Narrative TBD. Activity added during April 2009 reprogramming.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $37,289,099

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

It is estimated that over 3 million people are infected with HIV in Nigeria. The Nigerian PEPFAR 5-year goal for care and

treatment is to reach 1,750,000 people infected by HIV/AIDS with care services and place 350,000 people living with HIV/AIDS

(PLWHA) on antiretroviral therapy (ART) by 2009. At the end of COP07, USG/Nigeria had provided care services (excluding TB

services) to 269,506 PLWHA and treated 149,091 clients. In COP09, USG/Nigeria partners will provide care and support services

to 486,951 adult and 40,187 pediatric clients, and an additional 220,000 people affected by AIDS (55.4% of the 5-year goal). In

COP09, PEPFAR implementing partners (IPs) will provide ART services to 269,843 adult clients and 29768 pediatric clients (85.6

% of our 5-year goal) at 372 tertiary, secondary, and primary level service delivery sites in 36 States and the Federal Capital

Territory (FCT).

USG PEPFAR/Nigeria has increased access to care and treatment for PLWHA, incorporated "prevention with positives" (PwP)

services at various service points, and ensured that enrolled clients receive the basic care package. Some IPs are decentralizing

services to lower levels of care and improving service provision in the communities, in collaboration with community

institutions/structures. In previous COP years, the USG PEPFAR and Government of Nigeria (GoN) Adult Care & Treatment

program have concentrated services in the tertiary and secondary levels of care. This has resulted in overburden of these levels

of care. In addition, the network, referral and linkage systems, though improving, are still weak and the existing infrastructure and

capacity of the health system are inadequate. Less emphasis has been placed on pre-ART care services and programming, which

as a low cost per target, and results in high attrition rate.

In COP09, the USG/Nigeria PEPFAR Adult Care and Treatment program will reach targets for the country by (1) continuing the

decentralization of care and treatment to Primary Health Care (PHC) levels using the "Hub and Spoke" model developed in

collaboration with GON; (2) improving quality of care and treatment services using HIV/QUAL and other quality improvement and

assurance (QI/QA) systems; (3) enhancing networking and referral mechanisms, including patient tracking; (4) supporting task-

shifting policy development and implementation, (5) further strengthening linkages between adult and pediatric care and

treatment, PMTCT, and OVC programs, nutritional services, and support groups; (6) expanding strategic integration of HIV/AIDS

care and treatment services into the routine and existing health systems such that it is beneficial to all patients, including non-HIV

infected clients patronizing the health facilities; (7) supporting programming for pre-ART clients aimed at improving retention in

care; and (8) promoting health systems strengthening (HSS) activities. These are priority activities and strategies for the Adult

Care and Treatment program area in COP09.

The USG/Nigeria Adult Care and Treatment program is comprised of facility-based and Community/Home Based Care (CHBC)

activities for HIV-infected adults and people affected by AIDS aimed at extending and optimizing quality of life for HIV-infected

individuals from diagnosis through illness. Program activities include the provision of clinical, psychological, social, economic,

spiritual, and prevention services. Ensuring continuity of care is a goal of the adult care and treatment program and will require

attention to priority areas that include: PwP; nutrition care; pain management and palliative care; procurement and distribution of

ARV drugs and Cotrimoxazole (CTX) prophylaxis, early referral and retention in care and treatment; monitoring, reporting, and

program evaluation of activities; quality of care and treatment services assurance; task-shifting (i.e., training and deployment of

additional categories of care providers to provide care and treatment); centralized procurement mechanism; and strategic

geographic concentration of partners' activities.

ART eligible clients are placed on a first line regimen (2 Nucleoside Reverse Transcriptase Inhibitors [NRTIs] + 1 Non-Nucleoside

Reverse Transcriptase Inhibitor [NNRTI], specifically Lamivudine [3TC], Azidothymidine [AZT], and Nevirapine/Efavirenz

[NVP/EFV] with alternative of Stavudine [D4T], 3TC, and Tenofovir [TDF]) as outlined in the National ART guidelines, except as

otherwise indicated. Through CHBC, USG/Nigeria will continue to emphasize ART adherence in the home setting through

education and addressing adherence barriers, utilizing volunteers, peers and buddy systems and pill boxes as reminders for

effective drug adherence. In order to strengthen HIV-TB programs, all care and treatment sites are co-locating with TB-DOTS

(Directly Observed Treatment Short-course for tuberculosis) programs. Where co-location is not possible, effective linkages will

be facilitated to encourage implementation of the "three Is"; Intensified Case Finding, Infection Control, and Isoniazid Preventive

Therapy.

Service provision data are collected by the use of National Patient Management and Monitoring (PMM) forms and ART cards.

Most partners have in place electronic systems for information collection and analysis. These databases improve efficiency in

service provision including tracking early or missed appointments. Despite a lack of a national task-shifting policy, facilities are

training nurses to triage patients and prioritize access to physician care. Attention is also being paid to ensuring a more

manageable physician-to-patient ratio at facilities with secondary and tertiary facilities graduating stable patients to lower level

facilities.

Psychological support includes group and individual counseling and culturally-appropriate end-of-life care, bereavement services

and effective adherence education and counseling. Spiritual care addresses the major life events that cause people to question

their purpose and meaning in life. The interventions are culturally sensitive and include a life review and assessment, involving

clergy and spiritual leaders. Social care assists individuals and family members maintain linkages to various social services,

including community-based support groups, stigma reduction activities, training and support of caregivers, transportation support,

economic empowerment, food support, and/or legal assistance. Prevention services, including Prevention with Positives (PwP),

are designed to prevent transmission of HIV to others, as well as protect PLWHA from re-infection with HIV or infection with other

STIs. Existing CHBC teams comprised of health care workers, community volunteers, including PLWHA, have sufficient skill sets

to provide the range of facility, community and home care services. CHBC services are linked to facility services through a

coordinated network and referral systems.

The minimum care package of services provided to each PLWHA includes clinical care with a basic care kit and two supportive

services delivered at the facility and CHBC levels in accordance with the National ART and Palliative Care Guidelines. Service

providers keep records of services offered to clients, while the USG Care & Treatment team conducts supportive supervisory site

visits to monitor and evaluate these services periodically. USG PEPFAR/Nigeria will in collaboration with GoN and other

stakeholders (Nigeria Medical council, Nursing council, Laboratory council etc) to develop a policy on task shifting allowing other

trained cadres of health care workers to provide care, and particularly, treatment to clients.

USG/Nigeria in COP09 will continue close linkages with Global Fund Initiatives. To ensure adequate and appropriate geographic

and epidemiologic coverage and retention, USG/Nigeria partners are encouraged to do state expansion where they have a

comparative advantage, as we move into the phase of reaching out to Primary Health Care levels to improve access to care.

USG/Nigeria will continue provider initiated testing of inpatients in hospital wards, pregnant women, TB patients, and STI patients

as a part of the counseling and testing strategy to improve enrollment and access to care. All ineligible clients for ART will be

enrolled in HIV care and wellness programs for regular periodic follow-up and to identify change in ART eligibility status. Linkage

of adult programs to OVC programs will be established so that children of enrolled PLWHAs are able to access OVC services in

the communities. Strengthening of the support group programs through restructuring of activities and reaching out to non-ART

eligible individuals, will further ensure retention of pre-ART clients in care. USG/Nigeria PEPFAR program already has in place

"pre-ART" registers for monitoring these Non ART Eligible patients. The care and treatment program also seeks to increase

gender equity in programming through counseling and educational messages targeted at vulnerable women and girls. Through

gender-sensitive programming and improved quality services, the program will contribute to the reduction in HIV/AIDS stigma and

discrimination, and address male norms and behaviors by encouraging men to contribute to care and support in their families.

USG/Nigeria employs point persons for supply chain management, including ARV drugs. These individuals work with

implementing partners to keep track of ARV drugs for all USG/Nigeria partners and the GON to ensure adequate stock and

maintenance of ARV drugs, supplies, and other commodities. USG/Nigeria also supports strengthening National procurement

and distribution systems by investment into the Supply Chain Management System (SCMS) managed by Partnership for Supply

Chain Management. This implementing partner serves to provide technical assistance in procurement plans and capacity building

of in-country procurement and logistics staff. SCMS will work with the USG Procurement & Logistic team to train implementing

partners and site counterparts in drug forecasting and management. USG will utilize SCMS for care commodities, OIs and ARV

drug procurement as SCMS increases its services in Nigeria. USG/Nigeria will work closely with GON and the Global Fund to

harmonize and institute a nationwide supply chain and logistics management system that will not only cater to ART drugs, but will

increase efficiency and effectiveness of distribution of other commodities and supplies, such as OI drugs and Basic Care Kits.

USG/Nigeria will continue to partner with the Clinton Foundation and the Global Fund to utilize opportunities to reduce costs.

USG/Nigeria will continue to work towards sustainability by supporting renovation of physical infrastructure, improving laboratory

support systems, and ensuring community involvement and ownership of programs. USG/Nigeria will also participate in and

support the harmonization process led by GON that is in line with "one national program at all levels". It will also participate in

building the capacity of health care providers as well as facilitate private partnerships with organizations, such as ExxonMobil and

Accordia, to increase patient access to care and treatment services. To further strengthen health systems in Nigeria, facilities and

partners are encouraged to arrange a mechanism for partial cost-sharing to enable all clients at facilities to have access to

laboratory and other services formerly limited only to HIV positive clients.

In keeping with the PEPFAR's commitment to the "three ones" through alignment with the GON National framework, coordinating

authority, and monitoring and evaluation systems, the USG/Nigeria PEPFAR care and treatment program has become an integral

part of the National Care and Treatment plan, strategies and program monitoring and evaluation. USG/Nigeria has integrated

quality assurance and improvement systems into its existing care and treatment program, and, in collaboration with GON, will

continue to monitor and evaluate the COP09 strategies to ensure optimal quality of care, utilizing jointly organized and

implemented onsite supportive supervision, HIVQUAL, data reporting systems (monthly data collection, collation and analysis)

with feedback through the monthly bulletin developed by the Strategic Information Unit of the PEPFAR Program. The USG/Nigeria

Clinical Care meetings and Technical Work Group meetings will continue providing implementing partners with technical

assistance, sharing best practices, identifying emerging challenges and developing strategies to address them. QA/QI has been a

strong component of the laboratory services in country, which as resulted in most laboratories providing internationally acceptable

service level for ART.

The care and treatment training plans for COP09 are aimed at quality assurance and improvement. These include the training,

retraining, and mentoring of care and treatment providers using the National Care and Treatment Training Curricula. Additional

training plans include further expansion of HIVQUAL program for QA/QI. USG/Nigeria will coordinate implementing partners'

activities to train master trainers in good clinical care. All care and treatment training will emphasize pain assessment and

management using the National Guideline, which includes the World Health Organization (WHO) step-ladder approach.

PEPFAR/Nigeria has proposed two public health evaluations (PHEs) in COP09: an assessment of barriers to ART initiation

among clinically eligible patients (the role of patient- and site- factors in delaying treatment initiation); and an evaluation of patient

retention in pre-ART care. A program evaluation of the national Care and Treatment Program will also be conducted in

collaboration with the GON to evaluate the quality and outcome of services.

Table 3.3.08: