ACTIVITY DESCRIPTION:

This is a new activity that is closely aligned with continuing activities by the implementing partner (IP) from

COP07. The IP will continue to collaborate with and provide Technical Assistance (TA) to the National

Agency for the Control of AIDS (NACA), National AIDS and STI Control Program (NASCP), selected states

and other stakeholders to improve HIV/AIDS Monitoring and Evaluation (M&E) systems. In the proposed

TB/HIV activity, the IP will collaborate with ENHANSE and Nigerian Prisons Medical Services in a cross-

sectional survey of the Nigerian prison population. The survey will gather sero-prevalence data on HIV

along with TB incidence data and demographic (e.g., age, site, period of incarceration, gender and

education), health, knowledge, attitude and behavioral data in order to assess influencing factors on the HIV

and TB burden among this population. The hypothesis is that HIV/AIDS and TB prevalence among

incarcerated populations is higher than in the general population. This survey will attempt to determine if

that is correct, and which factors play a role in increased prevalence. TB and HIV co-infection rates will also

be assessed.

The Nigerian Prison Service (NPS) consists of about 144 main and 83 satellite prisons with about 45,000

inmates and staff of about 27,000. Prisoners are mostly between the ages of 20 and 40 years—the age

bracket most affected by HIV/AIDS in Nigeria. The state of health services and nutrition among prisoners is

poor, and the likelihood of risk behaviors high. Of programmatic importance is the fact that this population is

a likely bridging population for perpetuating transmission beyond the prison system and civilian prisons

communities into the larger population, as they reintegrate back into society. A sero-prevalence survey

carried out in 2001 among 442 prison inmates showed a prevalence rate of 8.8%, and in Lagos prison a

rate of 6.7% from a sample of 300 in 2006.

This study will follow the National Testing Algorithm for HIV screening and use non-cold chain dependent

rapid test kits. Inmates who test positive will be given an opportunity to receive anti-retroviral therapy (ART),

depending on the results of their pre-assessment. All inmates that would be selected in the sample to

undergo HIV testing will receive pre- and post- counseling and give their consent before the test is

performed on their blood samples. Inmates will receive group counseling for pre-counseling and individual,

confidential post-counseling. The study will respect the "3 Cs" of informed consent, confidentiality, and

counseling.

Nigeria has the World's fourth highest number of TB cases. HIV pandemic has led to a resurgence of TB in

Nigeria and particularly among Prison inmates because of the risk factors they are exposed to. Over 35% of

HIV positive individuals in Nigeria die as a result of TB infection. In this survey, sputum smear microscopy

will be used. Inmates with suspected TB will be asked to provide three sputum specimens following the spot

-morning-spot method. If any of the two specimens examined are positive for Acid Fast Bacilli (AFB), the

inmate is considered a TB case. Since sputum microscopy does not effectively detect active TB in persons

infected with HIV, a confirmatory Chest X-ray will be done for smear negatives that show clinical symptoms

of TB.

The sampling design is a stratified random sample. States will be stratified according to HIV prevalence

bands (1.0-2.0; 2.1-4.0; 4.1-6.0; 6.1-8.0; and 8.1-10.0) and from each HIV prevalence band, a state will

be selected at random. Within each selected state, at least 2 prisons will be selected (one urban and one

rural), from which 300 prison inmates (150 each) will be randomly selected for potential inclusion in the

study sample. The sample size is based on the estimated HIV prevalence in the country, an acceptable

error margin of 2.5%, and a 95% level of confidence. The basic level of calculations will be the states (sites)

and results will be aggregated for the country. Site prevalence rates will be determined by expressing the

number of positive samples as a percentage of the total samples tested. Probability limits will be determined

for all rates.

USG Co-Investigators will participate, as appropriate. The implementing partner will obtain appropriate IRB

approval from local participating institutions and USG PEPFAR Nigeria agencies prior to data collection and

analysis. Nearly all UMD supported "hub" sites have an Ethics Committee with a current Federal Wide

Assurance filed with the US Office for Human Research Protections. This activity is anticipated to take one

year from the development of protocol through data collection and analysis. The projected budget is

$170,000.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

Survey data will inform program development and intervention strategies, and may well have additional,

positive spin-offs in developing advocates and peer educators among groups that are often hard to reach

with TB and HIV prevention and care services. The findings of this survey will provide information about the

magnitude, severity and distribution of the problems in these populations and thus allow for the

development of appropriate strategies and interventions to combat them. It will also allow for evaluation of

the current policy for HIV/AIDS addressing the prisons population and whether there is a need for review of

this policy and other interventions that are currently being carried out in the sector. This information will also

form the basis for advocating to the prisons hierarchy in Nigeria for an increased commitment of resources

to address HIV/AIDS and TB in prisons and provide justification to seek out additional resources from the

MDG office (Debt Relief Gain) and the WB MAP program through NACA.

LINKS TO OTHER ACTIVITIES:

Information gathering among an at-risk population has direct links to prevention and care and treatment

program areas, as well as linkages with strategic information and policy strengthening.

POPULATIONS BEING TARGETED:

Nigerian prison population, policy makers, and TB and HIV program managers.

EMPHASIS AREAS:

The major emphasis area of this activity is SI.

The Implementing Partner (IP) will provide Technical Assistance (TA) to the Federal Ministry of Women

Affairs and Social Development (FMoWASD) to improve information on OVC outcomes and to strengthen

the Ministry's capacity to collect, analyze, and use strategic information relevant to OVC programs. There

will be three activities in COP08. The first activity will provide technical assistance and training to

FMoWASD and other stakeholders at the national and state level in the adaptation and implementation of

the Child Status Index (CSI) tool. The CSI will be adapted for monitoring the status of OVCs at two levels;

monitoring coverage and children served, and surveillance of anticipated results. The CSI will provide care

givers with a system to monitor children served by programs and to better direct services to children in need

as a result of changes in various psychosocial indicators. The CSI will also be used as a surveillance tool to

monitor how OVCs in general are faring at the program level. This will mean designing and implementing a

program level system that will provide information on a group of children and will be pilot-tested in one or

two programs only. The TA and training to FMoWASD, the National Agency for the Control of AIDS (NACA),

and OVC IPs will cover use the CSI tool and information generated through it for decision-making at the

level of individual children and/or programs. This information will be helpful for guiding OVC program

management decisions on for delivering quality care and support to children. This activity will be supported

technically by central level OVC TA as well as through a local advisor.

The second activity will focus on capacity-building aimed at strengthening the organizational and

institutional capacity to produce information for use in improving program management and policy

formulation. The strategy for strengthening FMoWASD's M&E capacity will include targeted training in

routine M&E, improving data quality, and data use. When possible, FMoWASD staff will be included in M&E

trainings offered through SI activities. Also, if available, regional training opportunities in M&E will also be

sought out for FMoWASD staff. This M&E capacity building is expected to improve FMoWASD's staff M&E

technical skills, planning, use of information, training of lower level staff, and engagement of key

stakeholders in development and implementation of M&E activities. The primary thrust of the capacity

building will center on a training of trainers mechanism. IPs and other development partners will work at the

state and LGA levels to support the step-down training at the lower level, which will also include care-givers.

The third activity will include TA to the FMoWASD to further analyze data from the forthcoming national

OVC situational analysis and 2008 Nigeria Demographic and Health Survey (NDHS), especially the OVC

module. This will enable the FMoWASD and other stakeholders to develop a more focused OVC

intervention program that responds to the needs and vulnerabilities of the target population at state and

lower levels. Overall, the proposed activity will reach 125 trainees. Follow-up TA will be provided to review

the adaptation of the CSI and a workshop will be convened to identify and share the best practices.

Combined with other assistance, the expected results will improve the overall well-being of children affected

and infected by HIV/AIDS through improved implementation of OVC programs in Nigeria.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

The technical assistance and training being proposed by the IP will build on existing work by other IPs and

stakeholders. The proposed activity will contribute to effective and efficient execution of OVC program

interventions by the GoN (FMoWASD and NACA), USG IPs, and other development partners, such as

UNICEF, the World Bank and British Department for International Development (DfID). Availability of

accurate and timely data on the OVC situation will inform key strategies for program managers and policy

makers in designing activities for addressing OVC needs. In addition, information from further analysis will

provide input to the design and formulation of policy guidelines and other standard operating procedures for

quality service delivery. An anticipated 125 people will be trained as part of this activity.

LINKS TO OTHER ACTIVITIES:

TA to FMoWASD and PEPFAR partners is directly linked to system strengthening and policy development.

Targets for TA provided to agencies (5) and M&E training for individuals (125) will be reported in the SI

narrative. Linkages between TA in data collection, analysis and utilization of information will strengthen the

capacity of organizations and personnel to generate reliable, timely and accurate information that will

improve the ability of health managers, care-givers and providers at all levels to plan activities, set priorities,

and allocate human and financial resources in response to needs. The IP will collaborate with stakeholders

at all levels to improve data collection, reporting and use, and form linkages as appropriate, especially with

other SI capacity building activities.

TARGET POPULATIONS:

Children affected by HIV/AIDS are the ultimate beneficiaries of improved evidence-based programmatic

decision-making and planning. Others include policy makers, program managers, community health

workers, volunteers, guardians and caregivers, and M&E staff, particularly from FMoWASD and NACA, who

will participate in the design of OVC assessment tools and the CSI training to enhance their skills in

systematically monitoring the outcomes of OVC interventions programs. Current PEPFAR IPs will also

benefit from the assessment results and training to enhance program management decisions. Training and

TA will extend to state, LGA and other OVC service providers at lower levels through step-down training

activities and supervision, to enable them to apply the CSI tools for monitoring OVC program performance.

EMPHASIS AREAS:

The major emphasis area for the IPs activities is supporting FMoWASD with TA and capacity-building in

OVC program M&E. This will provide program managers, policy makers, beneficiaries and implementing

agencies with information to support strategy development and activities to address the needs of OVC and

subsequently improve their overall well-being. As part of this effort, the IP will enhance the capacity of

FMoWASD and other stakeholders in the application of the Child Status Index tools for monitoring OVC

program performance.

ACTIVITY NARRATIVE:

This activity continues from COP07. The Implementing Partner (IP) will continue to collaborate with and

provide Technical Assistance (TA) to the National Agency for the Control of AIDS (NACA), National AIDS

and STI Control Program (NASCP), selected states and other stakeholders to improve HIV/AIDS Monitoring

and Evaluation (M&E) systems. The activity will improve HIV/AIDS information systems through training and

follow-up with Local Government Agencies (LGAs), facilities, and other IPs to improve reporting rates, data

quality and use of information for effective decision making. The IP will support these activities with two

Resident Advisors (both with capacity to provide technical support to all activities listed below), and TA from

headquarters (1-2 international TA visits to support each of the planned workshops, plus an appropriate

amount of remote support on all activities). Specific activities include:

SUPPORT TO NACA/NNRIMS: The IP will continue supporting the Nigeria National Response Information

Management System (NNRIMS), which has been rolled-out in all states with harmonized forms using

COP05, 06 and 07 funds. With COP08 funds, the IP will collaborate with Supply Chain Management

System (SCMS) to scale up the implementation of the SCMS/Voxiva web portal electronic platform to

improve reporting from facilities using the core indicators from NNRIMS. COP08 activities will focus on

building capacity at national and sub-national level (in 2-3 selected states) and developing a monitoring and

supervision framework that will be used by the stakeholders to ensure timely reporting, data quality, and

information use. This will be done in collaboration with the U.S. Government strategic information (USG SI)

team, SCMS/Voxiva to support IPs, and NACA to improve supervision. Three to four refresher workshops

on NNRIMS and training in use of the web portal will be provided. In FY08 the Community Level Program

Information Reporting (CLPIR) Toolkit will be applied to improve the quality and use of community based

indicator data. The IP will work with NACA and community and faith-based organizations to implement the

Engagement Tool of the CLPIR Toolkit, which guides front-line service providers to identify their own

information needs, produce adapted data collection forms and indicators, and facilitate information use.

SUPPORT TO NASCP: The IP will provide TA to NASCP and NACA (SACA at state level) on data

management, analysis and use of information for facility and program staff at all levels. In addition, the IP

will provide supportive supervision to selected states and facilities in collaboration with Government of

Nigeria (GoN) officials (National and state) to ensure improved data quality and use of information.

M&E CAPACITY BUILDING AND INSTITUTIONALIZATION OF M&E TRAINING COURSES: The IP, in

collaboration with a local training institution, will facilitate 2 general M&E workshops for GoN staff, IPs, USG,

and other non-governmental organizations (NGOs) to build M&E capacity for HIV/AIDS programs. This

activity will include institutionalizing the training by providing TA to a local university to incorporate M&E

courses or modules into their training or teaching curricula. The institutionalization of the training within a

local institution in Nigeria will enhance the sustainability of the M&E capacity building process.

DATA QUALITY/DDIU WORKSHOPS: The IP will support 4 specialized workshops—two on Data Demand

and Information Use (DDIU), and two on Data Quality Assurance (DQA). The DDIU training will focus at the

lower level such as states, and include staff from facilities and USG IPs to improving their skills in

information utilization. Participants will develop data use action plans using available HIV/AIDS information

from the SCMS/Voxiva web portal, surveys and other sources. The DQA workshop will cover data quality

tools to improve IP reporting including training appropriate SI field staff in the quality assurance tool to

address the upstream and downstream framework for target setting and results reporting as well as double-

counting. The IP will initially conduct DQA site-visits to determine existing levels of data quality and related

issues, and provide supportive technical assistance. These site-visit results will guide subsequent data

quality workshops which are expected to enhance and broaden IPs and GoN skills in providing TA to the

lower levels (states and facilities).

SECONDARY ANALYSIS: The IP will continue to participate in design and data analysis of national

outcome evaluation studies such as the Nigeria AIDS and Reproductive Health Survey, Integrated

Behavioral Sentinel Survey and the Nigeria Demographic and Health Survey and routine information from

NNRIMS as needed.

SI SUPPORT TO USG: The IP will continue to assist USG to prepare semi-annual/annual PEPFAR reports.

The IP will continue to actively participate on the SI working group established and coordinated by USG

Nigeria. Overall, the proposed workshops will reach 250 trainees. Combined with other assistance, the

expected result is improved HIV/AIDS M&E capacity and improved quality of HIV/AIDS data. With funding

from the OVC program area, this IP will provide TA to FMoWASD, several selected IPs, and other national

and state level stakeholders in the adaptation and implementation of the Child Status Index (CSI) tool

developed by MEASURE Evaluation to monitor the status of individual children. Anticipated training targets

described in the OVC narrative number 125 individuals, thus bringing the total target to 375.

CONTRIBUTIONS TO OVERALL PROGRAM AREA: Focused TA to an anticipated five agencies (NACA,

NASCP, a local University, and 2-3 SACAs) in SI and FMoWASD in CSI tool implementation and analysis of

data (described in the OVC narrative), collaboration with SCMS/Voxiva, and the capacity-building

workshops will build on existing work from previous years under the MEASURE Evaluation Project, and are

expected to improve M&E capacity among public sector partners and USG IPs. With improved capacity,

partners will be more likely to report HIV/AIDS information consistently, with better data quality, and use

information for effective decision making. The proposed activities will contribute significantly to the USG

Nigeria objective of promoting and improving data demand and information utilization with the goal of

strengthening program management and decision-making. This TA will contribute to and promote the Third

One—one national M&E framework—as well as contribute to the sustainability of the national information

system. Ultimately, this activity will provide USG with a better understanding of progress toward a broad

range of desired HIV/AIDS outcomes, as well as more accurate and streamlined reporting, allowing for

improved planning and management of multiple PEPFAR supported HIV/AIDS activities.

LINKS TO OTHER ACTIVITIES: TA to NACA, states, NASCP, the Federal Ministry of Women Affairs and

Social Development and PEPFAR partners is directly linked to system strengthening and policy

development. Linkages between TA in data collection, analysis and utilization of information will strengthen

the capacity of the organizations and personnel to generate reliable, timely and accurate information that

improves the ability of health managers and providers at all levels to plan activities, set priorities, and

allocate human and financial resources in response to needs.

Activity Narrative:

POPULATIONS BEING TARGETED: Orphans and Vulnerable Children is a population being targeted

under this activity.

EMPHASIS AREAS: The emphasis areas for this activity are local organization capacity building and SI.