention programs, and encourage

testing and targeted outreach to high-risk populations. The establishment of networks and referral systems

from prevention efforts at the community level to PMTCT and HIV care and treatment will help facilitate the

scale-up of the overall program.

Activity Narrative:

LINKS TO OTHER ACTIVITIES

This activity relates to activities in counseling & testing (5424.08), AB (15652.08), care & support (5369.08),

TB/HIV (3222.08), ARV services (6715.08), and OVC (5415.08). The provision of such services at the

community level will serve as an important platform from which general HIV/AIDS information can be

provided and risk reduction strategies discussed.

Populations Being Targeted

These activities seek to target young people and adults, particularly those from high-risk populations.

Prevention messages will also target HIV infected individuals who are receiving ART and care services.

Targeting these populations is important to encourage safe sexual practices, HCT and other prevention

measures. Health care workers will also be targeted for training on the most effective prevention measures

for various risk groups.

Key Legislative Issues Addressed

These activities address gender equity issues by providing equitable access to prevention services for men

and women. In some cases, our activities seek to target men who may be at high risk for HIV in order to

promote condom use as a means of prevention and access to services for their sexual partners. Male

targeted counseling seeks to address male norms and behaviors in order to encourage safer sexual

practices. Strong prevention programs that accommodate the array of societal and cultural norms can also

help reduce stigma and discrimination. The provision of such services at the community level will serve as

an important platform from which general HIV/AIDS information can be provided and risk reduction

strategies discussed.

EMPHASIS AREAS

Through these activities, we place major emphasis on community mobilization and participation, as an

element of outreach for prevention efforts. Additionally, we place major emphasis on training and minor

emphasis on infrastructure and human resources in order to build the capacity of counselors and providers

in a full range of prevention strategies. We also place emphasis on information, education and

communication as an essential element of outreach to high-risk populations, and on developing networks

for linking these activities to HCT, PMTCT, and other ART activities to serve as a source of prevention

information.

ACTIVITY DESCRIPTION:

In COP08 APIN+ will expand its provision of basic care and support services from 24 sites under COP07 to

36 sites in 9 states (Benue, Borno, Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). All 36 APIN+

supported sites will identify HIV-infected persons not only through the traditional approach of HCT in the

PMTCT, HCT, TB and ART centers but also through provider initiated HCT and opt out HCT in an open

access approach to ensure that HCT is available to all clients utilizing a facility. These 36 sites include 11

tertiary teaching hospitals, 25 secondary hospitals and 2 primary health care clinics. 28 of these sites

provide comprehensive ART services while 8 additional PMTCT sites also provide ART to infected children

identified through the PMTCT program. All HIV-infected individuals are clinically pre-assessed for eligibility

for ART services. Palliative care services are consistent with the Nigerian Palliative Care Guidelines. Facility

-based palliative care services will be provided to approximately 16,900 ART ineligible PLWHA and 53,600

ART eligible PLWHA for a total of 70,500 PLWHA clients. People Affected By HIV/AIDS (PABAs) will be

reached through the community and home based care (HBC) of the PLWHA clients; therefore, it is expected

that a total of 211,500 people will access services (70,500 PLWHA and 141,000 PABA). A network model of

care will be used for service delivery. APIN+ will provide at least one clinical service (laboratory, OI

prophylaxis & management, HBC) and at least two other services in the psychosocial, spiritual or preventive

domains to all PLWHA served.

Implementation of the PEPFAR-Nigeria LGA coverage strategy in the program areas of PMTCT and

TB/HIV, designed to ensure the provision of PMTCT and TB/HIV services in at least one health facility in

every local government area (LGA) of 6 identified states, will also provide direction to the APIN+ care and

support scale-up planning for Plateau state. In connection with APIN's role in the LGA coverage plan for

Plateau state, scale up of palliative care services will occur in 12 LGAs where APIN currently supports sites

and in 5 additional LGAs. This will ensure that adult and pediatric patients identified through associated

PMTCT and TB/HIV activities in these 17 LGAs will be provided with care services at 25 secondary health

facilities with referral networks to 2 primary health facilities.

APIN+ will ensure that 50% of BC&S funding is directed to HBC activities. The program will identify,

collaborate with and strengthen the capacities of support groups, including AIDS Alliance, and CBOs to

deliver palliative care services, including the provision of community and HBC services such as domestic

support, management of minor ailments, pain management, referral services, and counseling services.

Supported sites will provide a range of facility and HBC services, including prevention for positives

(balanced ABC messaging as appropriate), clinical care, prophylaxis and management of OIs, lab support,

adherence counseling, psychosocial and spiritual support, and active linkages between hospitals, health

centers, and communities. Through counselors and clinicians, APIN+ will provide referrals for TB, family

planning, safe motherhood, wraparound services and child survival programs as appropriate. As medical

needs of patients are identified, they will be provided with clinical care services by clinicians or referred for

specialty care as necessary. HIV-infected individuals will be provided with cotrimoxazole prophylaxis

according to national guidelines. Diagnostics for common OIs may include: Candida albicans, protozoal

infections, and gastrointestinal parasites. CD4 count is performed at least every 6 months for all PLWHAs.

Activities that focus on prevention with positives (PWP) include 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. APIN+ will support integration of syndromic management of STIs and risk

reduction interventions into care. All enrolled into care will receive risk assessment and behavioral

counseling to achieve risk reduction. These activities are provided through individual counseling and

outreach by site PLWHA support groups. All PLWHA will be provided with a basic care package including

clean water kits, ITN, and IEC materials on PWP. Pain management assessments will also be conducted by

clinicians and HBC providers and analgesics will be provided. Commodities distributed as a part of the

palliative care services are procured centrally through the APIN+ Abuja program office and central medical

stores in Lagos. Distribution of commodities to individual sites is coordinated through supply chain

mechanisms in place for laboratory test kits and ART drugs. During COP08, APIN+ will collaborate with

SCMS for the procurement and distribution of specified OI drugs.

Facility-based and community-based HBC teams partner to provide a continuum of HBC services

depending on client needs. When ART patients miss scheduled clinic visits, or bed ridden clients are

reported by the community HBC team, the ART site HBC team provides follow-up according to a program

based SOP, utilizing a HBC kit provided to these outreach teams. The team will provide basic medical

assessments of signs and symptoms, basic nursing care, nutritional assessments and psychosocial support

and make appropriate referrals. An HBC kit (consisting of ORS, bleach, cotton wool, gloves, soap, calamine

lotion, vaseline, gentian violet, etc.) will be used by HBC teams and, when needed, visiting teams will

provide refills of cotrimoxazole, paracetamol, additional clean water kits and additional bed nets to patients

and their families.

APIN+ partners with PLWHA support groups and CBOs to mobilize communities provide psychosocial

support to PLWHAs and their families, provide ART adherence counseling, and assist with patient follow-up

and HBC activities. APIN+ will build the capacity of these groups to develop innovative means of interacting

and supporting HIV infected populations and PABAs. Site HBC activities will be supervised by a hospital

team.

A total of 700 health care and non-health care workers will be trained in palliative care, including HBC, using

national training manuals. This will be in line with the National Palliative Care Guidance and the USG

Palliative Care policy. These activities will strengthen the overall health systems and provide an integrated,

comprehensive health care package to patients. During COP08, APIN+ will place special focus on scaling-

up pediatric palliative care services through the initiation of training efforts in this area and the establishment

of linkages for these services related to the identification of HIV-infected babies through PMTCT activities.

In connection with SI activities, APIN+ will utilize data collected in this area for monitoring and evaluation.

APIN+ will also develop and implement QA/QC protocols and develop a quality improvement program which

evaluates health system processes and patient outcomes in order to enhance quality of care.

CONTRIBUTION TO OVERALL PROGRAM AREA

Harvard will contribute to the COP08 palliative care goal by providing basic palliative care services in 36

health facilities. Palliative care services will be provided to 70,500 PLWHA and 141,000 PABA for a total of

Activity Narrative: 211,500 people served. The program will contribute to strengthening human capacity through training of

health workers, community workers and PLWHAs and their families. These activities are consistent with the

PEPFAR 5-year strategy as they seek to scale up palliative care services and build capacity to provide care

and support for PLWHA.

LINKS TO OTHER ACTIVITIES:

This activity relates to activities in TB/HIV (3222.08), PMTCT (3227.08), ART Services (6715.08), OVC

(5415.08), AB (15652.08) and COP (9216.08). Linkages between sites will be developed for referral

networks and capacity building in this area; improved outreach to the community will allow for different

levels of medical intervention as needed. APIN+ will facilitate linkages with other organizations providing

livelihood development programs for PLWHA and PABAs. Identified OVC-headed households will be linked

to OVC programs. The program will also link to other USG IPs, the private sector and the GON.

POPULATIONS BEING TARGETED:

This activity targets all HIV infected patients who seek treatment and care at the 36 Harvard APIN+ sites

participating in this program. In addition, PABAs are targeted for services. A total of 700 individuals will be

trained in palliative care.

EMPHASIS AREAS:

This activity focuses on community mobilization and the development of networks through palliative care

and outreach initiatives. Additionally, this program focuses on logistics, commodity procurement for

treatment and care modalities, training, and information, education and communication. This program

seeks to increase gender sensitivity in programming through counseling and educational messages

targeted at vulnerable women and girls. Furthermore, through gender sensitive programming and improved

quality services the program will contribute to reduction in stigma and discrimination and encourage men to

contribute to care and support in the families.

ACTIVITY DESCRIPTION:

APIN Plus/Harvard sites will identify HIV infected patients through PMTCT, HCT centers and ART centers

and hospitals. These sites constitute a network of delivery points in nine states (Benue, Borno, Ebonyi,

Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe) and include tertiary teaching hospitals (11) and secondary

hospitals (24), for a total of 36 TB/HIV service delivery sites in COP08. APIN+, with other implementing

partners, will execute the PEPFAR-Nigeria LGA coverage strategy in Plateau and Lagos, ensuring the

provision of TB/HIV services in at least one health facility in every local government area (LGA) of these

states. This is an essential step toward universal access to TB/HIV services, and will focus on developing

programming at the secondary and primary level. All HIV-infected individuals are clinically pre-assessed for

eligibility for ART treatment; it is expected that 33,350 HIV positive clients will be screened for TB in COP08.

TB screening by sputum examination is conducted according to national guidelines. The 48,500

maintenance patients already on ART will also be monitored for TB. All HIV infected women (5,475) from

our 36 PMTCT sites will be assessed for ART eligibility and screened for TB. The TB clinics at 9 of our sites

are National TB centers offering the government DOTS program. At all of our associated DOTS clinics, we

will implement HCT for 10,000 clients presenting to the DOTS center; it is expected that 5,000 of these will

have TB. In all, it is expected that 16,550 TB/HIV HIV/TB co-infected patients will be identified and will

receive treatment for TB and be linked to APIN+ ART clinics for evaluation of eligibility for ART and

provision of treatment and palliative care.

NIMR is the National Tuberculosis Reference Laboratory and will provide an important resource to other

APIN+ sites in strengthening their capacity for TB diagnosis and cross-training of health care workers in

TB/HIV. TB services provided at these clinics will be integrated with ART services and HCT in order to

promote the development of a comprehensive system of care for individuals with HIV/TB co-infection. This

will be part of the 500 health care workers in both HIV and TB clinical and laboratory settings to be trained

in COP08. APIN+ TB/HIV program officers and facility staff will be provided with formal TB/HIV training to

enhance their productivity, including retraining on x-ray diagnostic skills for clinicians and retraining on good

sputum specimen collection and laboratory AFB sputum smear diagnosis for laboratorians. A dedicated TB

program officer provides TB expertise to all APIN+ sites and is responsible for training efforts and reporting

of TB patients to the NTPLCP.

APIN+ will prevent nosocomial transmission of TB to HIV+ patients through such measures and principles

such as basic hygiene, proper sputum disposal, and good cross ventilation at clinics. Facility co-location of

TB/HIV services is preferred to clinic co-location. The national guidelines on TB infection control on co-

located sites will be implemented in all sites. Patient and staff education on infection control measures will

be routinely carried out to ensure program success. APIN+ will upgrade facilities as needed through

infrastructure support such as basic renovations, upgrading equipment and procuring supplies and

consumables (e.g. sputum containers).

To date, more than 30% of APIN+ clinic attendees present with pulmonary tuberculosis. Depending on

clinical status, many patients will be treated for TB prior to receiving ART, following the NTBLCP Guidelines.

Concurrent ART and TB treatment follows the National guidelines of d4T+3TC+EFV (800mg). All co-

infected patients with CD4 values <200 cells/mm will receive cotrimoxazole. INH prophylaxis therapy will

only be provided on a case by case basis following the NTBLCP guidelines. Five hundred HIV+ patients are

estimated to be given IPT. The TB DOTS sites will be supported to provide holistic patient care according to

National and IMAI guidelines.

APIN will also continue to work with GON in providing support for the Federal Public Health Laboratory,

which was developed into a national reference lab in COP07. TB diagnostic capacity will include culture,

PCR, and sequencing for resistance testing. At NIMR, APIN will provide technical assistance in the

implementation of MDR-TB and XDR-TB surveillance activities in Nigeria.

Pursuant to the State LGA coverage plan, APIN+ will work with secondary sites in 17 LGAs of Plateau and

Lagos states. Secondary sites will be linked with two tertiary care sites for specialty care and are fed by

patient referrals from primary health care centers. To ensure continuous availability of drugs and

commodities in supported sites, APIN will partner with the USG PEPFAR team to strengthen logistics

management within the states where it works.

CONTRIBUTION TO OVERALL PROGRAM:

The provision of TB diagnostics and treatment within participating ART facilities is consistent with the

PEPFAR goal of ensuring that all facilities offering ART develop the ability to diagnose TB and provide

nationally accepted DOTS sites within their facility. There will a deliberate attempt to locate HCT in DOTS

centers so as to increase detection of co-infected TB/HIV patients. At these facilities, APIN estimates that it

will provide clinical treatment for TB to 16,550 patients with HIV/TB co-infection either prior to or during their

ART therapy, thus contributing significantly to the 2008 PEPFAR goals. At all APIN+ sites referral to TB

DOTS sites that are either co-located or within short proximity will be provided. The provision of TB

diagnosis and treatment, infrastructure building and health care personnel training under this program will

work towards building and maintaining Nigerian National tuberculosis treatment capacity, which is

consistent with the PEPFAR 5-year strategy.

LINKS TO OTHER ACTIVITIES:

This activity also relates to activities in HCT (5424.08), Care & Support (5369.08), ART Services (6715.08),

PMTCT (3227.08) and OVC (5415.08). Through this activity linkages between participating treatment sites

and the National Tuberculosis Reference Laboratory will be provided. Additionally, linkages to potential

patient populations through outreach initiatives, HCT activities, and ART services will improve utilization of

care opportunities created through PEPFAR funding. This activity is linked to care and support and ART

services because TB diagnosis and treatment are provided as a part of patient palliative care and support at

sites which also provide ART. A high TB co-infection rate has a major impact on ART management.

POPULATIONS BEING TARGETED:

This activity targets adults and children with HIV and TB co-infection by providing a mechanism for critically

important TB diagnosis and treatment both prior to the initiation of ART and also during the course of ART

therapy. Newly enrolling ART patients will be prescreened for TB in COP08 and TB that develops in

patients that are currently on ART therapy will be diagnosed and treated. All HIV infected pregnant women

participating in APIN+ PMTCT programs will also be eligible for TB diagnosis and treatment under this

Activity Narrative: program.

EMPHASIS AREAS:

Emphasis areas include local organization capacity building, and health-related wrap around activities.

This activity will increase gender equity by focusing on strategies which seek to reach an equitable number

of co-infected men and women. Furthermore, it seeks to provide additional focus on support for pregnant

women who have TB/HIV. Through data collection and patient surveillance from this activity, APIN will be

able to show the breakdown of men and women who are accessing TB diagnostics and treatment services.

Outreach activities and patient counseling also seek to address stigma and discrimination and increase

access to information, education and TB diagnosis and treatment for women and girls with HIV.

ACTIVITY DESCRIPTION:

In COP07, APIN Plus/Harvard (APIN+) conducted OVC activities in 25 sites in 7 states (Plateau, Oyo,

Borno, Lagos, Kaduna, Benue, and Enugu). In COP08, APIN will work at 36 sites in 9 states (Benue, Borno,

Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). These OVC sites constitute a network of delivery

points including 11 tertiary teaching hospitals, 24 secondary hospitals and 1 primary health care facility.

APIN+ will identify HIV-infected OVC through PMTCT, HCT centers, ART centers, and hospitals through an

opt-out, family centered approach in which all children below 18 years that are identified through an HIV+

adult family member or caregiver (PMTCT client, adult ART client or adult BC&S client) will be offered HCT.

APIN+ also provides these services through one CBO. Expansion to the 36 sites will include the addition of

primary and secondary health facilities in 5 new LGAs in Plateau state. While many of the APIN+ supported

original PMTCT sites are classified as secondary or community-based in nature, the expansion sites in

Plateau state and elsewhere represent a continuation of the overall movement from tertiary to secondary

and primary sites as these new sites are virtually all secondary or community-based. APIN+ will strengthen

the coordination of PMTCT, ART and OVC services for seamless movement of HIV+ children across the

various services. The experience gained from the initial rounds of this activity will assist in more efficient

implementation of OVC activities in the new centers. In addition, active PMTCT programs at 36 sites will

identify HIV-exposed infants who will require PCR diagnosis and clinical assessment to determine ART

need.

OVC who are ART eligible will be provided ART services funded under APIN+ ART activities. APIN+ will

provide care and monitoring through the OVC program to 4,500 HIV positive children who are on ART, 336

HIV infected infants identified through the PMTCT activities, and 100 HIV infected children identified through

the HCT activities. In addition, APIN+ will provide OVC services to 3,864 HIV negative children whose

parents or caregivers had or have HIV/AIDS. These 8,800 OVC will receive multiple services through APIN

+ activities.

All HIV-infected OVC will be provided with cotrimoxazole prophylaxis according to national guidelines.

Preventive care services for all OVC including diagnostic testing for common opportunistic infections (OIs)

will be performed at pre-assessment including testing for malaria. Preventive care kits, including kits

obtained from SFH (a USG supported IP) and provided to APIN+ by the USG will be distributed. Kits include

multivitamins, clean water kits, ORS (preparation and use), and bed nets and will be provided to caregivers

for all infants and children covered under this activity. All OVCs are also provided with nutritional

assessments and support, psychosocial support, birth registration assistance, and referrals for wraparound

services in this area based on identified needs. APIN+ will utilize referral mechanisms for education and

nutrition support where appropriate and will prioritize partnering with these new USG-supported wraparound

services in states where these activities are co-located with APIN+.

Monitoring and evaluation of all aspects of the OVC program will be conducted as a part of the SI activities.

APIN collects electronic data on patient care, which is used for site and program specific evaluation of

services provided in each of the OVC program areas, including evaluation of CD4 counts, loss to follow-up

and viral suppression. This data is used to conduct program evaluation and provide feedback to site

investigators on a quarterly basis. Onsite data managers will conduct monthly evaluations. APIN+ will also

develop and implement an internal QA/QC program in this area to provide feedback to sites on performance

and identify best practices and areas for strengthening and support.

APIN+ will partner with persons living with HIV/AIDS (PLWHA) support groups to provide outreach to OVC

and their families and caregivers through HCT advocacy, ART education and counseling, stigma reduction,

risk reduction and ART adherence. These PLWHA community outreach groups will provide support to ART

patients, their families, and other persons affected by AIDS (PABA) on the many psychosocial issues

involved in HIV infection and ART treatment. These PLWHA groups will also assist with patient follow-up

and home based care. Outreach through the PLWHA support groups will also encourage utilization of HCT

services by other family members. Support will include referrals for wraparound services, including: special

educational services for OVC, food and nutritional support, and income generating activities for caregivers

and older OVCs. APIN+ will work with the USG team to identify ways in which it can utilize leveraged

resources for developing therapeutic nutritional programming such as community therapeutic care

programs. APIN+ will build the capacity of the support groups to develop more innovative means of

interacting and supporting HIV-infected and affected populations. APIN+ will also explore partnerships with

traditional OVC providers in the communities in which it works for potential synergy of activities.

This funding will also support training for 400 healthcare providers and caregivers of HIV-infected OVC.

Healthcare providers to be trained include pediatricians, counselors and nurses in the area of pediatric care

and support services. Training in this area will be coordinated with FMOH and follow National Guidelines on

pediatric care. These activities will strengthen the capacity of sites to provide comprehensive care to OVC.

Training of caregivers will be done through community and home based programs with support groups and

home based care providers.

CONTRIBUTION TO OVERALL PROGRAM AREA:

Outreach activities through PLWHA support groups will seek to provide comprehensive psychosocial

support for OVC and their families. These services are consistent with the National Plan of Action for OVC

in Nigeria and the Standard Operational Guidelines for OVC services. Additionally, APIN+ seeks to

strengthen the capacity of the PLWHA support groups to continue to provide psychosocial support and

outreach to PLWHA and OVC. Capacity development at the community and facility levels and consistency

with national guidelines will ensure sustainability. Through working with pediatric ART and PMTCT sites to

provide pediatric C&S services for HIV-infected OVC, APIN+ will scale-up the ability of participating sites to

provide comprehensive and sustainable services for this OVC population, which is consistent with National

objectives and the PEPFAR 5-year strategy.

LINKS TO OTHER ACTIVITIES:

This activity also relates to activities in PMTCT (5415.08) through a system of referrals to provide pediatric

care and support services to HIV-infected pregnant women and their infants. Linkages will be made to

BC&S activities for adults (5369.08) and TB/HIV activities (3222.08) in order to ensure a comprehensive

system of care for OVC and their families. The integration of pediatric ART services (6715.08) and care

linked to active PMTCT and adult ART centers will facilitate the development of the overall network of care

for HIV-infected families and communities. Linkages to outreach initiatives and HCT (5424.08) activities

Activity Narrative: seek to improve the utilization of care opportunities created through PEPFAR funding. Additionally, through

SI activities (3226.08) information about efficacy of care, derived from data collected on the patients treated

under this activity, may be used to develop new treatment protocols to increase the quality of pediatric OVC

services.

POPULATIONS BEING TARGETED:

These activities seek to target OVC who have been exposed to HIV through pregnancy and breastfeeding

from an HIV-infected mother through the identification of exposed infants from PMTCT programs. We will

also identify OVC from other areas as targets for supportive pediatric care and family outreach. Outreach

initiatives also seek to target mothers and family members of HIV-infected OVC, including PLWHA, to

ensure comprehensive family psychosocial support. Caregivers of OVC are also targeted to encourage

HCT for potentially exposed children. APIN also targets caregivers by providing them with preventive care

packages to be utilized for the benefit of the OVC. APIN will target street youth and out-of-school youth

through community outreach initiatives based in HCT clinics. With the 36 PMTCT sites proposed, which

includes support for existing sites and expansion, the target of 8,800 will be reached without difficulty.

EMPHASIS AREAS:

Emphasis is placed on training through activities focused on training healthcare providers and caregivers in

the care of HIV-infected and affected OVC. These activities will also place an emphasis on the development

of networks and referral systems in order to support the development of a comprehensive system of care

through links to community PLWHA support groups and PMTCT, HCT and ART sites.

ACTIVITY DESCRIPTION:

This activity provides comprehensive counseling and testing services (HCT) to at risk individuals, delivered

through 40 service outlets (28 comprehensive APIN+ sites, 8 additional PMTCT sites with ART services for

HIV+ children identified through PMTCT services, and 4 stand alone HCT centers) in 9 states (Benue,

Borno, Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). This is an increase from the 20 active sites at

the end of COP07. At these sites 78,500 individuals will receive HIV counseling & testing and receive their

results; targeted populations include Most At Risk Populations (MARPs), clients presenting to the health

care facilities, blood donors, and family members of PLWHA. Provider initiated HIV testing is utilized as an

additional strategy to reach clients at the health care facilities. Seventeen of these additional sites will be in

primary health centers and secondary hospitals some of which will be activated through the implementation

of the PEPFAR-Nigeria LGA coverage strategy in the program areas of PMTCT and TB/HIV, designed to

ensure the provision of PMTCT and TB/HIV services in at least one health facility in every local government

area (LGA) of 6 identified states.

Individuals identified as HIV-infected at stand-alone HCT clinics will be referred for palliative care, PMTCT

and ART services as appropriate. Those identified as positive at APIN+ comprehensive sites will be referred

to PMTCT and ART clinics for treatment and palliative care services. Prevention for HIV positive individual

will be incorporated into HCT activities including promotion of 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. APIN+ sites use family counseling sessions and "love letter" strategies to

encourage partners of HIV-infected patients to access HCT so that couples receive HIV counseling and

testing together. Counselor training will include couple counseling to strengthen this program. Pediatric

patients that are identified at testing points of service will be enrolled into the APIN+ supported OVC

program and ART as necessary. HCT will also be offered to patients receiving TB services at each of the

APIN+ sites throughout TB/HIV program activities. HCT is offered to blood donors as per Blood Safety

activities. Patients identified as HIV-infected are provided with referrals to ART and palliative care services.

APIN+ will use the National "Heart to Heart" logo at supported HCT sites so as to reflect the integration

within the national program. Through these activities, 4 stand-alone HCT service outlets are also maintained

which provide HIV testing as well as pre- and post-test counseling and condom distribution. At all HCT

outlets, patients are provided with Information, Education & Communication (IEC) materials on HIV

prevention and referrals for ART services and palliative care as appropriate. The materials will address HIV

prevention using the "ABC" model, providing information about healthy behaviors, safer sexual practices,

STI prevention, PMTCT, and condom usage.

HCT services are also provided in community settings in conjunction with projects in Lagos, Plateau and

Oyo states that serve specific MARPs including: outpatient STI patients, bar workers, sex workers, border

traders, military personnel, fashion designers, and motor mechanics. Mobile HCT services will be used to

reach these populations. Activities targeting these populations are linked with APIN+ sites to provide referral

linkages to PMTCT, Palliative HIV/TB and ART services depending on eligibility for ART.

Condoms will be made available at all HCT sites in conjunction with the delivery of AB messages. The

Society for Family Health (SFH) will supply condoms. Training of 420 individuals in counseling and testing

will use the National testing algorithm and will educate trainees on appropriate counseling messages

specific to the different high risk groups with which they work. Refresher training will be provided during the

year, particularly after final revision of the National training curriculum. HIV testing is performed with rapid

test assays and same day results are given. Following HIV diagnosis with the National testing algorithm,

immunoblot confirmation will be provided during assessment for ART. This is done by HIV laboratories at

APIN+ comprehensive ART treatment centers.

The UCH Virology lab will establish and coordinate a regular QA/QC program to insure that HIV serologic

testing at HCT centers meets national and international standards. This lab will also ensure coordination of

HIV testing SOPs and provide regular training for new lab personnel. The USG team will be providing

APIN+ with rapid test kits that will be managed by the pharmacy logistics team in Lagos and stored and

distributed from the APIN+ central warehouse. APIN+ will continue to harmonize the logistics process with

GON LMIS and ICS activities.

CONTRIBUTION TO OVERALL PROGRAM AREA:

APIN+ HCT activities are consistent with the PEPFAR 2008 goals for Nigeria, which aim to increase uptake

of HCT by supporting HCT centers, which are linked to treatment and care services, and to expand their

reach through mobile testing services. By continuing to support and build the capacity of HCT centers and

provide linkages to treatment and care centers, these activities will be able to meet the increasing utilization

of these services, expected to result from HCT outreach initiatives identifying infected individuals. The

network of HCT centers linked to HIV services and care will provide a sustainable network for infected and

affected individuals in APIN+ catchments areas.

LINKS TO OTHER ACTIVITIES:

This activity also relates to activities in Palliative Care & Support (3222.08), Condoms and Other Prevention

(9216.08), TB/HIV (3222.08), ART Services (6715.08) and OVC (5415.08). Through these activities, APIN+

has incorporated a number of currently funded HCT prevention programs (i.e., Gates Foundation) to provide

access to a broad range of palliative care, support and ART services. This network of community, research-

based and tertiary care institutions should provide sustainable and high quality HIV and related services to

the communities served. Furthermore, both primary and satellite APIN+ sites are linked in order to provide

laboratory and specialty care support, as related to the HCT activities.

TARGET POPULATIONS:

These activities target adults for HIV counseling and testing, particularly those from most at risk populations,

as described above. Targeting these populations is important to encourage utilization of HCT services and

provide ART treatment for eligible HIV infected individuals. Counseling provided through these activities

also seeks to target PLWHA who are newly diagnosed by encouraging them to bring their partners and

other family members in for HCT. In addition, target populations include orphans and vulnerable children.

EMPHASIS AREAS:

Emphasis is on in-service training contributing to human capacity development, and quality assurance and

Activity Narrative: supportive supervision. These activities will also address gender equity issues by providing equitable

access to HCT services for men and women. In some cases, the activities seek to target men who may be

at high risk for HIV in order to provide a mechanism for HCT as a means of prevention and access to

services for their sexual partners. Male targeted counseling seeks to address male norms and behaviors in

order to encourage safer sexual practices. Counseling also seeks to address sexual norms and issues of

HIV related stigma and discrimination.

Track 1 and 2 funds are combined for this activity.

ACTIVITY DESCRIPTION:

Through these activities, Harvard/APIN+ will provide ART drugs to 48,500 adult and pediatric patients at 36

APIN+ sites in nine states (Benue, Borno, Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). These sites

include 28 comprehensive ART sites serving pregnant women, adults and children, and eight PMTCT sites

that also provide HIV+ children identified through the PMTCT program with ART. At all sites APIN+ will

provide the ART prophylaxis options and triple drug regimens for eligible pregnant women consistent with

the national guidelines. Thus, a total of 36 APIN Plus sites will be providing ART drugs through ART or

PMTCT services.

In COP08, APIN+ will begin to collaborate with Clinton Foundation for the procurement of second line drugs

for adult patients and all pediatric drugs for pediatric patients. Drugs procured through SCMS will be

shipped to APIN's Central Medical Stores (CMS) in Lagos, from which they will be distributed to sites in

accordance with an internal supply chain management system. We will purchase first-line ART drugs

directly from drug manufacturers and through different ART purchasing agents, including IDA and SCMS,

as applicable, in accordance with USG regulations and NAFDC Registration and following Nigerian National

ARV drug regimens. We have developed SOPs for supply chain management, drug usage, drug regimen

tracking, drug distribution, warehouse storage and individual pharmacy site management. These SOPs are

also used for procurement and distribution of OI drugs and certain lab supplies and test kits.

All drug orders are based on projections of patient numbers as determined by several factors including: rate

of patient enrollment, weight class of patients affecting drug dosage, gender, rates of toxicity, and rates of

failure. Our rates of drug ordering and estimation of buffer stock needs have been informed by our

experience with lengthy and variable order to delivery times, global shortages (e.g. BMS and Merck),

splitting of most orders, delays in NAFDAC registration and lengthy clearance of drugs in country. As a

result, our drug orders had been adjusted to accommodate with an increase in buffer stocks. This year, we

have buffer stocks for approximately 3-5 months for all of the requisite first and second line drugs, most of

which are fixed dose combinations and other FDA-approved generic drugs.

Capacity building and training for our APIN+ CMS at NIMR and individual site pharmacies is ongoing to

support pharmacy management and implementation of the National ART Program. Harvard/APIN+ is

participating in the ART harmonization process with the GON. The goal of these activities is to facilitate the

pharmacies' ability to scale up capacity as patient utilization of ART increases. The CMS is located at NIMR

(Lagos), where the project operates and manages a warehouse that provides storage for drugs once they

enter the country. An electronic bin card system is utilized to track and monitor drug stores and distribution.

A subcontract with Fed-Ex provides monthly distribution to all site pharmacies. Assessments of all facilities

to determine infrastructure needs have been conducted in COP07 and will continue to be conducted in

COP08 for new sites. These site capacity assessments have been the basis for efforts to strengthen the

supply chain management system for new sites. Ongoing assessments ensure sustainability of pharmacies

and supply chain management at the sites. All site pharmacists have participated in regular training

sessions and work with site data managers in providing regular supply chain information electronically to

our central pharmacy. The computerized supply chain information system linked to patient clinical records

also provides reporting data for M&E at each site. Our logistician consultant conducts regular drug inventory

audits to our central warehouse and individual site pharmacies.

Our long-term goal is to support a sustainable supply chain management system for ART that incorporates

existing and bolstered Nigerian institutional structures and is harmonized with GON activities. Continued

collaboration with SCMS and GON procurement efforts contribute to this goal. Implementation of the

PEPFAR-Nigeria LGA coverage strategy in the program areas of PMTCT and TB/HIV, designed to ensure

the provision of PMTCT and TB/HIV services in at least one health facility in every local government area

(LGA) of 6 identified states, will help to guide the ongoing site expansion for ART and PMTCT. As a part of

that plan, secondary health care facilities covering all 17 LGAs in Plateau state will be targeted for

pharmacy support and drug distribution. As expansion of ARV drug services is prioritized to rural areas,

APIN+ will strengthen existing referral channels and support network coordinating mechanisms. Each new

site will be visited by a team of technical staff from Nigeria and Boston as well as other sub-partners.

Pharmacy and logistics management procedures will be assessed and be part of the site development plan.

Recommendations for drug storage, equipping of pharmacies and minor renovations are considered. All

APIN+ pharmacists have completed the IDA ARV training program. Pharmacists hold meetings on a

quarterly basis and training updates are provided. On a monthly basis, drug updates are provided to all

APIN + investigators by email. Pharmacists and their data entry staff also participate in the electronic data

tracking system; regular training in computer entry and database management are also provided.

This funding will specifically support the procurement of ART drugs, their distribution and storage in a

central pharmacy established at NIMR (Lagos). Funding supports the central pharmacy, security, equipment

and two full time pharmacists. Subcontracts to JSI and Crown agents for supply chain management are also

included. All drug regimens are consistent with the National ART guidelines for adult and pediatric patients.

Funding in this activity provides drugs for 44,000 adult and 4,500 pediatric patients on appropriate ART

drugs.

Harvard has allocated $3,015,506 of its ARV Drugs budget to SCMS for procurement of commodities. This

amount is captured under the SCMS Drugs activity.

CONTRIBUTION TO OVERALL PROGRAM AREA

Through these activities we will have provided ART drugs to 48,500 patients at 36 ART service outlets. We

have almost doubled the number of ART service provider sites from 17 and increased the number of states

from seven to eight. In addition, we have scaled up our PMTCT activities with 36 points of service providing

access to PMTCT services for 56,250 women. Through these activities, we will continue to strengthen the

structure of our ART drug procurement system, as described above, in accordance with PEPFAR goals in

order to ensure cost effective and accountable mechanisms for drug procurement and distribution.

Furthermore, efforts to build local capacity through infrastructure building and training mechanisms are

consistent with PEPFAR 5-year goals to enhance the capacity of supply chain management systems to

respond to rapid treatment scale-up. Additionally, through procurement via SCMS, we seek to provide

support to efforts to build national capacity related to drug procurement and distribution.

Activity Narrative: LINKS TO OTHER ACTIVITIES

This activity also relates to activities in TB/HIV (3222.08), ART Services (6715.08), and Strategic

Information (3226.08). Through this activity, we will maintain significant linkages with PMTCT (3227.08) and

ART Services through the procurement of ART drugs for individuals served by these programs. Additionally,

we will develop and maintain linkages to TB/HIV activities, with expansion focusing on co-locating ARV sites

with existing DOTS sites. The supply chain management system will serve to provide drugs to ART sites

that are providing TB services in conjunction with ART services. SI activities will provide crucial information

for M&E as well as efficacy of the drug regimens, which may impact drug procurement decision-making.

POPULATIONS BEING TARGETED

The primary target of these activities are health care workers, including program managers doctors, nurses,

and pharmacists who are involved in the drug procurement and distribution process. Furthermore, by

building mechanisms for drug procurement, these activities seek to target PLWHA, both adults and children,

who are in need of or already receiving ART care.

EMPHASIS AREAS

Emphasis areas include strategic information and local organization capacity building.

Training initiatives have also been incorporated into these activities in order to build the local human

resource capacity to manage a sustainable drug procurement and distribution system.

Track 1 and 2 are combined for this activity.

ACTIVITY DESCRIPTION:

In COP07 Harvard/APIN+ provided comprehensive ART services in 17 sites In COP08 will provide high

quality ART services to eligible patients at a total of 36 sites; 28 comprehensive ART sites (11 tertiary and

17 secondary facilities) and eight PMTCT sites that also provide ART for HIV+ children identified through

PMTCT services. The 28 sites are located in the nine states of Benue, Borno, Ebonyi, Enugu, Kaduna,

Lagos, Oyo, Plateau, and Yobe. This will provide ART services to a total of 48,500 individuals, including

44,000 adults (14,000 new) and 4,500 children (1,500 new) at the end of the reporting period. At the

additional eight PMTCT sites there will also be ART services provided for eligible pregnant women and

eligible infected infants. Implementation of the PEPFAR-Nigeria LGA coverage strategy in the program

areas of PMTCT and TB/HIV, designed to ensure the provision of PMTCT and TB/HIV services in at least

one health facility in every local government area (LGA) of 6 identified states, will increase the reach of

adult and pediatric ART services as well.

For patients at the Federal ART sites, the program anticipates GON provision of first line ARV drugs and

PEPFAR support for ART care and services. As patients require alternative or second line drugs, they will

receive PEPFAR provided drugs. GON provision of first line drugs, when actualized, will allow for additional

adult and pediatric targets. APIN+ estimates that 2,500 additional adults will be placed on therapy through

the leveraging of GON drugs. APIN+ will also partner with Clinton Foundation and Global Fund (GF) as

appropriate to leverage resources for providing antiretroviral drugs to patients. The site investigators and

project managers will actively participate in the GON National ART program. Harmonization of data

collection for M&E will be coordinated with USG and GON efforts. APIN+ has provided technical assistance

and training expertise to the National ART program's training program for adults and pediatric patients,

which will continue in 2008. APIN will continue to participate in the USG coordinated Clinical Working Group

to address emerging topics in ARV service provision and to ensure harmonization with other IPs and the

GON.

ART provision and monitoring follows the 2005 revised National ART guidelines for adult and pediatric care.

All sites focus on the integration of ART services for all patients regardless of the source of funding for

different components of treatment (e.g. external funding sources for services or lab commodities). A

standardized protocol for adult and pediatric ART services is followed at all APIN PEPFAR sites. At each

site support is provided for the management of electronic data and patient medical records for use in the

provision of clinical care. Continued support to ART sites in the area of pediatrics, including the training of

pediatric clinicians, will build capacity at sites to provide pediatric ART. TB diagnosis and treatment is

provided to all patients via facility co-location of DOTS centers and/or referral of patients into ART from

DOTS sites. ART eligible patients identified through HCT conducted at a DOTS site will be provided with

ART. By the end of COP07 all APIN+ ART sites will be co-located with DOT centers to facilitate TB/HIV

service linkages. All HIV infected clients will be symptomatically screened and confirmed with laboratory

and radiological diagnostics as indicated while all TB patients will be offered HIV testing.

Patients are identified through HCT services including facility based, mobile, and family centered strategies.

Those initiating ART are provided ART EAC prior to and during ART provision. ART EAC will follow the

National Curriculum for Adherence Counseling and includes partner notification, drug adherence strategies

and other prevention measures. Care services including prevention for positives will be provided for all ART

patients as outlined in the BC&S narrative.

Non-ART eligible individual that are enrolled in care will have periodic follow-up to identify changes in

eligibility status. Patients are also encouraged to refer family members for HCT. ART EAC is reinforced with

PLWHA support groups at each site, which serve both PEPFAR and Federal ART patients. PLWHA on

treatment are encouraged to have a treatment support partner to whom he/she had disclosed status to

improve adherence and to optimize care.

Scheduled physician visits are at three, six, and 12 months and every six months thereafter; patients pick

up ART drugs monthly. At each visit, clinical exams, hematology, chemistry, and CD4 enumeration are

performed. All tertiary site labs perform the necessary lab assays. Secondary and primary sites with limited

lab capability send samples to an affiliated tertiary site lab for analysis. Electronic clinic and lab records

provide data for high quality patient care and centrally coordinated program monitoring.

Clinical staff meets monthly for updates and training. Each site has a clinic coordinator and a central

committee determines and approves drug regimen switching. As clinical training needs are identified for

new sites or new staff at existing sites, APIN+ provides training on regimen switching and other relevant

topics. APIN+ will continue to implement internal and external QA/QC programs through SI activities and will

allow sites to further monitor the level of patient care. In COP07, APIN+ developed standardized indicators

and piloted QA assessments at ART sites; results were utilized to strengthen services at sites. In COP08,

APIN+ will continue to implement these assessments at additional sites. At each site, indicators specific to

site needs and activities will be developed.

In addition to providing training to improve care at supported sites, APIN+ will also fully support the training

of 100 lab scientists working at GON and GF supported sites. APIN+ will utilize its training lab to train them

in ARV lab monitoring including good laboratory practices, HIV rapid testing, automated CD4, hemogram

and chemistries. This will serve to increase the quality and sustainability of ARV services outside of

PEPFAR-supported sites.

This funding will support the personnel, clinic and lab services for training of 800 people, monitoring of

44,000 adults and 4,500 pediatric patients at the end of COP08, which includes 14,000 new adult and 1,500

new pediatric patients. Funding is also used to support renovations of physical infrastructure at expansion

sites to build physical capacity for the provision of ART services. A total of 48,500 patients will be provided

with ART services. Treatment is provided as a part of the National ART Program in 11 tertiary care teaching

hospitals and federal medical centers, located in Plateau, Lagos, Oyo, Borno, Kaduna, Enugu and Benue

states. Services will also be provided in 17 secondary level hospitals/clinics in Oyo, Yobe, Borno and

Plateau States. Mobile services are also provided to patients served by a CBO in Ebonyi State.

CONTRIBUTION TO PROGRAM:

ART activities are consistent with the PEPFAR goal of scaling up capacity to provide ARV drugs, services

Activity Narrative: and lab support to serve more HIV+ people. The 28 comprehensive ART sites represent a significant

increase in the number of ART sites. Additionally, APIN+ will expand to two new states, with the majority of

new expansion sites being secondary level sites. APIN+ will seek to support the expansion of ARV services

into more local areas by developing a network of secondary or primary health care clinics providing ART

services that are linked to tertiary health care facilities. Plateau State will be targeted for additional

expansion through PMTCT services as a component of the PEPFAR Nigeria LGA coverage plan. As

expansion of ARV drug services is prioritized to rural areas, existing referral channels and support network

coordinating mechanisms will be strengthened. These networks will ensure that facilities are able to develop

linkages, which permit patient referral and the provision of specialty care support. A tiered structure for ARV

provision and monitoring established in COP07 provides a model for additional expansion efforts in COP08

in order to meet PEPFAR treatment goals.

LINKS TO OTHER ACTIVITIES:

This activity is linked to ART drugs (9888.08), OVC (5415.08) for pediatric palliative care, adult BC&S

(5369.08), PMTCT (3227.08) as the program will support 36 PMTCT sites, TB/HIV (3222.08) to provide

ART to patients with TB, Lab (6716.08) to provide ART diagnostics, HCT (5424.08) as an entry point to

ART, and SI (3226.08) will provide the GON with crucial information for use in the evaluation of the National

ARV program and recommended drug regimens. This program is linked to PMTCT services to optimize the

PMTCT by providing ART to eligible pregnant women.

POPULATIONS BEING TARGETED:

The care and treatment components of these activities target HIV-infected adults and children for clinical

monitoring and ART treatment. The operational elements of these activities (M&E, health personnel training,

infrastructural supports, technical assistance and quality assurance) target public and private program

managers, doctors, nurses, pharmacists and lab workers at PEPFAR sites. The expansion of ART services

to secondary health facilities will increase access to necessary services in poor communities.

EMPHASIS AREAS:

Emphasis areas include in-service training. This increases gender equity by providing equitable access to

ART services for both sexes. Counseling services will seek to identify and provide appropriate referrals for

women who are or are at risk of becoming victims of violence. ART EAC will seek to provide referrals to

wraparound services, such as food & nutrition programs and educational services. ART EAC will also seek

to address stigma and discrimination.

Track 1 and Track 2 funding will be combined for this activity.

ACTIVITY DESCRIPTION:

This activity provides maintenance of activities at the National Central Public Health Reference Lab

(NCPHRL) and HIV labs at tertiary (11) and secondary (22) health facilities in Plateau, Oyo, Borno, Yobe,

Lagos, Enugu, Kaduna, and Benue States. These 34 labs represent an overachievement of our COP07

target (30 labs in the same 8 states). In COP08, APIN+ proposes adding additional expansion sites by

building the infrastructure and capacities of 3 labs in secondary health facilities in Plateau state to for a total

of 37 labs. In addition, we will expand the capacity of labs at primary health facilities throughout Plateau and

Oyo states (HIV testing). By the end of COP07, our 11 major tertiary level labs and the NCPHRL will have

capabilities for hematology, automated chemistry analyzers, and laser-based lymphocyte subset

enumeration. Ten of these facilities will also have PCR technology.

APIN will work with GON in developing the NCPHRL into a national reference lab, a project identified by the

MOH as a priority. This lab will serve national HIV QC/QA needs and with 2-3 additional APIN+ supported

labs, will serve as a national laboratory training center. This lab's capacity will include standard HIV assays,

clinical chemistries, hematology, and TB culture. In addition, we will continue to strengthen existing labs by

providing backup equipments to major tertiary sites in geographically isolated areas to avoid interruption in

service. Equipment maintenance is coordinated through assistance from a consultant trained in the

maintenance of freezers and through the manufacturers for other items.

All 37 labs will provide HIV diagnosis through rapid test technologies. All 36 ART sites will have western blot

capacity to confirm HIV status prior to initiation of ART. HIV serology, hematology, chemistries, and CD4

enumeration will be supported at all secondary hospitals with referral to the tertiary labs for PCR diagnostics

and viral loads. Primary health care facilities are closely partnered with secondary and tertiary care facilities,

allowing for baseline and periodic evaluation with full lab monitoring. The primary facilities provide limited

lab monitoring with basic clinical, hematologic and CD4 assays. We are currently screening for TB by

sputum and/or pulmonary X-ray at all ART sites. We will be evaluating the use of PCR diagnosis of TB at

selected tertiary sites in COP07; this will help to guide programmatic decisions regarding its use in COP08.

Our labs with infant PCR diagnostic capabilities will continue to assist other PEPFAR IPs, using dried blood

spots (DBS) to transport specimens from distant satellite sites. APIN+ will support the PEPFAR-Nigeria LGA

coverage strategy (PMTCT and TB/HIV). Secondary sites will have lab capacity for HIV serology,

hematology, chemistries, and CD4 enumeration. Primary feeder sites will be limited to HIV serology with

referral to the secondary sites for additional lab monitoring.

Standardized lab protocols have been developed to accompany the PEPFAR clinical protocol and

computerized lab results link with patient records. These protocols include provisions for the disposal of

biomedical waste in accordance with good laboratory practices. Quality control / quality assurance (QA/QC)

policies have been developed and detailed annual assessments of all lab activities are conducted. Quarterly

QA/QC lab site visits are conducted by the HSPH project management team and will use a standardized

assessment tool developed in Nigeria by the Lab Technical Working Group (LTWG). Results from the

proficiency testing and site visits will be sent into a centralized system within Nigeria, developed and

supported by the PEPFAR LTWG. EQA for lab tests was established in COP07 and is operational for CD4,

HIV, HCV and HBV serology, chemistries, VL and HIV PCR diagnostics; through individual lab registration

with UK-NEQAS and CAP. All PCR labs will participate in the CDC's DBS DNA PCR proficiency program

(EID QA). We provide support for 264 lab staff persons (based at sites), responsible for implementation of

lab protocols, data entry and performance of lab tests. In addition, we provide support for 7 APIN+ staff who

provide technical assistance to sites. Regular lab training allows the development of high quality lab

standards in our PEPFAR labs and this has been networked to our secondary and primary labs with specific

tailoring to the needs and skills at each level. Biannual trainings are provided on specific techniques/topics

integrating QA/QC, good lab practices and biosafety. Competency monitoring/evaluations and refresher

trainings will be provided within individual labs. PEP protocols have been implemented at each of our labs,

supported under our ART drugs activities. APIN has supported international laboratory accreditation for

NIMR and in COP08 will seek international accreditation for 2 additional labs and local accreditation for 10

other labs.

A laboratory information system (LIS) will be implemented at sites, with appropriate capabilities, to

streamline the capture of lab data, minimize transcription errors and facilitate data entry and results output.

We will continue to participate in LTWG monthly meetings to ensure harmonization with other IPs and the

GON, including the development of a common lab equipment platform (appropriate for each lab level).

Procurement of lab reagents is structured in two ways. Reagents available in Nigeria are procured directly

by the sites from specific distributors. Labs are advised to maintain a 3 month reagent buffer. Most reagents

needing importation are ordered at HSPH and shipped to our central warehouse in Lagos. PEPFAR funding

supports procurement of lab equipment, generators and water purifiers necessary for lab work. Equipment

costs for tertiary labs can be high in the first year, but represents significant infrastructure development.

Secondary and primary labs, including VCT facilities, have lower start up costs. Maintenance costs include

minimal renovation costs for some labs, replacement of small lab equipment and training costs for additional

personnel. As further regional networks are developed around these centers of excellence, training, lab and

clinical support will be provided to secondary and primary points of service.

CONTRIBUTION TO OVERALL PROGRAM AREA:

These activities contribute to the goal of maintaining high quality services as the PEPFAR program

expands. APIN will perform 1,137,248 tests in COP08, including HIV diagnosis and tests for disease

monitoring including CD4 enumeration, PCR diagnosis of infants and VL. In addition, we seek to train 720

lab staff members in FY08. APIN will provide training at their supported training facilities to a large number

of non-APIN and non-PEPFAR supported laboratorians. Training lab staff will assist in building the human

resource capacity of our sites to provide sustainable lab support to sites providing high quality HCT and

ART treatment. Nine labs at tertiary care hospitals will have the capacity to perform early infant diagnosis

(EID) by HIV DNA PCR. These labs are also linked to PMTCT sites, to provide a mechanism for EID as a

part of the PEPFAR supported national scale-up plan (consistent with 2008 PEPFAR objectives for Nigeria).

APIN will partner with the GON and Clinton Foundation for procurement of EID test kits and specimen

collection supplies. The NIMR PCR lab will provide QA support for the EID program in the Southern half of

Activity Narrative: Nigeria (through retesting). Through a tiered system of labs at tertiary, secondary and primary sites we are

able to ensure that patients at community based primary facilities are provided with a full complement of lab

monitoring as a part of ART treatment and care. Our training activities include management and

competency training, which seeks to build sustainability. We have provided training to lab workers through

the MOH ART training program at the NIMR. Lab workers from all 36 states and the FCT are invited to

participate on a biannual basis at the NIMR and JUTH sites. Three of our sub-partner sites are actively

involved in lab training for the MOH training program resulting in 14,000 indirect targets without budget

allocation.

LINKS TO OTHER ACTIVITIES:

These activities relate to activities in PMTCT (3227.08), Counseling & Testing (5424.08), Palliative Care

TB/HIV (3222.08), ART Services (6715.08) and OVC (5415.08). Our labs are crucial in providing adequate

HIV diagnostics in PMTCT, C&T, OVC, Palliative care and ART services. Furthermore the lab provides

other diagnostics such as OIs. As a part of this activity, we seek to build linkages between labs and our

patient care sites in order to ensure that lab information is fed back into patient records for use in clinical

care. Our SI (3226.08) activities provide support in M&E, including data management of testing results.

POPULATIONS BEING TARGETED:

This program targets public and private health care workers with training to maintain high quality lab

standards.

EMPHASIS AREAS:

This activity focuses on infrastructure building, creating a network of quality labs supported by strong tertiary

labs, as well as commodity procurement and logistics. This activity also focuses on QA, training and the

development of networks / linkages. QA and training are reinforced by the collaborative nature of the tiered

network of labs. This program seeks to address gender equity by building the capacity of labs at affiliated

sites to conduct testing related to PMTCT. Increased lab capacity will permit the sites to provide equitable

treatment for both women and men.

ACTIVITY DESCRIPTION:

In COP07 APIN+ provided support for SI activities at 38 sites. In COP08, APIN+ will provide support to 40

sites (36 ARV and PMTCT sites, four stand alone HCT sites). These activities include Monitoring and

Evaluation (M&E), Health Management Information Systems (HMIS), operational research studies,

improved data management and maintenance of data quality in all APIN+ sites and the central public health

laboratory. Funds will also be utilized to build the capacity of site staff and Harvard School of Public Health

(HSPH) personnel in the above areas and promote efficient use of data to improve services and influence

policy. In collaboration with the HSPH team, a data manager and an M&E Officer assist the sites with on-

site clinical, pharmacy and project reporting data collection. APIN+ will collaborate with the GON at both the

federal and state levels. In line with the PEPFAR-Nigeria LGA coverage strategy, APIN+ will engage in

scale-up for the capture of data from primary and secondary health facilities in each of the 17 LGAs of

Plateau state. Data capture from these facilities will be coordinated through data entry and management

teams at secondary and tertiary health care facilities in Plateau state.

A relational database system interlinked by ID number has been developed and contains different data

required in the course of care and treatment, ART drug pharmacy logs, toxicity records, discontinuation

forms, PMTCT and pediatrics. All paper files are stored in locked file cabinets as hospital patient records.

Data are electronically entered at sites by trained data entry clerks. The data are then uploaded to a

password protected web server, accessible to authorized personnel and data managers in Nigeria and

Boston. Electronic data is used to prepare timely reports for GON and USG. Data managers conduct M&E

of the data collection and reporting process and provide feedback to each site. The APIN+ electronic record

system is functional and responsive to the GON Patient Management Monitoring (PMM) forms and provides

access to pharmacy pickup data, lab results and other clinical patient information. This data is used for site

and program-specific evaluation of services provided in each program area, including evaluations of CD4

counts, loss to follow-up and viral suppression. SOPs govern data entry, security, management and report

generation related to the ART treatment and care protocol. Paper based National registers are also in use

at APIN+ supported sites. Where the electronic register is available, data is entered from paper documents

to the electronic format. Refinement of instruments and databases is ongoing to accommodate program

reporting requirements from HQ, central, and the GON. In addition, facility based data reporting will be

harmonized with the new National Public Health data system.

APIN+ will provide computer hardware and software support to sites as services expand. Site evaluation

teams will implement an annual M&E plan for APIN+ globally and for each site, with M&E results fed back to

the sites to promote systems improvement. HSPH will continue to participate in the National M&E technical

workgroup (TWG) and the SI team will continue to be active participants on the USG-Nigeria SI TWG.

In 2006 and 2007, JSI conducted Quality Improvement (QI) visits to APIN+ supported ART sites, focusing

on ART services. Through HIVQUAL, additional QI indicators will be added in a coordinated fashion with

USG-Nigeria and the GON. These QI efforts are linked with similar long term efforts in other Harvard

PEPFAR countries (Tanzania, Botswana). In COP07, APIN+ initiated and piloted an internal QI initiative,

designed at collecting qualitative and quantitative data regarding quality indicators on the provision of adult

ART services at each site. In COP08 APIN+ anticipates scaling up these activities to conduct QI

assessments at additional sites that have not been previously evaluated and to expand to other program

areas including PMTCT and pediatric treatment. In COP08, APIN+ will adopt most of the QI activities to this

cross-site model with significant input from Boston, the Nigerian program offices and colleagues in

Botswana and Tanzania. Each site will be visited regularly by APIN+ M&E staff throughout the activity

period; on-site TA and supportive supervision will be provided. Each site will also be assessed internally

once it has had patients enrolled for at least one year. Regular inter-site interactions will be encouraged,

facilitated by HSPH personnel in Nigeria and from the US. All related activities will be carried out in all

supported sites to develop management experience for sustainability. APIN+ will facilitate good working

relationships with state level M&E staff and will regularly communicate on monitoring activities, thereby

encouraging their active involvement. This involvement will build the capacity of the state level staff and

promote sustainability.

In COP08, 800 individuals will be trained in monitoring and evaluation (M&E), surveillance, and HMIS.

APIN+ M&E and data staff conduct 3-4 training sessions centrally per year. In addition, they conduct

regional data management training for personnel working with medical records and patient data on a regular

basis. For other disciplines such as clinicians, nurses, pharmacists and laboratorians, data collection and

M&E modules are incorporated into their respective technical training sessions.

Public Health Evaluations (PHEs) assess the efficacy of ART at all sites to provide feedback on program

implementation, PMTCT activities and related ART interventions (funded under their respective program

areas). During COP08, APIN+ will conduct a PHE to evaluate the rate and predictors of mother to infant

transmission across five different antiretroviral therapy prophylaxis regimens, dependent on time of entry

and mother's health status, in accordance with the Nigerian National PMTCT guidelines. APIN+ will also

investigate the rate of breast milk transmission in infants found to be HIV negative at six weeks and followed

until 18 months of age. Additionally, APIN+ will conduct a PHE to investigate drug resistance relative to viral

subtype. These subtype drug resistance PHE has been supported by National Institute of Allergic and

Infectious Diseases (NIAID)/National Institute of Health (NIH) funding in the past. Results of these PHEs will

provide information to the Nigerian National ART (NNART) committee about co-infections and the levels of

drug resistant virus for use in the evaluation of national drug regimens.

CONTRIBUTION TO OVERALL PROGRAM AREA:

SI activities supported by APIN+ are consistent with the 2008 PEPFAR goals to strengthen site capacity in

the areas of data management and analysis. APIN+ will also provide SI support to its local administrative

office, central pharmacy and warehouse. Training provided by APIN+ is consistent with 2008 PEPFAR

goals to conduct human capacity assessments and training to build SI human resource capacity at sites

providing ART. In 2008, PEPFAR plans to strengthen surveillance efforts and PMM systems in Nigeria.

APIN+ SI activities are consistent with these goals in that funding will be used to refine and implement a

global M&E plan for all supported sites and for each site individually. Furthermore, APIN+ will continue to

collect data on the efficacy and utilization of ART at current sites and build data management capacity at

new sites. The data collection activities will facilitate the ability of PEPFAR to report on Emergency Plan

indicators, which may be used for programmatic decision-making.

Activity Narrative: LINKS TO OTHER ACTIVITIES:

These activities are linked to PMTCT (3227.08), OVC (5415.08), TB/HIV (3222.08), HCT (5424.08) and

ART Services (6715.08), where SI is used for QA/QC and M&E. In M&E activities, APIN+ will link to the

National M&E TWG and Nigeria MEMS. Additionally, through the provision of information technology (IT)

support and data management personnel, APIN+ will provide linkages between all supported sites as

related to data sharing and HIV surveillance in PEPFAR program areas. Through operational research

studies, APIN+ will collaborate with the FMOH, GON, NNART committee and the NIAID/NIH.

POPULATIONS BEING TARGETED:

The SI M&E activities target program managers and evaluation officers, site coordinators and principal

investigators to provide them with a mechanism for programmatic evaluation. The data collection and

management components of these activities target medical record clerks, data managers, and other health

care workers who are involved in the implementation of these processes. Lastly, the M&E and capacity

building efforts target implementing organizations, including community based and faith based organizations

involved in the provision of ART, HCT, BC&S, TB/HIV and PMTCT services.

EMPHASIS AREAS:

These activities emphasize monitoring, evaluation, and reporting through data collection and

implementation of M&E plans. Emphasis is placed strategic information, PHE, human capacity development

and local organization capacity building.

This activity will address gender equity issues through the collection of data on the breakdown of sex

accessing ART care. Through this data collection, we will be able to contribute to national surveillance on

the impact of HIV on both sexes. This data will be essential to the development of outreach, treatment

programs and education to reach an equitable number of men and women.