ACTIVITY DESCRIPTION:

Utilizing a network model with PMTCT care centers linked to secondary and tertiary "hub sites" that provide

more complex PMTCT care and lab testing, in COP08 111,500 women will receive PMTCT counseling &

testing and receive their results. A total of 106 PMTCT sites will be supported (64 sites established by the

end of COP07 and 42 sites added by the end of COP08). Sites are located in 23 states: Akwa Ibom,

Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina,

Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, and Sokoto.

As part of the USG local government area (LGA) coverage strategy in PMTCT, ACTION-supported PMTCT

services in Bauchi, Lagos, and Plateau will be focused at the primary health center level. PMTCT stand

alone points of service in the network are linked to adult and pediatric ARV care through utilization of a

PMTCT consultant coordinator in each network based at the hub site, network referral SOPs, monthly

PMTCT network meetings, and incorporation of team approaches to care in all training and site monitoring.

Through this SOP, HIV+ pregnant women who require HAART are linked to an ARV point of service.

Particular emphasis is placed on the involvement of community health workers who are the primary source

of care for women in the pre and post-partum period and are integral to a program that seeks to engage

women where they seek care. This program will work closely with the care and support team to maximally

engage community based PMTCT and ARV linkages. In addition to receiving PMTCT services, each HIV+

pregnant woman will be referred to OVC services in order to facilitate care for all of her affected children.

Opt-out HCT with same day test results will be provided to all women presenting for ANC and untested

women presenting for labor and delivery. All women are provided pre-test counseling services on

prevention of HIV infection including the risks of MTCT. Partner testing is offered as part of counseling

through referral to on-site HCT centers. A step down training of couple counseling and a prevention for

positives package will be utilized in all sites. This will provide an opportunity to interrupt heterosexual

transmission, especially in discordant couples. Master trainers for HCT will train labor and delivery staff in

the use of HIV rapid tests for women who present at delivery without antenatal care.

An anticipated 5,575 HIV+ pregnant women will be identified and provided with a complete course of ARV

prophylaxis (based on ACTION's current program prevalence of slightly over 5%). HIV+ women will have

access to lab services including CD4 counts without charge. This will be available on-site or within the

network through specimen transport. Women requiring HAART for their own health care are linked to a

network ARV center. For the anticipated 2/3 of women not requiring HAART, the current WHO

recommended short course ARV option will be provided which includes ZDV from 28 weeks or ZDV/3TC

from 34/36wks, intra-partum NVP, and a 7 day ZDV/3TC post-partum tail. Women presenting in labor will

receive SDNVP and a 7 day ZDV/3TC post-partum tail. All HIV+ women will be linked post-partum to an

HIV/ARV point of service, which will utilize a family centered care delivery model whenever feasible, co-

locating adult and pediatric care and providing a linkage to family planning services. Women frequently face

barriers to facility-based treatment access as a result of demands on them for child care and to contribute to

the family economic capacity. To address this, mobile clinic outreach as described in the ARV service

provision and care and support narratives will be integrated at the community level to bring services to

women who otherwise will opt-out of care and treatment.

HIV+ women will be counseled pre- and post-natally regarding exclusive breast feeding with early cessation

or exclusive BMS if AFASS using the WHO UNICEF curriculum adapted for Nigeria. Couples counseling or

family member disclosure will be utilized to facilitate support for infant feeding choices. Consistent with

national policies on importation of infant formula and recent concerns regarding appropriate use of BMS,

ACTION will not utilize EP funds to purchase BMS. As part of OVC programming ACTION will provide safe

nutritional supplements as well as water guard, bed nets and other home based care items. HIV+ women

will be linked to support groups in their communities which will provide both education and ongoing support

around infant feeding choices and prevention for positives. PLWHA are currently employed at ACTION ARV

points of service as treatment support specialists. The use of dedicated treatment support specialists for

PMTCT in the clinic and community will be expanded based upon the successful "Mothers to Mothers"

model in Southern and East Africa. This will ensure that HIV+ women remain in care throughout pregnancy

and receive appropriate services for herself and her infant.

Infant prophylaxis will consist of single dose NVP with ZDV for 6 weeks in accordance with Nigerian

National PMTCT Guidelines. Cotrimoxazole suspension is provided to all exposed infants pending a

negative virologic diagnosis. Eight regional laboratory centers for DNA PCR have been established by

ACTION with an additional 2 planned for COP08. Testing of infants will be carried out using dried blood spot

(DBS) specimen collection. ACTION will actively participate in the national early infant diagnosis initiative by

providing DNA PCR testing of DBS at ACTION-supported labs. The source of DBS samples will include

ACTION and non-ACTION supported PMTCT sites. A systematic coordinated approach to program linkage

will be operationalized at the site level and program level including linkages to adult and pediatric ART

services, OVC services and basic care and support. Quality monitoring will be undertaken through site visits

using an existing assessment tool and routine monitoring and evaluation indicators.

ACTION will train an average of 4 HCWs from each of the 106 sites including community-based health

workers in the provision of PMTCT services and infant feeding counseling. The national PMTCT training

curriculum, national infant feeding curriculum and new national training tools currently under development

will be utilized. Under COP07, ACTION has adapted and piloted a modified version of the PMTCT National

Curriculum for traditional birth attendants (TBA) which focuses on HCT and referral of HIV+ women.

ACTION piloted this with 20 TBA in COP07 and will expand to an additional 50 in COP08. Two Trainings of

Trainers (18 trainees each) on infant feeding will conducted in conjunction with the MOH. Thus the total

direct training target is 510. ACTION will continue to collaborate with the GON and the Clinton Foundation

to conduct trainings focusing on EID procedures including specimen transport and for EID commodities.

In addition to routine monitoring and evaluation activities, ACTION will contribute to a PHE that will evaluate

best practices and document best program models for increasing the number of HIV+ pregnant women who

receive HAART. The aim is to identify which models of ART service delivery to pregnant women result in

the best uptake for PMTCT and maternal treatment interventions.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

This activity will provide counseling & testing services to 111,500 pregnant women, and provide ARV

Activity Narrative: prophylaxis to 5,575 mother and infants pairs. This will contribute to the PEPFAR goal of preventing

1,145,545 new HIV infections in Nigeria by 2009. With 106 operational sites, the PMTCT activity is in line

with the desire of the GON to have 1,200 PMTCT sites operational by 2008 and the USG's target of having

80% PMTCT coverage.

LINKS TO OTHER ACTIVITIES:

This activity is linked to care and support (3259.08), OVC (5417.08), ARV services (3255.08), laboratory

infrastructure (3256.08), condoms & other prevention (9210.08), AB (15651.08), and SI (3253.08).

Prevention for positives counseling will be integrated within PMTCT care for HIV+ women. The basic

package of care provided to all HIV+ patients will be available to HIV+ pregnant women. ACTION lab staff

will ensure that HIV testing provided within the PMTCT context is of high quality by incorporating PMTCT

sites into the laboratory QA program. ACTION will collaborate with UNICEF in the support of PMTCT

services at some sites, leveraging resources without duplication and creating a more sustainable service

support structure.

POPULATIONS BEING TARGETED:

This activity targets pregnant women who will be offered HCT, HIV+ pregnant women for ARV prophylaxis

and infant feeding counseling, and exposed infants for prophylaxis and EID.

EMPHASIS AREAS

The key emphasis area is training as most supported personnel are technical experts. A secondary

emphasis area is commodity procurement as ARVs for prophylaxis and laboratory reagents for infant

diagnosis will be procured. Another secondary emphasis area is network/ referral systems as networks of

care will be supported which are critical to ensuring quality of care at the PHC level, identifying women in

need of HAART, and ensuring access to HAART within the network. In addition, partners and PABAs will be

identified for linkage to care and support services. In addition, this activity addresses gender since treatment

will be provided to women and will focus on family centric issues including male involvement in PMTCT

programming.

ACTIVITY NARRATIVE:

ACTION will be a new partner in the program area of Abstinence/Be Faithful (AB) in COP08. ACTION 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 through a balanced portfolio of AB

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

will extend its reach with AB services into focused communities in six states (Plateau, FCT, Benue, Kaduna

and Kano and Edo). Through its other program areas ACTION has a large population of HIV+ adults,

adolescents and children to which it is already providing services; these associated points of service will be

utilized as referral centers for any clients that may be interested in HCT as a result of AB services. In

addition, ACTION 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). A good number of youth

and young adults in this age group are in tertiary educational institutions where they can be accessed for

appropriate AB messages. It is expected that a combination of prevention messaging approaches will

ensure they are reached with prevention interventions and will facilitate behavior change.

In COP08 ACTION will implement this activity at tertiary educational institutions (Polytechnics and

Universities) that are located in cities where linkages are available to treatment centers so that as AB

messages are delivered and individuals are interested in getting tested, there will be appropriate linkages

where necessary. ACTION will work principally at the educational institutions but will have spill over to the

community levels utilizing a combination of multiple strategies in this implementation. These will include; (1)

community awareness campaigns specifically focusing on Small Group Discussions (SGD) that will be

based on departmental levels; (2) school based approach which will leverage existing curricula developed

jointly by the Federal Ministry of Education and the Society for Family Health ; and (3) peer education plus

activities focusing on drama groups.

The curriculum will be used to train lecturers and guidance counselors who will now provide AB messages

in their routine teachings. Students will also receive AB messages from SGD that will be based in the

different departments. In addition, ACTION will implement this activity through the peer education plus

activities by supporting a dance drama group that will perform in these same targeted institutions. These

dramas will have culturally and age group relevant scripts written by a professional consultant using input

from the SGD. The content will be piloted for acceptability and accurateness of the messages before

performances are carried out to these institutions.

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

campaigns by other USG partners such as the successful Zip-Up campaign. AB messages will be balanced

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

other PEPFAR services being provided at five hospital networks and their surrounding communities which

will serve as the centers for referrals for ACTION prevention activities in the coming year in the six states.

The goal of the program is to be focused on the school 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 AB messaging: (1) on a regular basis and (2) via the three

strategies ACTION will employ (community awareness campaigns, school based programming and peer

education plus activities). The target for this intensive AB messaging campaign is 11,480 individuals. A total

of 700 persons made up of teachers, guidance counselors, school health care workers, and peer educators

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

ACTION will also collaborate with International Institute of Christian Studies (IICS) an NGO that has worked

with the Nigerian Federal Ministry of Education and has implemented effective AB services in secondary

schools in Nigeria. This program will be carried out in accordance with the USG and GoN HIV/AIDS five-

year plan. Through this mechanism ACTION will liaise with several community based organizations (CBOs),

faith based organizations (FBOs), and support groups at its facilities and surrounding communities in other

PEPFAR programming activities. These CBOs, FBOs and support groups will serve as appropriate partners

in the dissemination of balanced ABC messaging to catchment populations utilizing the peer education

model. These CBOs as secondary beneficiaries will be invited to concerts organized in these institutions so

that ABC messages would be reinforced. IICS will organize these activities in tertiary educational institutions

under the supervision of ACTION and will include activities such as dance drama presentations, musical

events and focus group discussions. In collaboration with the HCT program area, ACTION will also support

the establishment of HCT services in these institutions so that on-site HCT and condom outlet services will

be available, thereby complementing the balanced AB messaging campaign.

Another focus of the program in COP08 will be improvement of the linkages between appropriately

balanced ABC services and HCT/HIV treatment activities. The incorporation of HIV AB messages by

lecturers who have access to this age group on a regular basis will institutionalize the AB services. In

addition prevention activities will be assimilated into points of health care service in each institution

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

reduction counseling.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

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

of the community awareness campaigns, the school based programs, 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 - educators, healthcare workers

and related populations of PLWA. This program will contribute to the Global HIV/AIDS Strategy by reaching

11,480 people with AB messaging and 5,740 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 (5550.08), by increasing awareness of HIV. It also relates to care and support

activities (5552.08) through dissemination of information by home based care providers and ultimately by

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

other prevention (9208.08) as a complementary prevention strategy and to OVC programming (5547.08) by

targeting orphans and vulnerable children.

POPULATIONS TARGETED:

Key populations targeted are youths (particularly university and polytechnic students), teachers and adults

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

EMPHASIS AREAS:

Emphasis will be on human capacity development. 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 features of the program.

ACTIVITY DESCRIPTION:

ACTION will support the USG effort to assist the Nigerian National Blood Transfusion Service (NBTS) in the

development of a nationally-coordinated blood program to ensure a safe and adequate blood supply by

supporting four large tertiary hospitals as model blood banks to effectively utilize screened blood from NBTS

Zonal Centers for the majority (80%) of their transfusion needs by the end of COP08. These activities will be

facilitated through the provision of step-down training, proper blood storage and testing equipment, and

supplies. For their emergency transfusions as an interim measure, the four model sites will be supported to

utilize the NBTS standard donor screening questionnaire, provide full HCT services for all emergency

donors, and screen all emergency donors for the four transfusion transmitted infections (TTIs) (HIV I and II,

syphilis, hepatitis B, and hepatitis C) in accordance with NBTS policies. The model blood banks will also be

supported to carry out proper universal precautions, good laboratory practice, waste management, and

QA/QC for all serological testing. Approximately 50 other facilities supported by ACTION and carrying out

blood transfusion services will be supported to utilize the NBTS donor screening questionnaire, provide pre-

donation HCT, and implement standardized blood collection methods. Safe injection program area

resources will be leveraged to facilitate proper universal precautions and waste management.

In COP08, ACTION will work closely with NBTS and Safe Blood for Africa Foundation (SBFA) in all aspects

of its blood safety program. ACTION 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.

ACTION will work with NBTS Centers to implement blood drives at supported facilities and surrounding

communities. To assist in the development of efficient national coordinated and centralized donor

recruitment, blood screening, and distribution systems in accordance with the Nigerian National Blood

Transfusion Policy, four selected ACTION sites which are large tertiary hospitals involved in the provision of

blood transfusion services will be supported as model blood banks linked to the nearest NBTS Center.

Model blood banks will include: University of Abuja Teaching Hospital linked to the FCT Zonal Center,

Bauchi Specialist Hospital linked to the North Central Zonal Center in Jos, University of Benin Teaching

Hospital linked to the South-South Zonal Center in Benin, and Nnamdi Azikiwe University Teaching Hospital

linked to the South-East Zonal Center in Owerri. Model blood banks will be supported to screen and bleed

donors in addition to implementing donor referrals to Zonal Centers. The NBTS/hospital blood exchange

program will put a system in place whereby NBTS will develop and implement a delivery system with these

hospitals with appropriate blood banking facilities in place. NBTS will pick up unscreened blood units that

the hospitals have appropriately collected and stored and will transport these units back to NBTS centers

where they will be screened for the four transfusion transmissible infections (TTIs) of HIV I and II, hepatitis

B, hepatitis C and syphilis using ELISA techniques. In addition to collecting unscreened units, NBTS will

deliver to these four hospitals their requested order of screened units for blood banking and use at the

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

blood units collected by each facility. Infrastructure support for these model sites will include renovation of

the site donor bay and blood bank to provide for proper ambient temperature for laboratory testing,

provision of proper blood storage refrigerators, and provision of a centrifuge and disposables for cross

matching.

Recognizing that the transition to full reliance upon the NBTS Centers for all blood products will take some

time, model sites will be supported to follow NBTS policy in the identification and collection of blood from all

donors including blood for emergency transfusions. It is anticipated that the four model sites will require

12,000 units of blood during the COP08 period with a goal of 80% (9,600 units) of these screened and

provided through the NBTS Centers. Procedures for emergency donors at the site will mirror NBTS Center

procedures to the extent possible. This will include the use of the NBTS donor screening questionnaire for

all donors with deferred as necessary based on responses, and the provision of standard HCT services to

donors using the National HIV rapid testing algorithm. In order to maintain high quality laboratory results,

ACTION will include the blood bank in its laboratory QA/QC program that involves on-site quarterly

monitoring and retraining as well as selective retesting and proficiency panels for all serologic testing.

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 form contracting infections, especially HIV.

Proper waste management will be encouraged through the use of biohazard bags, suitable sharps

containers, and the use of incinerators. In addition, each site will have in place a Post-Exposure

Prophylaxis (PEP) protocol and starter kits in the event of an occupational exposure (described under the

ARV services narrative).

Ten staff will be trained at each of the four model sites by SBFA who in turn will utilize standardized training

modules that are appropriate to the various levels of trainees and approved by NBTS. In order to avoid

double counting, these 40 targets are counted under the SBFA blood safety narrative. For core TOT

modules developed by SBFA, ACTION will conduct step down training to 40 direct targets.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

Activities in this program area will support PEPFAR and GON goals to avert new infections through

ensuring that all blood transfused at selected facilities are HIV free by instituting safe blood activities at all

sites. Screening for TTIs will provide information on prevalence among blood donors and guide future policy

formulation on TTI screening. ACTION activities will support the implementation of GON operational

guidelines for blood transfusion practice in Nigeria and actualization of a well coordinated and centralized

blood supply system in the country, while the QA program will serve as a mechanism to measure and

evaluate the success of the intervention strategy.

LINKS TO OTHER ACTIVITIES:

This activity is linked to HCT (5426.08) as directed donors and voluntary donors will be provided with full

HCT services prior to blood donation. This activity is also linked to infection control activities under injection

safety (6821.08) as a post exposure prophylaxis policy will be instituted, universal precaution supplies

including safe disposal containers will be provided, and training will be conducted. Linkages to laboratory

infrastructure (3256.08) also exist. Strategies for HIV positive donor referral to clinical ARV facilities will

promote treatment access goals and provide encouragement of donors to have HIV testing done. Linkages

to AB (15651.08) and condoms and other prevention (9210.08) will also exist as HIV prevention materials

and free condoms will be provided at the blood screening sites to encourage HIV prevention among donors.

Activity Narrative: SI (3253.08) will support data gathering related to blood donations.

POPULATIONS BEING TARGETED:

The target populations are blood donors, laboratory workers, physicians and blood donor organizers at

public facilities who will be the focus of capacity development and voluntary blood donations.

EMPHASIS AREAS:

An emphasis area for this activity is training as capacity development for sustainability is a key focus.

Organizational capacity building is also a focus as capacity around blood donor drives and blood banking

abilities in facilities is strengthened. Renovations are a minor emphasis.

This activity will increase awareness and build skills around safe blood issues at facility and community

levels, reducing stigma and discrimination among health care workers. It is expected to also promote

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

volunteers available for blood donations.

ACTIVITY DESCRIPTION:

In COP07, ACTION supported 46 sites in 13 states (Anambra, Edo, FCT, Nassarawa, Kogi, Niger, Kano,

Cross Rivers, Bauchi, Benue, Rivers, Delta, and Lagos) with injection safety programming. In COP08,

ACTION will collaborate with JSI/MMIS to provide safe injection programming to 106 ACTION-supported

sites in 23 states (Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo,

Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto). In

COP06 and COP07, JSI procured commodities for all sites while ACTION and JSI divided sites by state in

the provision of training and commodity management. Under COP08, JSI will provide initial training and

seed commodities to all sites, while ACTION will provide step down training and ongoing commodity

procurement and management for all sites. An ACTION program officer is dedicated to oversight of this

program area with the support of regionally based medical and nursing program officers. The focus of this

activity is to reduce exposure to blood borne pathogens, particularly HIV, and the incidence of medical

transmission of these pathogens.

Health care workers targeted for this activity include physicians, nurses, community health extension

workers (CHEWs), laboratory workers, and waste handlers. JSI will be responsible for conducting initial

training at the site level; this will include both the training of new sites and the retraining of existing sites.

ACTION will support follow-up and step down site level trainings to train an average of 8 additional staff per

site for a direct training target of 848. Physicians and nurses from the inpatient wards, clinics, labor and

delivery, and the surgical theater will be targeted. In addition, HCT counselors performing rapid tests,

laboratory scientists, blood bank staff, and waste handlers will be trained. Training topics will include BCC

strategies to reduce unnecessary medical injections, safe injection practices, proper handling and disposal

of syringes and sharps, infection control policies and practices, universal precautions, use of personal

protective equipment (PPE), protocol for post-exposure prophylaxis (PEP, see ART services), and

appropriate waste segregation, handling, and disposal. Standard curricula and IEC materials developed by

JSI/MMIS and approved by the GON will be utilized. In addition, training materials developed in the context

of the OVC program that address issues of stigma and irrational fear related to "fear of contagion" will be

included with the goal that informed health care providers and CHEWs will help inform others in the health

care and community setting of what the true risks are rather than the widely held beliefs prevalent in the

community that contribute to stigmatization. Sites will also be provided job aids and IEC materials to

encourage behavior change and sustainability.

While JSI, the main procuring IP will provide a seed stock of all commodities, ACTION will continue to

provide personal protective commodities and will take on the new role of logistic supply of recurrent stocks

of injection safety commodities for all sites. ACTION will supply color coded bin liners for waste segregation

and universal precaution supplies including gloves, eye shields, boots, and aprons. Commodities and

disposables will be procured, warehoused and distributed by ACTION. They will be provided to sites based

upon a pull system using a site level inventory control system linked to the ACTION warehouse logistics

management information system. The current system can be easily harmonized with a national or PEPFAR-

wide logistics management information system and inventory control system once implemented. In addition,

ACTION will support safe health care waste management by supporting repair of existing incinerators at

sites.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

This activity will contribute to the reduction of medical transmission of HIV and other blood-borne diseases

by following universal precaution measures, as well as proper waste management. It will likely improve the

quality of health care and reduce stigma and barriers to comprehensive medical care for PLWHA by

addressing concerns of health workers and other hospital staff. Overall this will contribute to the USG goal

for Nigeria of the prevention of 1,145,545 new HIV infections by 2010 in Nigeria.

LINKS TO OTHER ACTIVITIES:

This activity is linked to laboratory services (3256.08), PMTCT (3257.08), ART services (3255.08), blood

safety (3258.08), HCT (5426.08) and SI (3253.08). 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:

Doctors, nurses, laboratory scientists, other health care workers and waste handlers are targeted for

training and services in the public sector.

KEY LEGISLATIVE ISSUES ADDRESSED:

This activity addresses issues of stigma and discrimination as the services will reduce stigma and

discrimination associated with HIV status in the health care facility setting.

EMPHASIS AREAS:

The emphasis area for this activity is training as nearly all supported personnel are technical experts who

focus on development of training materials, SOPs and the provision of training at the site level. A secondary

emphasis area is commodity procurement as supplies for safe disposal will be procured and supplied.

ACTIVITY DESCRIPTION:

ACTION will provide Condoms & Other Prevention (C&OP) Activities targeting 38,600 most at risk persons

(MARPs) and support 60 community based condom outlets in locations frequented by MARPs such as bars,

brothels and truck stops in addition to the hospital based outlets co-located at HCT/ART clinics. Sites are

located in states chosen consistent with the National ARV Scale-Up Plan with the goal of universal access.

They include: Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa,

Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, and Sokoto.

ACTION will build on COP07 successes to expand prevention services and linkages to wraparound

services (e.g., family planning). At the health care facility level this will complement prevention with positives

(PwP) activities described and supported under BC&S programming. Prevention services will take place in

community settings including: skills development centers, prisons, truck stops, markets, and OVC centers

targeting out-of-school youth. ACTION will complement mobile HCT with prevention services by supporting

NGOs to establish HCT/OP sites at locales where transactional and intergenerational sex are common

using five mobile HCT vans based out of ACTION regional offices. Under COP06, the HIV Sero-prevalence

among clients tested in a mobile setting was 19.1% and 27.5% in the first quarter of COP07. ACTION will

expand prevention programs in collaboration with experienced CBOs and peer educators along the Benin-

Lagos transport corridor, targeting truck drivers and those who engage in transactional sex at overnight

motor parks, increasing the targeted truck stops from 3 to 6. This will be based on a successful Mombasa-

Kampala corridor model developed in Kenya-Uganda. A Sero-prevalence exceeding 20% is anticipated.

Under COP07, ACTION provided HCT services at Kuje, Keffi & Suleja prisons and will build on that

experience to add prevention services for the incarcerated testing HIV- and will increase the number of

prison sites served. This will be done in collaboration with and in support of the HIV/AIDS unit of the GON

Ministry of Internal Affairs. ACTION will work with a CBO experienced in dealing with prison populations to

determine feasibility of providing ARV and other services while maintaining prisoners' confidentiality.

ACTION also targets out-of-school youth via community centers and organized activities supported through

OVC programming. C&OP will be balanced with AB prevention messaging and will be offered to youth in

these settings.

ACTION will implement its C&OP activities in line with the overall PEPFAR Nigeria goal of providing a

comprehensive package of prevention services to individuals reached through a balanced portfolio of

prevention activities which will also include abstinence and be faithful messages. In COP08 ACTION will

implement this activity at the community level utilizing a combination of strategies, including community

outreach campaigns, peer education models, and STI screening/management/treatment. Peer education

strategies will focus on Greater Involvement of People with HIV/AIDS (GIPA). The goal of the program is to

cover target communities with messages conveyed in multiple fora. Utilizing this 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 the three key strategies ACTION will employ (community outreach campaigns, peer education

models, STI screening/management/treatment). The target for this activity is 38,600 individuals. ACTION

will employ a dedicated staff person to oversee these prevention activities.

ACTION will enhance services for MARPs testing HIV- by coupling post test counseling with targeted

behavior change interventions that address individual risk. Individual counseling will include

abstinence/mutual faithfulness messages, promotion/instruction regarding correct and consistent condom

use, information education communication (IEC) materials and linkages to family planning services.

Community outreach through collaboration with PLWHA support groups will ensure that IEC materials and

counseling messages are culturally acceptable. Group counseling will be carried out in supportive settings

to discuss and promote HIV prevention behaviors including avoidance of STIs, recognition and seeking

early treatment for STI symptoms, and reduction of alcohol/illicit drug use. Condom promotion and

distribution will be coupled with prevention information about abstinence and mutual faithfulness, behavioral

change communication, and risk reduction education using peer educators. Sixty stationary condom

distribution points at locales frequented by MARPs (such as bars serving truck drivers) will be established

and maintained along with 78 situated within ART facilities making a total of 138 outlets.

Building on the model piloted in COP07, mobile HCT vans will be utilized for the provision of syndromic STI

services in conjunction with HCT services targeting truck stops and night spots frequented by MARPs. This

service will be provided by Community Heath Extension Workers (CHEWs) following standard SOPs for

syndromic STI management and will include treatment for syphilis, gonorrhea, and Chlamydia. Program

staff will work with sites to ensure appropriate linkage/referrals to STI care.

PwP strategies targeting HIV+ persons will be included in this package of services for MARPs using

approaches developed during COP07 and materials developed through USG Nigeria. ACTION will support

risk reduction and safer sex promotion activities among HIV positive clients, partners and their households.

The comprehensive package of prevention interventions will include provider and counselor delivered

prevention messages, family planning counseling, STI management and treatment, and testing of partners

and children. Lay counselors and peer educators will be mobilized for more in-depth counseling on key

prevention issues such as: sexual risk reduction, disclosure, adherence, reduction of alcohol consumption

and partner testing. Condoms and information on proper condom use will be available to all patients

attending ACTION supported ARV clinics. Other components of the comprehensive package of prevention

interventions are further described under the basic care and support program area.

Site/regional level trainings for CHEWS in STI syndromic management will be carried out by ACTION

program staff. Peer educators and PLWHAs will be trained by ACTION program staff and CBO

subcontractors using a curriculum developed by SFH focusing on truck stop and commercial sex settings as

well as a manual on Interpersonal Communications jointly developed by ACTION and SFH. General training

will include risk stratification, disclosure and couple counseling, proper condom use and syndromic STI

management training for health care workers. The direct training target is 380 persons.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

As high risk and "bridge" populations contribute to HIV transmission, this activity will support the Nigerian

Federal Ministry of Health (FMOH) and EP goal of reducing new infections and thus decreasing the overall

disease burden of HIV in Nigeria by enhancing HCT with targeted prevention messages and interventions.

Targeted efforts to promote correct and consistent condom use and STI management for MARPs can

Activity Narrative: reduce the risk of HIV infection.

LINKS TO OTHER ACTIVITIES:

This activity relates to activities in AB (15651.08), care and support (3259.08), ARV services (3255.08),

OVC (5417.08), HCT (5426.08) and SI (3253.08). A challenge of this program is to successfully link those

identified as HIV positive with services. The populations being targeted often do not access services via

traditional treatment venues. The program will create a means of strengthening these linkages and will

identify through the hub and spoke model innovative strategies for creating access to treatment in

convenient venues. Targeting MARPs will help to identify persons who need referral into care, ARV services

and prevention for positives counseling which will be an important component of posttest counseling of

HIV+ persons as part of HCT services and the basic package of care. Balanced prevention messages

targeting behavior change will complement HCT for all irrespective of HIV status. OVCs will be taught family

life and sex negotiation skills.

POPULATIONS BEING TARGETED:

This activity focuses on MARPs such as commercial sex workers and their clients, prisoners, out-of-school

youth, and mobile populations such as truck drivers. The prison population presents special challenges in

this regard because of potential for stigmatization in a dangerous environment. Doctors, nurses, other

health care workers in the public sector as well as PLWHA and peer educators are targeted for training.

EMPHASIS AREAS:

An emphasis for this activity is human capacity development as training as nearly all supported personnel

are technical experts who focus on this at the central and site level. Community development through

linkages with CBOs and PLWHA support groups is also emphasized.

This activity also addresses the issue of stigma and discrimination since HIV counseling reduces stigma

associated with HIV status through education.

ACTIVITY DESCRIPTION:

In COP07, ACTION provided comprehensive care and support services to 51,405 PLWHA through 24 sites.

In COP08, ACTION will expand this service provision to 87,725 HIV+ adults and support services to an

additional 175,450 persons affected by AIDS (PABAs) at 78 tertiary, secondary and primary health center

points of service within 28 hub and spoke model care networks in 23 states (Akwa Ibom, Anambra, Bauchi,

Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos,

Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto). $600,000 in COP07 HBHC funds are for use against

COP08 Care and Support targets as per the COP07 reprogramming exercise in July 2007. These funds

were reduced from the COP08 funding and redirected to the COP08 RFA accordingly.

In COP 08, ACTION will continue to provide lab services (CD4, hematology, blood chemistry, LFT, OI and

pregnancy testing if indicated), OI prophylaxis and treatment, nutritional assessment, pain management,

psychological, social, spiritual and home based care (HBC) to all PLWHA enrolled into care. ACTION will

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

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

services to all PLWHA. The laboratory services will be provided at least every 6 months with CD4 count to

monitor for change in status. Access to appropriate TB diagnostics and linkages with DOTS programs

described under TB/HIV are also provided. Care providers, including volunteers, are trained in screening for

signs and symptoms of TB such as chronic cough, weight loss, night sweats, etc. and clients with such

symptoms or signs are referred for diagnostic services. Screening for hepatitis B and malaria is supported

for all HIV+ persons if indicated. The nutritional status of PLWHA will be assessed at the initial clinical

contact and at follow-up visits. If diagnosed with malnutrition micronutrients will be offered and

referrals/linkages to wraparound services providing nutritional therapy will be given. All PLWHA will be

provided with a preventive care package including ITN, water guard, water vessel, soap, ORS sachets,

condoms and IEC materials on self care and prevention of common OIs. Prevention with positive services

provided to PLWHA include condoms and information on use, counseling on reduction of high risk

behaviors, abstinence messages, discordant couple counseling and syndromic management of STIs. A

standard formulary is provided to sites to treat common opportunistic infections and malaria.

PLWHA and PABAs will be afforded linkages to psychosocial support through participation in PLWHA

support groups and individual counseling operational at all points of service. The function of PLWHA

support groups is strengthened by an ACTION program officer with a counseling background who works

with the support groups to improve their programs and to ensure linkages between points of service and

communities. Community based and home based (HBC) patient assessments that tie in with community

clinic and mobile outreach clinical services are being expanded to bring a broader and more integrated

approach to BCS in order to better support patients at the community and home level and support retention

in care.

Services to be provided to PABAs at the clinic and community levels include: promotion of HCT; HIV

prevention education including balanced ABC services as appropriate; psychosocial support through on-site

counselors; and participation in support groups designed for family members focusing on prevention of

transmission, stigma/discrimination reduction, and serving as a treatment partner to support adherence.

Support groups will also provide linkages to spiritual support services through the active involvement of

spiritual leaders in the community. It is anticipated that many PABAs will be accessed in the community

rather than clinic setting through the community HBC program which will provide HCT access, linkages to

HIV care and other services, and peer support to PABAs as well as facilitation of home care to PLWHA by

PABAs.

Community HBC will be provided in each of the 78 network catchment areas ACTION supports. This is

implemented by a supervising community HBC nurse, health extension workers and volunteers. This activity

will be linked to primary prevention and HCT programs emphasizing the home based approach to these

other programs and ensuring family engagement in HBC. In addition to HBC for those requiring classic

"palliative care" interventions, HBC providers support ART adherence in the home setting through education

and addressing adherence barriers. HBC providers focus on linkage to services, ensuring that clients in

need of hospital care are able to access this care and linking family members to OVC, PMTCT, community

immunization, family planning, and TB DOTS services. ACTION will continue to utilize different models

depending upon the site preference including supplementing site staffing with dedicated HBC staff or

developing an agreement with a local NGO/CBO/FBO to provide this service. Extension workers will be

preferentially recruited from PLWHA support group memberships. These activities will be linked to the

patient's medical care source as the supervising community home based care nurse/PHC extension worker

will work under the medical direction of the site physician.

Training essential for program success will target nurses, community health extension workers (CHEWs),

counselors and PLWHA/community volunteers and is carried out by ACTION program staff at the site level

to maximize coverage. When feasible, training will be coordinated with IMAI curriculum for PHC staff and

will be harmonized to avoid redundancy. For healthcare workers, care and support training will be

coordinated with safe injection training. The total training target is 468. Standard training curricula for

healthcare workers and community volunteers have been developed by ACTION and include specific

modules on pediatric home based care. ACTION is participating in the National harmonization process to

ensure standardization of training. A quality control program focuses on assessment of knowledge at the

time of training and post-training, monitoring of metrics from HIVQUAL and from M&E indicators and

conducting field assessments. The ACTION training department analyzes these data to upgrade training

materials and to provide retraining where indicators demonstrate a gap in knowledge and implementation.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

This activity provides services which are a high priority for the 2-7-10 Emergency Plan strategy by providing

a basic package of care services to all HIV+ adults and PABAs. The services are consistent with the draft

Guidelines for Palliative Care in Nigeria and the USG Palliative Care Policy as well as the Nigerian

Guidelines for Antiretroviral Therapy which stress home based care, symptom management, and OI

prophylaxis. Capacity development at the site level and consistency with national guidelines will ensure

sustainability.

LINKS TO OTHER ACTIVITIES:

As part of ACTION's integrated treatment to care model, a more seamless integration of services at all

Activity Narrative: levels of the care system is being implemented, and BC&S plays a critical role in this linkage process. Using

the Hub-and-Spoke model in site selection also leverages resources and improves referrals between

tertiary, secondary and primary health care facilities. This activity is linked to HCT (5426.08), condoms and

other prevention (9210.08), ARV services (3255.08), OVC (5417.08), TB/HIV (3254.08), lab (3256.08), and

SI (3253.08). HCT targeting most at risk populations is established proximate to BC&S points of service. All

patients are monitored and linked to ARV therapy when indicated. Services are co-located with TB DOTS

centers and ACTION staff work with sites to ensure coordination systems are in place. High quality

laboratory services supported by an ACTION facilitated laboratory QA program are available at sites. Home

based care programs will be implemented by a number of indigenous NGOs, CBOs, FBOs and PLWHA

support groups. Sub-agreements will be coordinated with other Emergency Plan IPs to ensure non-overlap

of funding and services.

POPULATIONS BEING TARGETED:

Populations targeted include persons in prostitution, TB patients OVC and pregnant women. Services are

offered to adults living with HIV/AIDS and PABAs. Sites have been chosen to maximize linkages with

national TB DOTS sites and to provide services for HIV+ pregnant women identified through PMTCT.

Doctors, nurses, other health workers (public sector) as well as people living with HIV/AIDS and caregivers

of PLWHA are targeted for training.

EMPHASIS AREAS:

Emphasis areas include human capacity building as capacity development for sustainability is a key focus.

Local organization capacity building and TB-related wraparound programs are another focus.

ACTIVITY DESCRIPTION:

In COP07 ACTION supports integrated TB/HIV services at 44 sites and will develop 34 additional sites

under COP08 for a total of 78 comprehensive care sites. ACTION, with other implementing partners, will

implement the PEPFAR-Nigeria LGA coverage strategy ensuring the provision of TB/HIV services in at least

one health facility in every local government area (LGA) of ‘LGA Coverage' designated states. This is a

critical step toward the states providing universal access to TB/HIV services. Consistent with this strategy

and structured under a hub and spoke network model, additional stand alone TB DOTS sites will be

supported to provide HCT services for TB patients for a total of 92 sites in 23 states (Akwa Ibom, Anambra,

Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara,

Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto) in COP08. $566,700 in COP07 TB/HIV funds are

for use against COP08 TB/HIV targets as per the COP07 reprogramming exercise in July 2007. These

funds were reduced from the COP08 funding and redirected to the RFA accordingly.

The integrated management of HIV/TB co-infected patients at ACTION points of service (POS) will remain a

major focus. TB screening and diagnosis follows the National algorithm and is in line with National

guidelines. At ARV POS, patient record forms have been modified to prompt for TB screening indicators

and site level training of health workers is on utilization of symptom history including chronic cough, fever,

weight loss, or night sweats to prompt referral for TB evaluation. Chest x-ray is supported for sputum

negative patients and for candidates for INH prophylaxis. ACTION has collaborated extensively with the

National TB and Leprosy Control Programme (NTBLCP) to conduct a feasibility pilot of INH prophylaxis for

HIV-infected patients. Eligible TB/HIV patients will also receive Cotrimaxozole Preventive Therapy (CPT).

The TB DOTS sites will be supported to provide holistic patient care according to National and IMAI

guidelines. In addition, HIVQUAL will be utilized as a clinical quality indicator and improvement strategy at

sites. ACTION M&E staff support the National surveillance program by ensuring that sites properly report

incident TB cases to FMOH.

Under COP08, ACTION will support HCT for 25,000 clients being evaluated for TB at 92 DOTS points of

service. These will include stand alone DOTS centers, linked PMTCT-DOTS services in LGA-coverage

states, as well as DOTS centers at comprehensive care sites. Of these, it is expected that 10,000 of those

getting HCT will have TB. ACTION will reach a total of 6,128 TB/HIV co-infected patients with TB treatment.

Infection control at health centers is a priority to limit nosocomial transmission of TB to HIV+ patients. Basic

hygiene, proper sputum disposal, and good cross ventilation at clinics will be promoted. Facility co-location

of TB/HIV services is preferred to clinic co-location. National guidelines on infection control for co-located

sites will be implemented at all sites.

ACTION has supported the GON in carrying out preparatory HCT trainings for DOTS staff at the National

TB and Leprosy Training Centre (NTBLTC) in Zaria under COP07. In COP08, DOTS staff at targeted

centers will be trained on the National testing algorithm using the National HCT training curriculum. Training

will be conducted by ACTION HCT program staff or ACTION regional HCT master trainers. All clients

presenting to DOTS centers will receive HIV pre and posttest counseling with rapid testing carried out using

an opt-out approach to provide same day results. Those testing HIV+ will be referred for further evaluation

and care to an ARV POS within the network. Regionally based ACTION HCT program officers will ensure

referral linkage for DOTS stand alone sites.

ACTION will build on the successes of ongoing collaboration with the NTBLTC in Zaria to strengthen the

integration of high quality TB detection, diagnosis, and resistance testing with care delivery in support of the

National TB control strategy. Under COP07, ACTION partnered with the GON to train staff from every state

in Nigeria in HCT and TB diagnosis. These trainings have been jointly supported by the Global Fund (GF)

and the synergy between the two funding streams has been important in capacity development as part of

the national TB response in Nigeria. In addition, a QA program for TB smear microscopy based at the

NTBLTC has been implemented and includes: joint site visits with the FMOH or relevant state MOH for

observation/retraining, selective review of completed smear examinations for external quality assessment,

and proficiency testing with "unknown" slides provided by the QA team. The collaboration under COP08 will

focus on training in TB culture and sensitivity developed at the NTBLTC and two other ACTION regional

training laboratories under COP07. The conventional Bactec culture system is implemented using both the

MGIT 960 automated system at referral centers and the complimentary manual BACTEC tube at tertiary

and secondary sites. The microscopic observation drug susceptibility (MODS) assay is piloted as a more

scaleable alternative. In all activities infection control and safety is optimized. Focusing on sustainability, 30

lab scientists from selected ACTION and GF/GON supported sites will be trained in TB culture at NTBLTC

in COP08. A minimum of 184 TB DOTS staff from ACTION supported sites and 180 DOTS staff from

GON/GF supported sites will be trained in HCT in a TB setting and refresher trained in smear microscopy at

the NTBLTC. Twenty-eight senior site physicians will be trained in a TOT focusing on diagnosis and

management of TB/HIV co-infection. They will each train a minimum of 20 health care workers at their

respective sites for an indirect target of 560. Thus the direct training target is 422. Approximately 200

additional TB DOTS staff funded by other donors such as GLRA and MLR will also be trained.

ACTION will conduct three TB/HIV PHE activities in COP08. The first is collaboration with WHO and

NASCP to explore the use of manual MGIT at sites that link to the national TB referral center. It will evaluate

if this enhanced intervention to identify and treat TB/HIV co-infected patients decreases early mortality. It

will also determine its effectiveness for expanded culture capacity for TB/HIV co-infected persons. In

addition, ACTION will collaborate with NASCP, NTBLCP and WHO to evaluate a new cost effective MODS

technology against the standard automated MGIT system. The aim is to determine the optimal screening

tool to identify TB/HIV co-infected patients in resource restricted settings. The third PHE is also a

collaboration with NASCP, NTBLCP, and WHO to identify challenges faced by the clients from HIV/AIDS

service delivery sites in accessing TB DOTS services.

ACTION will also work with SCMS in country to procure equipment and supplies. Commodity management

of HIV test kits and supplies will be provided by ACTION using the current regional distribution system.

ACTION will upgrade facilities through infrastructure support such as basic renovations, upgrading

equipment and procuring supplies and consumables. ACTION will strengthen the pharmacy services at

supported TB DOTS sites to improve forecasting and avoid stock outs and will work with sites to recognize

if stock outs are due to facility level or government level TB logistics issues.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

Activity Narrative: Training and support to improve the quality and integration of TB/HIV services are consistent with FMOH

and EP priorities. Activities will be carried out collaboratively with FMOH and state MOH to promote

sustainability through capacity development and integration into the health sector system. COP08 activities

will focus on sustainability of the national training program and the national model facility for laboratory

diagnosis and clinical care with a decreasing dependence upon ACTION technical expertise and a focus on

the training of a cadre of Master Trainers.

LINKS TO OTHER ACTIVITIES:

HCT targets in this section are not included in the testing target in the HCT narrative and those in the HCT

narrative do not overlap with these targets. This activity is linked to HCT (5426.08), BC&S (3259.08), OVC

(5417.08) and ARV services (3255.08) lab (3256.08), and SI (3253.08). ACTION will expand HIV treatment

access to community venues including DOTS centers, an approach that will also strengthen treatment

adherence for both TB and HIV and articulate TB and ARV services to promote seamless transition from TB

to HIV treatment and care. The collaboration with the NTBLTC will also include training to ensure that HCT

is available at all DOTS POS. Linkages to TB diagnosis and treatment is an important component of adult

BC&S and OVC services. Linkage to ARV services and proper management of patients requiring ARV and

TB medications is a focus.

TARGET POPULATIONS:

Persons at risk, including household members, people who have documented TB, OVC, pregnant women

and PLWHA are targeted. Screening of close household members for both HIV and TB will promote a public

health strategy reaching populations at risk with diagnosis and services. ARV services are offered to HIV+

infants/children and adults with TB. Doctors, nurses, laboratory workers community outreach workers, GON

staff, and DOTS staff are targeted for training in both the public and private sectors.

EMPHASIS AREAS:

Emphasis areas include construction and renovation, human capacity development, local organization

capacity building, and TB related wraparound programs. This activity focuses on the issue of wraparound as

the activity relies upon non-EP TB funding and promotes linkage with HIV-specific programs to ensure that

comprehensive services are available to TB/HIV co-infected persons.

ACTIVITY DESCRIPTION:

In COP07 ACTION reached 7,203 OVC in 23 states with services. In COP08, ACTION will provide OVC

services through a comprehensive package of care to 10,000 children at a minimum of 53 sites in 23 states

(Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna,

Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto). This will include 5,943

HIV infected children (5,443 requiring ART) and 4,057 uninfected OVC who will be directly provided with

three core OVC services of health care, food/nutrition, and psychosocial support and linked to community

OVC providers to ensure access to the other core OVC services of shelter & care, protection, and education

when needed. $500,000 of FY07 reprogrammed funds will be applied against COP08 targets for UMD.

Health care services will include access to free lab monitoring for 500 HIV-infected children not requiring

ARV treatment including: CD4 count, hematology, and chemistry. (For those on ARVs this is covered in the

ARV services program.) The basic health care package which will be available to all of the 5,943 HIV-

infected children receiving services includes: access to appropriate TB diagnostics and linkage with GON

sponsored DOTS programs described under TB/HIV, instruction for parents/caregivers in appropriate water

purification and provision of water guard, provision of ITNs, provision of cotrimoxazole prophylaxis,

diagnosis and treatment of malaria, and symptom management including provision of pediatric formulations

of antidiarrheals/ antihelminthics/ analgesics/ antipyretics. In addition, a standard formulary will be provided

to sites to treat common OIs.

Community home based care (HBC) for children is in need of extensive development in Nigeria. Under

COP07, ACTION updated its HBC curriculum to include modules on HBC for children. HBC for children will

be linked to HBC for adults and provided in all 28 network areas under COP08, so that at least 1,000

children of the 10,000 total target receive pediatric specific HBC. This is implemented by a supervising

community HBC nurse, health extension workers and volunteers. This activity will be linked to primary

prevention and HCT programs emphasizing the home-based approach to ensure that family members at

risk including other children in the household are tested and counseled. This strategy supports family

engagement in HBC and identifies family members in need of HIV care. In addition to HBC for those

children requiring classic "palliative care" interventions, home based care staff support parents with ART

adherence for children in the home setting through education and addressing adherence barriers. Home

based care staff focus on linkages to services, ensuring that clients in need of hospital care are able to

access this care and linking family members to PMTCT, community immunization, family planning, and TB

DOTS services. ACTION will continue to utilize different models depending upon the site preference

including supplementing site staffing with dedicated home based care staff or developing agreements with

local NGOs/CBOs/FBOs to provide this service. Extension workers will be preferentially recruited from the

PLWHA support group membership. HBC will be linked to the child's medical care source as the

supervising community home based care nurse/PHC extension worker will work under the medical direction

of the site physician.

Access to food and nutrition support is a major need for children. Leveraging support from the Clinton

Foundation, ACTION will provide comprehensive nutritional support for OVCs through the provision of

fortified cereals, Kwashi-pap & PlumpyNut, targeting HIV-infected children as well as HIV-exposed infants

weaning after exclusive breast feeding. This will include nutritional assessment and counseling as well as

multivitamins/mineral supplementation. In the provision of nutritional supplements, ACTION will build the

capacity of care givers by providing raw materials and instructions so that Kwashi-pap can be prepared by

them at home. ACTION will prioritize partnering with new USG-supported wraparound services in states

where it is co-located with these activities.

ACTION has worked in COP07 to strengthen psychosocial support for children by improving the quality of

counseling available for HIV-infected children at points of service through training focused on counseling of

children. In COP08 ACTION will expand this training and will utilize a psychologist to train Master Trainers

(10 very experienced counselors) in a curriculum developed by University of Maryland and recently piloted

in Zambia. This curriculum includes formal child development, socialization, limit setting, pediatric

counseling, diagnosis disclosure, grief and loss, and adherence to medications. Each of these master

trainers will be supported to conduct regional trainings and provide on-site mentoring. This step down

training and mentoring will include not only HBC and facility based providers but will also focus on improving

psychosocial support for OVC in orphanages. ACTION partners with community OVC providers including

the Sisters of the Poorest of the Poor, the Anglican Church and the Mothers Welfare Group in provision of

OVC services to OVC in their homes and to OVC in orphanages. Through these partnerships this step

down training will ensure improved provision of psychosocial services not only to OVC in their homes but

also to OVC in orphanages who are awaiting family placement.

In addition to HIV-infected children and HIV-exposed infants, ACTION will support community OVC

providers to serve HIV uninfected but affected children, particularly orphans, directly providing food/nutrition

and psychosocial support as detailed above. Linkages with community NGOs and faith based

organizations as well as traditional community OVC providers will be established for community based HCT

for orphans in order to identify positive ones that need to be enrolled into care and also access to other core

OVC program services including: shelter and care, protection, education/vocational training, and economic

opportunities/strengthening. A tracking/referral form will be utilized to ensure that each child has access to

these key core program services. ACTION will provide services for adult HIV negative PABAs through

counseling and provision of a preventive care package. These kits will be supplied by SFH and will be

distributed at the site level and through community HBC.

Training of health workers and community volunteers will be conducted primarily at the site level to ensure

maximum coverage in the most cost effective manner. The TOT and regional counseling trainings are

described above. The total training target is 358. Upgrading training in the issues of HIV for NGOs engaged

in OVC services and for social workers will target improved understanding of the stigma surrounding HIV

positive children and the need to integrate healthy HIV positive children into mainstream social and school

settings without fear due to lack of understanding of risks surrounding HIV transmission in school-aged

children.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

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

services to all HIV+ children. The services are consistent with the National OVC Standard of Practice and

Activity Narrative: OVC National Plan of Action. Capacity development at the site level and consistency with national

guidelines will ensure sustainability. Capacity development will be achieved through regional training and

skills development.

LINKS TO OTHER ACTIVITIES:

This activity is linked to HCT (5426.08), ARV services (3255.08), TB/HIV (3254.08), AB (15651.08), lab

(3256.08), and SI (3253.08). HCT services will be available to HIV affected family members (PABAs) in

need of HIV testing including in-home HCT through HBC services. All patients are monitored and linked to

ARV therapy when indicated. OVC services such as psychosocial support for families and symptom

management promotes ARV adherence. Home based care programs will be implemented by a number of

indigenous NGOs, CBOs and FBOs. Sub-agreements will be coordinated with other EP IPs to ensure non-

overlap of funding and services. Services are co-located with TB DOTS centers and ACTION staff work with

sites to ensure coordination systems are in place. High quality laboratory services supported by an ACTION

facilitated laboratory QA program are available at sites. This will include EID available in all catchment

areas (see lab narrative).

POPULATIONS BEING TARGETED:

OVC services are offered to HIV positive infants and children, children orphaned by HIV, caregivers of OVC

and HIV/AIDS affected families. Doctors, nurses, social workers, care givers, teachers, family members and

other health workers in the public and private sector are targeted for training. Community groups including

CBOs, NGOs and FBOs will be targeted for training, linkages and identifying OVCs.

EMPHASIS AREAS:

Emphasis is placed on training and human resources as capacity development for sustainability is a key

focus and much of the community linkages are through partners. In addition, community mobilization and

infrastructure development of CBOs/FBOs is critical for the identification and care of OVC.

This activity addresses the area of wraparounds as activities will strengthen/develop linkages between

HIV/AIDS services and other sectors for food resources. The activity also addresses the key area of stigma

and discrimination as training of health care workers and community volunteers will reduce stigma.

ACTIVITY DESCRIPTION:

In COP08 ACTION will provide Counseling & Testing (HCT) services to 157,000 people at 121 points of

service (POS). $655,000 of COP07 reprogrammed funds will be applied against COP08 targets. HCT

services will be supported at 78 ART POS, 28 PMTCT and HCT sites, and 15 HCT stand alone sites for a

total of 121 service outlets in 23 states (Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo,

FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun,

Plateau, Sokoto). With a mobile HCT van in 5 regions, ACTION will collaborate with indigenous NGOs to

offer testing to most at risk persons (MARPs) using a mobile strategy linking HCT to Condoms and Other

Prevention (C&OP) activities. HCT carried out at an additional 92 TB DOTS POS will be supported under

the TB/HIV program.

HCT services will be provided by trained counselors using the national testing algorithm and opt-out

approach in accordance with the national HCT SOP and testing strategy. The national "Heart to Heart"

branding logo will be utilized at all POS. Counseling and IEC materials will focus on abstinence, be faithful,

and consistent and correct condom use (ABC). In addition, IEC materials will include information promoting

couple counseling and counselors will be trained on partner based approaches to counseling. Discordant

couples will receive a package of services including safer sex behavior messages, condoms and

information targeting both positive and negative partners. This activity will be linked to PwP (prevention with

positives) as detailed in the Basic Care & Support narrative. Whenever feasible, client witnessed testing will

be carried out to encourage client confidence in the result. Intensive advocacy for implementation of HIV

testing by non-laboratorians has taken place, thus counselors will carry out rapid tests in most settings. To

ensure the quality of test results, laboratory program officers assist with training and a QA program focused

on rapid test monitoring is in place. Prevalence will be monitored regularly to optimize targeted screening of

populations with high rates of infection.

Posttest counseling for those testing negative will focus on prevention using a balanced ABC approach, and

partner testing will be encouraged. Based on risk assessment, a follow-up testing interval will be

recommended. Posttest counseling for those testing positive will include PwP counseling which also

includes balanced ABC messaging as appropriate. Counselors are trained to encourage disclosure to

spouse and sexual partners while addressing potential negative consequences of such disclosure. PLWHA

treatment support specialists are employed at ART treatment sites to ease the referral and linkages for

newly diagnosed clients. Newly identified HIV+ clients at free standing or community based HCT centers will

be linked to HIV care centers in the network.

Hospital-based HCT services will be provided in all tertiary, secondary and primary health facilities

supported by ACTION. These services will be available to all individuals within the institution and the

catchment area of the facility. HCT services will be emphasized throughout facilities, and particularly to

MARPs such as STI patients. Other strategies to increase access and target HCT in facilities will be the

training of health care providers to facilitate the provider initiated HCT approach. HCT staff will round

regularly on the wards to identify inpatients in need of HIV testing in collaboration with medical staff. For

those health facilities providing blood transfusion services, all potential blood donors will be offered HCT at

the facility and receive standard HCT services as part of pre-donation screening. In addition, HCT staff will

support DOTS center staff in the provision of HCT services to patients presenting for evaluation as detailed

in the TB/HIV narrative.

Community based mobile HCT services will be expanded, with one van based at each of the five ACTION

regional offices, to assist hospital based HCT teams that frequently provide HCT in the community setting

and to link HIV+ patients identified to the points of service. The M&E staff will compile data on rates by

target population and venue and use data to guide systematic screening strategies. Under COP06, the HIV

seroprevalence among clients tested in a mobile setting was 19.1% and this has risen to 27.5% in the first

quarter of COP07, demonstrating the ability to identify communities at high risk of HIV acquisition and

transmission. Another strategy to increase access to HCT outside of facilities is to train and equip HBC

teams to provide home-based HCT to family members of HIV+ HBC clients. In addition, 15 community

based testing sites will be developed through collaborations with indigenous NGOs and local public health

clinics. The NGOs will establish stationary HCT sites and utilize the mobile HCT van at truck stops and

other venues appropriate to access hard to reach MARPs as detailed in the C&OP narrative. Those testing

HIV+ will be linked to care within the network. MARPs testing HIV- will be linked to C&OP services offering

education, counseling, social support, and syndromic STI management.

The M&E system will be primarily ledger based to maximize time devoted to service provision and facilitate

services in the primary health center and community mobile settings. Aggregate data will be reported to the

ACTION regional M&E program officer monthly. A referral tracking system for HIV+ clients has been

developed and will be utilized. The quality assurance (QA) strategy for counseling will include posttest client

surveys, quarterly site monitoring visits using an existing quality assessment tool, and routine reviewing of

M&E data. A major metric of the QA process will be the percentage of positives entering care. Feedback to

sites will occur quarterly with targeted refresher courses and regional TA for those needing capacity

building. An extensive laboratory QA program (described under lab program area) is in place to ensure the

accuracy of HIV rapid testing. Test kits and disposables will be warehoused by ACTION and provided to

sites based on a pull system using site level inventory control systems linked to ACTION's logistics

management information system. The current system can be easily harmonized with the national test kit

logistics management information system and inventory control system once implemented.

Under COP07, a cadre of master trainers drawn from sites was developed. ACTION program staff and the

Master Trainers will use the National HCT Training Curricula and SOPs for regional and site level training.

Training will target staff from new and existing sites, ensuring that refresher training is provided and couples

counseling is integrated at all sites. A minimum of 3 staff from each HCT POS will be trained for a direct

target of 363. This target will include the identification and training of 30 new Master Trainers from the 5

ACTION regions. They will conduct step-down trainings to reach 5 additional counselors each for a total

indirect target of 150. Training to facilitate the provision of HCT at DOTS POS is described under the

TB/HIV Program Area.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

This activity supports the national HCT scale up plan by promoting the accessibility of HCT services using a

FMOH approved training curriculum and procedures. HCT services are essential to identifying HIV+ people

Activity Narrative: to meet national prevention goals and the national ARV/HIV care scale-up goals. HCT services will target

most at risk persons to maximize this impact. The activity will support the FMOH and EP goal of having high

quality HIV testing available at all sites.

LINKS TO OTHER ACTIVITIES:

This activity is linked to care and support (3259.08), OVC (5417.08), ARV services (3255.08), condoms &

other prevention (9210.08), AB (15651.08), lab (3256.08) and SI (3253.08). PwP counseling and a

prevention care package will be integrated with posttest counseling for HIV+ persons. Access to care

services and ARV services will be provided. Other at risk family members including vulnerable children will

be identified through community based HCT approaches and referred to services. In appropriate settings,

testing will be carried out by counselors with training and oversight by ACTION laboratory staff. HCT sites

are incorporated into the laboratory QA program to ensure that HIV testing is of high quality.

POPULATIONS BEING TARGETED:

This activity serves children, youth and adults in the general population who will be offered HCT. However,

special focus will be given to MARPs, including commercial sex workers, discordant couples, mobile

populations, partners/clients of commercial sex workers and those who abuse alcohol and other

substances. Training targets health care workers, counselors and community volunteers.

EMPHASIS AREAS:

An emphasis for this activity is human capacity development as nearly all supported personnel are technical

experts who focus on this at the central and site level. Other areas of emphasis include local organization

capacity building and SI. This activity addresses the issue of stigma and discrimination since HIV

counseling reduces stigma associated with HIV status through education.

ACTIVITY DESCRIPTION:

In COP08 ARV drugs will be procured so that ARV treatment can be provided to 55,057 adults (17,998

new) and 5,443 children (2,000 new) at 78 clinical sites in 23 states in Nigeria. $1.3 Million of COP07

reprogrammed funds will be applied against COP08 targets. Sites are located in states chosen consistent

with the National ARV Scale-Up Plan with the goal of universal access and include: Akwa Ibom, Anambra,

Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara,

Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, and Sokoto. This support is an increase from the 44 ARV

treatment sites supported under COP07.

The first component of this activity includes forecasting and procurement of ARV drugs. It is estimated that

90% of patients begun on EP-provided ARVs will be adults and the remaining 10% will be children. Patients

on ARVs include those started on ARVs in prior years, patients in care who roll over into treatment, and

newly diagnosed patients needing ART. Overall, it is assumed that 8% of both adults and children begun on

ARVs during prior years will ultimately require second line treatment under COP08.

ACTION will follow the Nigerian ARV Guidelines in the provision of ARV regimens for adults and children.

The regimen mix has been forecasted based on current utilization and balancing best clinical evidence with

scalability. PEPFAR and FDA-approved generic formulations will be utilized whenever available. For all

regimens, a three-month buffer stock is maintained to minimize the likelihood of problems with drug

supplies. ACTION staff develop ARV projections, and plan procurements accordingly. In COP08 a minimum

of 50% of ARV procurement and shipping of has been budgeted for SCMS in order to provide support to

efforts to build a centralized capacity related to drug procurement and distribution. A standing open

purchase order for up to 50% has also been established with IDA Foundation as a backup. Based on

current drug unit costs, an additional 5% for procurement and 5% for shipping has been added to the

budget for both SCMS and IDA Foundation. Both SCMS and IDA inspect drugs for authenticity and test

selected batches prior to accepting for shipping. SCMS and IDA certify packaging and storage conditions

during shipping and provide insurance to the point of delivery at the frontier. Drug procurement will follow

USG regulations, National Treatment Guidelines, and comply with requirements for NAFDAC registration or

waiver.

Although collaboration with the FMOH may facilitate some sites being provided with first line ARV

formulations through Global Fund support, the full cost of ARV drugs required to care for new and

maintenance ARV patients has been budgeted in the COP at this time. Should FMOH be able to provide

first line ARV formulations, targets will be adjusted accordingly, and ACTION will ensure access to

alternative first line and second line ARVs, pediatric formulations, and wrap around services including lab

monitoring. Similarly, collaborations with the Clinton Foundation may result in the procurement of pediatric

formulations and second line adult ARVs. In that case, a similar procedure will be followed. Coordination

with the FMOH to plan site targets will ensure a single comprehensive HIV care program although there

may be multiple ARV sources. The key principle adopted by ACTION is that all patients receive equal high

quality clinical, laboratory, and community services regardless of the drug source.

The second component of this activity includes expediting commodities through the port of entry, followed

by storage, distribution, and management of the commodities. This includes site assessment of pharmacies

and storage facilities with corrective recommendations and actions. Needed site renovations for proper

security and storage conditions in pharmacy stores will be undertaken by ACTION. Training of site

pharmacists for drug commodity management using a computer or card-based inventory control system at

the site level and training in proper drug storage will be carried out. Storage and distribution of ARVs,

maintenance of a site level commodities management system, and instruction to site staff regarding the

system, has been subcontracted to the Axios Foundation. Axios documents proper storage conditions at the

central warehouse, regional warehouse, and site levels. With an expansion of ARV access to community

venues including mobile clinics, local health centers, DOTS centers, and community pharmacies, logistical

management of ART drugs will require increasingly sophisticated monitoring strategies. The success of

such approaches is vital to increasing adherence and avoiding patient default which program evaluations

have shown is often linked to distance traveled from home to the ARV center.

Quality control involves routine monitoring visits by ACTION staff from the central Abuja office or from

regional offices to all sites every six months to review the implementation of SOPs and to compare reported

usage based on monitoring and evaluation data with local manifests and pharmacy logs. The ACTION

training department analyzes data for patterns of deficiencies as well as individual site deficiencies in order

to improve training and target weaknesses to address through retraining.

UMD has allocated $10,684,000 of its ARV Drugs budget to SCMS for procurement of commodities. This

amount is captured under the SCMS Drugs activity.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

This activity supports the scale up of ARV treatment in Nigeria, a major priority for the FMOH. Through

these activities, ACTION will continue to strengthen the structure of its ART drug procurement system, 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,

ACTION seeks to provide support to efforts to build capacity related to drug procurement and distribution.

This activity also supports the ARV program for adults and children as well as the PMTCT program for

provision of ARVs to pregnant women and infants..

LINKS TO OTHER ACTIVITIES:

This activity relates to activities in TB/HIV (3254.08), ART services (3255.08), and strategic information

(3253.08). This activity will maintain significant linkages with PMTCT (3257.08) and ART services through

the procurement of ARV drugs for individuals served by these programs. Additionally, linkages to TB/HIV

activities will be developed and maintained. 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.

Activity Narrative: POPULATIONS BEING TARGETED:

The primary targets 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:

Human capacity development is an emphasis area. Training initiatives have been incorporated into these

activities in order to build the local human resource capacity to manage a sustainable drug procurement and

distribution system. Other areas of emphasis include the development of SI management, through M&E

activities, to provide feedback on the cost effectiveness of these drug procurement activities. SI

management also ensures accurate drug projections in order to prevent stock-outs.

ACTION will provide ARV services and lab monitoring to 60,500 individuals, including 55,057 adults (17,998

new) and 5,443 children (2000 new). In COP07 ACTION supported ARV services at 44 sites and under

COP08 will develop 34 more sites for a total of 78 sites: 28 tertiary or large secondary hospital "hub" sites,

25 smaller secondary hospitals, and 25 primary health centers (PHC) and DOTS satellite sites using the

hub-and-spoke model. $700,000 for COP07 reprogrammed funds will be applied against COP08 targets.

Sites will be located in 23 states (Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT,

Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau,

Sokoto). Sites are chosen jointly with the GON to complement the national scale-up plan being supported

by Global Fund (GF) and other IPs. Services at PHC and DOTS satellite sites are provided using three

different strategies to ensure quality of care and network linkages: physician and lab assistant team travels

from the "hub" site on selected days; nurse-managed PHCs/DOTS with nurses trained using the IMAI

national curriculum; and physician/lab assistant team utilizes mobile site/van equipped with CD4 and basic

lab equipment to visit PHCs on selected days. An alternative model employs a physician or nurse-led team

with transport of samples back to the hub site for lab testing. The choice of best model will depend on

which one provides timely and high quality results with good patient adherence. In all models of community

outreach a portable pharmacy is employed to deliver ARVs to patients at the community level.

Currently, 9% of ACTION-supported ARV patients are children; this will be increased to 10-15% under

COP08. Pediatric ARV care will be expanded to all supported tertiary and secondary hospitals and selected

PHCs. ACTION will collaborate with GON to adapt and expand the IMCI curriculum to facilitate quality

pediatric ARV care at the PHC level. ACTION staff participate actively in National ARV Guideline

Committees. Guidelines for adults and pediatrics were updated in 2007 for consistency with WHO 2006

guidelines. A corresponding National ARV SOP has been developed. ACTION ARV services are in line with

GON guidelines. Non-ART and ART eligible clients will be enrolled into care and will receive regular clinical

monitoring including CD4 count. ACTION supports PLWHA support groups to facilitate adherence and to

provide IEC materials. All sites are supported to employ treatment support specialists - PLWHA who

participate in patient education, client advocacy, and home visits to track defaulters. All ARV clients receive

care services including prevention for positives activities (e.g., balanced ABC messaging, couples

counseling), ITN, water guard, malaria diagnosis/treatment, OI prophylaxis/diagnosis/treatment (including

TMP/SMX), pain/symptom medications, and psychosocial support including linkages to community and

facility-based support groups. Home based care programs provide linkages between the medical home and

the community.

PMTCT stand-alone points of service (POS) link to adult and pediatric ARV care through utilization of a

network PMTCT coordinator based at the hub site. A specific referral SOP is used to ensure that HIV+

pregnant women who require HAART for their own care are linked to an ARV POS. Leveraging support

from the Clinton Foundation for test kits and specimen transport, EID will be available at PMTCT POS under

COP08 to improve the identification of HIV+ children for linkage into ARV services. In addition, community

based testing of children will be carried out in the OVC program.

ACTION uses ART expertise to ensure high quality care using a two-pronged didactic and experiential

training approach. Using expert staff from established POS as resource persons, 320 staff (physicians,

nurses, counselors, pharmacists) from COP08 POS will participate in central or regional trainings on adult

and pediatric ARV care, adherence counseling, and/or pharmacy SOPs. All training will include approaches

for prevention for positives integrated into the clinic and community setting. Adapted IMAI/IMCI manuals will

be used to step down trainings for secondary, PHC and DOTS sites. The curricula used were developed by

ACTION and other IPs and are being harmonized into National curricula appropriate for training various

cadres. Bedside teaching is also a component of ongoing education. IHV/UMD adult and pediatric HIV care

specialists are posted in Nigeria as preceptors. In addition, a preceptor program brings volunteer physicians

with extensive HIV experience from other US and European institutions, and also uses expert on-site staff

as preceptors. ACTION has developed 3 regional training centers which are equipped with training venues

adjacent to large clinical care facilities where best practices are modeled. Following completion of the basic

curricula, staff spend two weeks at the regional training center participating in case conferences and

bedside teaching. As follow-up, preceptors are periodically posted to sites to ensure sustainability of high

quality care. A clinical training center in Abuja provides a model clinic that integrates physician, nurse,

treatment support, pharmacy and community outreach teams to provide experiential training in a holistic

model clinic setting in order to demonstrate feasible and functional strategies bridging community to care.

Metrics collected in the context of this model approach provide an objective measure for refining best

practices that can then be successfully introduced more widely.

ACTION supports 4 regional training labs (described under ARV Lab). These facilities will train 400

additional lab scientists working at GON and GF-supported sites (i.e., non-PEPFAR supported sites) in ARV

lab monitoring including good lab 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.

A clinical QA program in ACTION's Training Department uses objective measures of health care team

capacity based on knowledge assessment of individual providers, metrics from SI analysis, and onsite

observational assessment of clinical practice and community linkages. Collaboratively with the USG and

GON, ACTION carries out site program review visits. The QA program has site level clinical QA

coordinators assigned at each POS who perform structured periodic chart reviews that are incorporated into

the QA assessment process. Site level CareWare aggregate data is evaluated and feedback provided.

ACTION supports training of medical officers in IAPAC and GALEN certification as HIV specialists and other

clinical staff in expanded support roles under the treatment team concept. Based on gaps in knowledge

identified the Training Department refines/updates training materials for new and ongoing training activities.

ACTION will also facilitate and actively support onsite standardized HMIS using GON forms and National

electronic platforms and will provide onsite assistance with data management and M&E to guide quality

improvement measures.

Sites are supported to carry out renovations to ensure clinic facilities are adequate and particularly that

pharmacy store and dispensing areas are able to store ARVs consistent with manufacturer guidelines.

ARVs are procured as described in the ARV drugs narrative. ACTION will partner with Clinton Foundation

and GF as appropriate to leverage resources for providing ARVs to patients. In this scenario, ACTION

provides pharmaceutical commodity management and ensures access to alternative first line and second

Activity Narrative: line ARVs, pediatric formulations, and wraparound services including lab monitoring and high quality clinical

care. Coordination with the FMOH to plan site targets will ensure a single comprehensive HIV care program

although there may be multiple ARV sources. Additionally, sites receive training, a standard SOP, and

emergency prophylaxis starter kits for post-exposure prophylaxis to address occupational HIV exposure of

health care workers.

UMD has allocated $3,086,000 of its services budget to SCMS for procurement of commodities.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

At the end of COP08 ACTION will be providing ART services to 60,500 people, contributing to

GON/PEPFAR targets for Nigeria. ACTION will build the skills of at least 720 care providers thus

contributing to national sustainability plans.

LINKS TO OTHER ACTIVITIES:

This activity is linked to drugs (5429.08), HCT (5426.08), HVOP (9210.08), OVC (5417.08), HBHC

(3259.08), TB/HIV (3254.08), PMTCT (3257.08), lab (3256.08), and SI (3253.08). Patients on ART will be

linked to home based care and support and community and social services. TB/HIV linkages will be

strengthened; all HIV infected patients will be screened for TB using the National algorithm. ACTION will

also provide onsite assistance with data management and M&E to guide quality improvement. HCT

targeting MARPs is established proximate to ARV POS. Using a network model, linkage to ARV services for

HIV+ women identified through PMTCT and HIV-infected infants are in place. Quality lab services supported

by an ACTION-facilitated lab QA program are available at comprehensive sites while manual lab methods

or specimen transport systems will be established for primary health center satellites.

POPULATIONS BEING TARGETED:

ARV services are offered to HIV positive infants, children and adults living with HIV/AIDS. Doctors, nurses,

and pharmacists are targeted for training in both the public and private sectors. Health workers and

laboratorians at non-PEPFAR supported sites will be targeted by offering dedicated central ARV training.

EMPHASIS AREAS:

An emphasis will be placed on human capacity development through training and local organization

capacity building.

ACTIVITY DESCRIPTION:

ACTION will support ARV Services, BC&S, OVC, TB/HIV, PMTCT, and HCT programs by building lab

infrastructure and training staff to accurately diagnose, stage and monitor patients. ACTION will monitor

laboratories through its QA/QC activities to ensure high quality results while upgrading the infrastructure at

new sites. A minimum of 1,057,434 lab tests will be performed in COP08. ACTION will continue to be at the

forefront of EID scale up and expanded viral load testing for adults based on an algorithm being evaluated

with the FMOH. $350,000 of COP07 reporgrammed funds will be applied against COP08 targets.

ACTION will support lab services at 151 individual points of service using a network model to provide

appropriate lab capacity and patient support at comprehensive sites as well as HCT stand alone and DOTS

sites. An integrated tiered referral lab network with mentoring by trained lab personnel in existing hub sites

has been established. This includes the use of appropriate technology at all service levels, using the USG-

PEPFAR Lab Technical Working Group equipment platform as a guide. At the tertiary or large secondary

hospital level, 28 network reference or hub labs provide high throughput hemogram, clinical chemistry, and

CD4 assessment services. Ten of these provide virology services and 3 of these provide TB culture. At the

small secondary and primary level, an additional 25 labs provide patient monitoring and diagnostic

capability including HIV rapid testing, hemogram, and CD4 count. Thus, a minimum of 53 labs will have the

capacity to perform HIV testing and CD4 measurement (26 tertiary, 18 secondary, nine primary). At 25 other

sites where ARV services will be provided, labs are equipped to provide HIV rapid testing, hemogram

(including lymphocyte count), and collect/package samples for transport to a more advanced lab in their

network. Novel approaches for access to lab services such as five mobile laboratories on HCT vans will be

piloted to provide high quality on-site lab services to small PHC sites. Services at HCT stand alone and TB

DOTS points of service are limited to HIV rapid testing. This approach facilitates the rapid scale up of ART

services at all tiers of health care facilities.

ACTION has 23 local lab program staff assigned to six units (Field Operations and Commodities, Special

labs, QA/QC, TB, Training and Maintenance) and five regional offices. ACTION has an aggressive QA/QC

program with specially trained lab staff dedicated to carrying out on-site quarterly monitoring, retraining, and

overseeing a proficiency panel testing program. QA monitoring is carried out jointly with the FMOH or

SMOH responsible for the point of service. Tools and expertise will continue to be shared with other IPs and

with the GON and technical support will be provided to the Medical Lab Science Council of Nigeria

(MLSCN). ACTION has expanded site lab capability to screen for Hepatitis B, to diagnose additional OIs

such as Cryptococcus, and screen for common STIs including syphilis. TB culture capacity has been

developed at three of ACTION's sites using the Bactec system. The microscopic observation drug

susceptibility (MODS) assay will also be piloted at these sites and is described under TB/HIV. ACTION will

coordinate with Global Fund supported initiatives in the roll out of TB culture capacity in Nigeria to maximize

regional availability.

Eight regional virology laboratories in seven states (Sokoto, Kano, Plateau, FCT (two), Edo, Anambra, and

Akwa Ibom) have been established by ACTION. Under COP08, one additional virology lab (Gombe state)

will be developed for a total of nine. These laboratories focus on EID regionally using the DBS collection

method described under PMTCT. ACTION has played a key role in the EID roll out in COP07, utilizing the

ACTION training and reference lab at PLASVIREC to provide QA for the national EID pilot and providing

training in proper DBS collection and transport. All PCR labs supported by ACTION will participate in the

CDC DBS DNA PCR proficiency program. ACTION is actively collaborating with the Clinton Foundation

(CF) and the FMOH to develop EID SOPs and is carrying out testing of samples from sites that are

geographically proximate including those supported by other IPs, GON, and the Global Fund. The CF also

supports procurement of DNA test kits and DBS collection supplies and transport of specimens/results. In

addition to EID, virology labs carry out viral load for selected patients identified through a standard clinical

algorithm. Leveraging expertise in viral sequencing, ACTION will develop a HIV genotyping and drug

resistance testing facility in COP08 which will be readily accessible to the USG and other IPs and serve as

a regional resource for West Africa.

Four training laboratories have been developed as national resources by ACTION and placed zonally (FCT,

Kano, Edo, Plateau States). These laboratories are each configured with a didactic and a lab bench training

venue with standard equipment utilized at EP sites for CD4 measurement, hemogram, and chemistry as

well as teaching microscopes. The training laboratories are staffed with a master lab trainer and assistant,

but utilize local site lab experts to serve as resource persons for specific trainings to promote sustainability.

The regional lab training centers will be used to train personnel from new sites and offer refresher training

guided by QA results to staff from existing sites. Centralized trainings will include: Good Lab Practices

(GLP), HIV diagnosis, pediatric diagnosis, viral load estimation, CD4 staging, hematology, blood chemistry,

record keeping and storage. This is followed up by refresher trainings carried out at sites. 566 lab staff will

be trained. Training laboratories established by ACTION have been and will continue to be utilized by the

FMOH, public private partnerships, and other IPs for capacity development for national ARV scale up,

PMTCT, and TB priorities. These facilities will also be used to train200 scientists for ARV monitoring

(described under ART Services) and an additional 400 lab scientist from other organizations (not counted

under IHVN training targets). The National TB and Leprosy Training Centre in Zaria (Kaduna State) is

supported by ACTION, and serves as a fifth training lab supporting the National TB and Leprosy Control

Programme. This facility and the regional training laboratories will provide training for 594 TB DOTS staff

and 28 physicians as direct targets (described under TB/HIV).

ACTION will work with the USG and MLSCN for accreditation of 18 laboratories. Regional labs and those

critical to PHEs will be the first to be accredited. Through the PEPFAR lab working group (LTWG) ACTION

will work with the MLSCN to integrate its QA/QC activity into a sustainable national QA program including a

national EQA program. For procurement of lab reagents ACTION will utilize SCMS and local vendors.

ACTION maintains a warehouse and distribution system in-country. To maintain lab equipment, ACTION

has two biotech engineers on staff who provide training, installation, routine preventive maintenance,

trouble shooting and regular calibration. The availability of spare parts and back up equipment at ACTION's

warehouse in Abuja allows for prompt response to site needs. PEP is available at all ACTION supported

labs. Waste management and disposal, including TA to sites on procurement of a proper incinerator, is a

key component of training and site activation.

Sites are located in states consistent with the National ARV Scale-Up Plan with the goal of universal access

to HIV services. They include: Akwa Ibom, Anambra, Bauchi, Benue, Cross River, Delta, Edo, FCT, Gombe,

Activity Narrative: Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

EID regional availability will strengthen PMTCT, OVC and ARV Services. Testing for OIs will strengthen

BC&S. Regional training and Virology laboratories established by ACTION will support other IPs,

particularly for PMTCT and ARV. ACTION will train lab personnel and healthcare providers from TB labs of

other IPs and FMOH DOT centers, strengthening both HCT and TB. Through Public Private Partnership,

private industry supported labs benefit from ACTION's training and QA/QC program. These activities will

provide essential lab services to people living with HIV/AIDS, HIV positive pregnant women, HIV positive

infants, and HIV positive children. The QA/QC program of ACTION will strengthen the overall quality

initiatives of the GON.

LINKS TO OTHER ACTIVITIES:

These activities will be linked to activities in PMTCT (3257.08), OVC (5417.08), ARV Services (3255.08),

Blood safety (3258.08) and SI (3253.08). Tests for opportunistic infections and training in theses techniques

will strengthen BC&S (3259.08), HCT (5426.08), and HIV/TB (3254.08). ACTION will collaborate with the

Clinton Foundation in EID and pediatric ARV scale up.

POPULATIONS BEING TARGETED:

These activities will provide essential lab services to people living with HIV/AIDS with or without co-infection

with TB, HIV+ pregnant women, HIV+ infants, and HIV+ children. Lab workers will benefit from the Lab

Training centers and developed SOPs and training curriculum. As part of a Public Private Partnership,

industrial health care providers will benefit from ACTION's training and QA/QC program.

EMPHASIS AREAS:

An emphasis for this activity is human capacity development for sustainability through in-service training,

supportive supervision and quality assurance/improvement for laboratorians. Also emphasized is

infrastructure development through lab renovations for new sites, local organizational capacity building, and

strategic information.

ACTIVITY DESCRIPTION:

ACTION will strengthen Strategic Information (SI) under the "One M&E Framework" by supporting

standardized HIV program reporting systems and Health Management Information System (HMIS)/Patient

Management Monitoring (PMM). In COP07 ACTION is supporting SI activities in 121 sites in 23 states

(Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna,

Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto). In COP08 it is

expected that ACTION will support SI activities in 151 sites in 23 states, including 78 ART and full service

sites, 28 PMTCT/HCT sites, 15 HCT only sites, and 30 DOTS sites providing HCT services.

Effective use of paper-based data (using national paper-based systems) and electronic data will be

promoted in clinical, laboratory, and pharmacy settings to enhance the enrollment, follow-up, assessment,

and referral/linkages to other services (e.g. TB, STI, home-based care, etc.) for all clients in HIV care.

National registers and data tools will be used at all service delivery points. Funds will be used to provide

information technology (IT) infrastructure and CAREWare at ART sites with capacity for automation. For

ART sites where there is other donor support, data collection and indicator reporting will be harmonized and

one reporting system will be used in accordance with the national guidelines and indicators. Evaluations

using data collected through facility-based services and community-based services will be performed to

provide evidence-based decisions for program quality, impact, and effectiveness. A goal of these

evaluations is to better integrate the outputs of SI data into clinically relevant reports that will facilitate

patient management and encourage improved data recording by clinical staff. Continuous quality

improvement (QI) (HIVQUAL) will be implemented in coordination with USG at all points of service where

appropriate. This will provide readily available quality metrics and individual patient data to site staff which

will enhance site staff investment in the M&E process.

To this end the ACTION SI team is working with HRSA to facilitate direct download of laboratory data

electronically from laboratory equipment rather than depending on manual data entry of electronic

information. Reports that record serial laboratory data in tabular or graphic form will strengthen patient care

practice by streamlining data reporting in a user friendly fashion. Additional means of developing site-based

tools to promote accurate laboratory data reporting to support patient care and treatment is vital to QI and

where possible clinical data to support patient care at the site such as through CAREWare will be

emphasized. This data will also be employed to monitor loss to follow-up, treatment adherence and other

key metrics of clinical quality that will guide improved assessment, training, retraining and help define best

practices and strategies.

ACTION conducts quarterly data analysis meetings at each supported site to ensure data quality and

provide recommendations for improvements. On-site TA with more frequent follow-up monitoring visits will

be provided to address weaknesses when identified during routine visits. Randomly selected individual

patient records will be reviewed across tools as one method of assessing accuracy. Data quality

improvements at the local level supported by ACTION will ensure accurate data provision to the Nigerian

National AIDS surveillance and information system as well as state and local governments.

Since 2000, with support from CDC, ACTION assisted the Federal Ministry of Health (FMOH) in developing

and implementing the National PMTCT Monitoring Information System (PMTCT MIS) in Nigeria. ACTION

will continue to technically support the GON as needed in software maintenance of the national system and

will continue to work with GON on a mechanism to align the PMTCT MIS and PMM systems effectively to

improve follow-up and continued care for HIV-infected women and their exposed infants.

In addition, ACTION facilitates the provision of site level data to SACA and SMOH for state level

surveillance activities. ACTION is engaged in providing TA to the State ACTION Committees on AIDS

(SACAs) and State Ministries of Health (SMOH) in the implementation of the Nigerian National M&E System

(NNRIMS). SACA and SMOH staff are invited to every SI training activity supported by ACTION that takes

place within their states. TA through joint field monitoring visits will also be explored. Each ACTION state

level point of service has a representative to the SACA. State level data for the NNRIMS is reported by the

SACA to the National Agency for the Control of AIDS on AIDS (NACA). In addition to state level support,

ACTION SI staffs collaborate on a regular basis with NACA and NASCP on development and review of

National data collection tools and guidelines. It is anticipated that the USG-supported VOXIVA system will

complement the NNRIMS when the VOXIVA web-portal becomes operational. ACTION will support the

implementation of this system at appropriate points of service. Additionally, ACTION will ensure the

reproduction and distribution of NNRIMS and patient registries at supported sites. The SI team will continue

to be active participants on the SI working group established and coordinated by USG-Nigeria.

ACTION program staff will provide training to 369 individuals in monitoring and evaluation (M&E),

surveillance, and HMIS. Trainees will include record clerks, M&E officers, clinicians, pharmacists, nurses,

laboratorians, NGO staff/counselors. Emergency Plan (EP) funding will be used to train health care

providers and medical data personnel on data collection, data use and reporting. Site level M&E staffs are

hired through the hospital or health center personnel system. While sites are asked to provide for M&E

staffing, temporary staffing support is available to new sites that must agree at program initiation to list

these staff in the budget request for the institution for the next fiscal year. Dedicated M&E program staffs

are posted at ACTION regional offices to implement site data quality control/quality assurance activities. In

addition, program staffs are based at larger treatment sites to ensure accuracy and completeness of PMM

data. In COP08, ACTION will hire additional SI program assistants to facilitate development and refinement

of M&E materials and provide support in the development and establishment of a systematic procedure for

patient monitoring and evaluation including collecting, collating and reporting data tracked by the ACTION

Nigeria program. An SI staff member will be dedicated to public health evaluations as listed below.

CONTRIBUTIONS TO OVERALL PROGRAM AREA

Strengthening SI will enable timely, transparent, and quality data reporting of substantial portions of 2008

EP targets for Nigeria and will, through collaboration with the GON, establish one standardized system to

monitor the National HIV program. Planned public health evaluations (PHEs) will guide decisions in

improving program implementation and scale-up and will be defined and coordinated with the USG team in-

country. The following PHE are proposed (funded under their respective program areas): evaluation of the

referral system at the National TB Training Center, Zaria; capacity for early diagnosis of TB and MDR-TB in

the current scale up (TB/HIV); mobile radiography for TB diagnosis (TB/HIV); improving loss to follow-up

through the PMTCT cascade for HIV+ women and their infants; evaluating care outcome of HIV/AIDS

Activity Narrative: services at primary health centers utilizing trained and mentored Nurses or Community Health Officers

(ARV services).

Of interest is evaluating barriers to care and access to care for HIV positives identified and referred through

HCT. ACTION will work to promote effective use of patient data by care providers to ensure best practices

of HIV care. These activities will contribute to improved use of information strategically at all levels. This

activity also contributes to Nigeria's 5-Year National Strategic Framework's (2005-2009) emphases on

documenting best practices on ART, HCT, PMTCT, OVC, etc., on information linkages between sites and

services, on one standardized reporting framework, and on program evaluations through increased

involvement of local evaluation officers.

LINKS TO OTHER ACTIVITIES:

SI activities are cross-cutting and relate PMTCT (3257.08), blood safety (3258.08), AB (15651.08),

condoms and other prevention (9210.08), basic care and support (3259.08), TB/HIV (3254.08), OVC

(5417.08), ARV services (3255.08), and lab (3256.08). Linkages between these program activities will be

strengthened to improve efficiency and effectiveness of services in order to catalyze the formation of

networks of care.

POPULATIONS BEING TARGETED:

This activity targets health care providers in best practices of information use and reporting. Provision of TA

targets host country government workers. HMIS and program evaluations target general population and

people affected by HIV/AIDS receiving services supported by the ACTION Project.

EMPHASIS AREAS:

This activity includes an emphasis on human capacity development and SI.

This activity will look at gender equity trends within service sites by collecting data to show breakdown of

women and men receiving prevention activities, treatment, and care services and by analyzing HCT client

data to assess service uptake among couples/partners.

ACTIVITY DESCRIPTION:

This activity is linked to the Counseling and Testing (5426.08), ART Services (3255.08), Basic C&S

(3259.08), PMTCT (3257.08), OVC (5417.08), and Other Prevention (9210.08) program areas.

ACTION will support the efforts of the Nigerian FMOH and nursing educational sector in strengthening the

skills of nurses for the national response to the HIV/AIDS epidemic in the country in line with the Health

Sector National Strategic Framework for HIV/AIDS. Nurses constitute the highest number of health care

workers in Nigeria and spend the highest number of hours with patients. However, there has not been a

specific program to address the weak nursing knowledge in HIV care that exists country wide. If adequately

trained and empowered to utilize learned skills, nurses could render more appropriate care for PLWHAs and

contribute meaningfully to mitigating the impact of HIV/AIDS as well as to sustaining the efforts supported

by the Emergency Plan. As the number of patients accessing ART services continues to increase without

an exponential increase in the number of doctors, especially in primary and secondary sites, doctors are

overworked and patient access to care is sub-optimal. With proper training, nurses can be utilized to

address the personnel challenges faced by ART sites.

This activity is aimed at establishing an HIV care nurse training program at the practice and nursing

education level to address the weaknesses that exist in the skill levels of nursing professionals in Nigeria in

a sustainable manner. This training will be tied in with an integrated care strategy being implemented at the

model HIV Clinical Training Clinic at University of Abuja Teaching Hospital at Gwagwalada. The care model

employs a care team strategy that upgrades the role of the nurse in care provision and frees the physician

to address patient management challenges rather than focusing on onerous paper work. A care team

consisting of a physician, several nurses, adherence counselors, and pharmacy staff work together to

facilitate efficiency and quality of patient care. A community liaison links the team and the patient to

community-based services targeting improved treatment access, adherence, nutrition, safe water and home

-base care. Evaluation of this model and expanded training of other sites in an evidence-defined care

model will help shape policy for operationalizing the IMAI/IMC approach.

In COP07, ACTION collaborated with FMOH, Nursing & Midwifery Council of Nigeria and other USG

partners, LMS in particular, to develop a standard HIV/AIDS curriculum for nurses in practice. A pilot TOT

was conducted for 45 trainers drawn from different facilities at all tiers of the healthcare system. Under

COP08, this training will be rolled out regionally to nurses in practice. In addition, the curriculum will be

adapted for incorporation in the standard education of nursing students country-wide and a pilot training for

nursing instructors conducted.

The standardized curriculum, developed through a South-South collaboration with Ethiopia, was developed

under COP07 for the training of nurses in practice. The curriculum was crafted to focus on specific skills

sets and knowledge needs identified by the Nursing and Midwifery Council of Nigeria and Nigerian nursing

educators. The curriculum incorporates the FMOH/NACA adopted IMAI/IMCI approach to HIV/AIDS care

with emphasis on such nursing skills as: aseptic technique, injection safety, universal precautions, nursing

triage, nursing assessment, follow up of stable ARV patients with prescription re-authorization, monitoring

for ARV adverse effects and treatment efficacy, adherence/general counseling, and linkages with

community care and other services. In addition, HIV palliative care is emphasized including treatment of

minor ailments (such as thrush, malaria, and diarrhea) using standing orders developed and approved by

supervising physicians. Through the training, nursing skills are enhanced to provide counseling for

prevention, HCT, disclosure/partner notification and other support services. As many of these skills are

transferable, the ability of nurses to manage and care for patients with other chronic disease conditions is

enhanced.

Under COP08, the 45 Master Trainers trained in COP07 will be supported to conduct 5 regional trainings

targeting 150 nurses drawn from mostly primary and secondary health facilities within the ACTION "Hub

and Spoke" and Global Fund "cluster" networks. Both trainers and trainees will be certified and earn

continuing education credits which the Nursing and Midwifery Council will be encouraged to consider as a

requirement for license renewal for those in practice. This will foster a culture of professional development

for Nigerian nurses. The IHV-Nigeria Training Department will oversee assessments and monitor for quality

and coordinate and strengthen training materials and activities.

Through advocacy by ACTION, the USG, and others, the Nursing and Midwifery Council of Nigeria has

mandated nursing schools to include HIV/AIDS nursing in their training curricula and has identified the need

to standardize the content of these curricula. The HIV/AIDS nursing training curriculum developed under

COP07 will be adapted by the Council as the model curriculum for HIV/AIDS nursing education under

COP08. ACTION will support meetings with key stakeholders to carry out the adaptation for nursing

students and support an initial pilot TOT for 25 nursing school faculty. In addition, nursing school

administrators will be encouraged to incorporate clinical rotations at ACTION and other IP supported

hospital and community based sites into their curriculum to enhance hands on experience for students. One

-hundred and seventy five people will be trained as part of this activity. Management structure and logistics

for the training program will be through USG funding to LMS (#6383), who will also lead the expansion of

the fellowship design for other health care workers.

ACTION currently supports ARV services at 44 sites and will develop 34 additional sites under COP08 for a

total of 78 sites structured under a hub and spoke network model. Twenty-eight hub sites are affiliated with

25 smaller secondary hospital sites and 25 additional primary health center ARV sites so that routine care of

stable patients can be available at the community level. These primary health center sites already have

established referral relationships with existing ARV sites at the secondary or tertiary level and will be

strengthened under COP08 to provide ARV in a more accessible location. Most of these sites are staffed

by nurses. ACTION anticipates that at least half of the primary health centers will be developed as "nurse

managed" ART sites with oversight from the affiliated hubs. These are ideal settings where this training

could be focused initially. The fellows will not be limited to Action supported sites, as the program is

designed to provide supports across PEPFAR and beyond. The states will also be broad and expanding

with the eventual objective a national training designed for support to a range of facility types with

empowered staff.

Sites were selected in line with the National ARV Scale-Up Plan with the goal of universal access. They

include: Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa,

Activity Narrative: Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

Curriculum development and implementation will lead to capacity development at the site level and nursing

schools. This is consistent with national guidelines to ensure sustainability. ACTION staff will ensure that

there is a step down training with trainees from various hospitals using the Training Centers in Benin, Kano ,

Jos and Abuja. The GON and other IPs will also utilize the curriculum and other trainers developed to

further step down the trainings with development of a cohort of trainers across the country.

EMPHASIS AREAS:

This activity focuses on training, as capacity development for sustainability is a key focus. This activity also

focuses on training curriculum and module development, provision of additional training resources for

trainers and trainees for step down training in hospitals, and human resources, as manpower shortfalls to

address HIV care needs will be addressed. This activity addresses "Twinning" as a South to South

partnership with another African country was utilized to develop the curriculum.