ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The significant change in MMIS activity from COP08 to COP09 is the expansion strategy to selected sites

as directed by USG and GON with inclusion of phlebotomy activities. This will entail implementation of

injection safety practices at sites supported by other USG Implementing Partners (IPs) in addition to sites

supported by JSI/MMIS only, the Government of Nigeria (GON), faith-based and other private health

facilities. MMIS' support to USG IPs will include IS training and coordination of all USG sites while supplying

a limited stock of safe injection commodities and guidance on external procurements of injection safety

commodities through alternative procurement systems.. Waste management strategies will cover only non-

USG sites after training completion. MMIS will also support setting up of support supervision system at sites

level.

Making Medical Injection Safer (MMIS) had implemented Injection Safety (IS) programs in five states

(Anambra, Edo, Cross River, Lagos, Kano) and the Federal Capital Territory (FCT) since 2004 and

individual USG and GON health facilities across another fourteen states (Bauchi, Benue, Nassarawa, Niger,

Plateau, Kwara, Ogun, Borno, Delta, Enugu, Kaduna, Katsina, Kebbi and Oyo States) during the FY08. By

the end of COP 08, MMIS would have trained a total number of 25,226 health care workers and 10,743

waste handlers. In COP09, MMIS will be conducting injection safety activities primarily in the 5 focal states

and FCT. Technical assistance will be provided to other PEPFAR Implementing Partner (IP) supported sites

through new and refresher trainings for initial sites and supportive supervision of trainers, health workers,

store keepers, and waste handlers . In COP 09, MMIS will expand to 30 new sites in a total of four States.

MMIS will continue to implement in the four major technical areas: human and institutional capacity building;

behavioral change of healthcare personnel to promote safe injection practices and the communities to

promote oral medication where possible; ensure availability of equipment and supplies; and appropriate

healthcare waste management at the 789 previously supported health facilities. In addition MMIS will extend

its activities to 30 public health facilities through ad hoc partnership with corresponding IPs and the

Government of Nigeria. In COP09, MMIS will provide Injection Safety (IS) training to a total of 5,000

individuals using FMOH adapted WHOAFRO/JSI training curriculum. A training of trainers on supportive

supervision will be provided for all IP injection safety staff to enable them to consolidate the gains of the

training and ensure behavioral change at implementing sites. All IPs will be encouraged to advocate for and

support infection prevention committees at facility levels.

Advocacy and behavior change communication (BCC) efforts include periodic advocacy meetings with

policy makers at all levels of healthcare management and dissemination of BCC materials, tools, job aids,

posters, and pamphlets to healthcare providers. MMIS will also promote safe injection practices, and oral

medication to reduce unnecessary demand for injections at community level through Community Based

Organizations (CBOs) interventions and the mass media . Collaborative BCC and advocacy work will

continue with national and local institutions/organizations such as NAFDAC, the National Orientation

Agency (NOA) and local/community and religious organizations. NAFDAC is supporting injection safety

through media messaging to discourage the populace from demanding injections from their health

providers, advocacy to pharmaceutical industries producing injectables in Nigeria to support local

production of safety boxes and promoting nationwide use of auto-disabled syringes. Community outreach

activities are expected to foster community engagement on issues of health with emphasis on injection

safety issues as it affects communities in Nigeria. In COP08, MMIS trained field staff of the NOA to deliver

appropriate injection safety messaging to grassroots organizations. This activity will continue in COP09.

MMIS will work to maintain grassroots coalitions and encourage those coalitions to advocate on issues of

injection safety with focus on the reduction of the demand for unnecessary injections, ensuring the safety of

all necessary injections, and proper healthcare waste management to the relevant health authorities and

government.

MMIS will continue to work towards commodity security. MMIS will procure limited stocks of IS commodities

such as injection devices and safety boxes through her sub-contractor, PATH (Program for Appropriate

Technology). Commodities will be stored at the Government Central Medical Store in Oshodi (Lagos) and

distributed by the USAID accredited courier distribution company, SDV, to the focal GON Stores. MMIS will

continue to use its tracking system to collect data on consumption and stock levels along the supply chain.

MMIS will support healthcare waste management through provision of seed waste segregation

commodities, building infectious waste pits, and encouraging the building of incinerators or use of

encapsulation in rural areas for appropriate final disposal options in accordance with WHO standards. We

will also support the repair and construction of existing incinerators and provide funds for operation and

maintenance whenever possible and where applicable. MMIS will work through the Federal Ministry of

Environment and the National Prevention Technical Working Group with other partners to map out the

Health Care Waste Management (HCWM) micro-plan for selected health facility sites, and to adapt the

national HCWM Plan's policies and guidelines at the lowest service delivery points. MMIS will facilitate and

guide the procurement of injection safety commodities by IPs outside of the MMIS procurement sub-

contractor. All IPs are encouraged to plan for sustainability of the program in their sites.

MMIS will continue to work with the Federal Ministry of Health (FMOH) and other major stakeholders (such

as the Nursing and Midwifery Council of Nigeria and Medical and Dental Council of Nigeria). MMIS will also

work with training health institutions, such as medical, dental, pharmacy, nursing and midwifery schools and

schools of health technology, to review, include, and update safe injection issues in their various curricula.

In addition, injection safety training will be part of the continuous medical education taking place at

supported sites mentioned above (old or new). A training package for new entrance health workers into the

healthcare system has been developed and will be used to reach newly employed health care workers after

completion of site trainings.

The National Policy on Injection Safety and Health Care Waste Management will continue to be

disseminated widely in COP09. MMIS will perform quarterly monitoring of all sites, including GON and USG

supported sites, using the MMIS tools. State MOH and other PEPFAR IPs will participate at state-level

Activity Narrative: meetings to give feedback for service delivery quality improvement.

CONTRIBUTION TO OVERALL PROGRAM AREA.

As MMIS plans to extend coverage to some sites supported by other USG IPs, this integrated HIV/AIDS

programming will improve collaboration amongst partners, will maximize the impact, and will contribute to

the prevention of 1,145,545 new HIV infections in Nigeria. This will also improve the equity in access to HIV

prevention services to the communities most in need, both rural and urban, by reducing the risk of

transmission to the community as well as to health care workers. These activities would contribute

substantively to NACA's National HIV Prevention Plan implementation develop strong links between MMIS

services and other service providers, such as PEPFAR IPs, National Primary Health Care Development

Agency (NPHCDA), UNICEF, the World Bank, WHO, and other organizations working on HIV/AIDS issues.

Improved safety in the work environment and implementation of universal precautions among health

providers will lead to higher quality of health services and reduction in stigma/discrimination towards

PLWHA.

LINKS TO OTHER ACTIVITIES

This activity also relates to activities in HIV Counseling and Testing, Laboratory, Palliative Care, TB/HIV,

ART Services and OVC. Health care workers involved in these programs will benefit from the training

program in injection safety and the adoption of utilization of single-use syringe and needles, needle stick

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

programmatic activities.

POPULATIONS BEING TARGETED

Targeted population include healthcare workers at focal health facilities; doctors, nurses, pharmacists,

laboratory scientists, phlebotomists, community health officers, environmental health officers, store keepers

and waste handlers. Religious and community leaders, community-based organizations are also targeted

within the communities. In addition, heads of service and administrators need to be aware of the policies put

in place to control medical transmission of HIV. Government policy makers, line ministries and National

AIDS control program staff are also targeted for advocacy to leverage policy decisions, national guidelines

and sustainability issues. Furthermore, these activities will indirectly target the general population on the

community outreach program, who will be provided with information on safer injection practices, which are

designed to prevent transmission of HIV and promote oral medications.

KEY LEGISLATIVE ISSUES ADDRESSED

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

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

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

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

EMPHASIS AREAS

Through these activities, major emphasis is placed on training of staff and institutional capacity

development. This program will provide the basis for a workplace program through professional medical

associations that will ensure that all treatment and laboratory specimens are handled safely, with minimal

risk to healthcare providers. Minor emphasis includes policy and guidelines, information, education and

communication, commodities procurement and quality assurance, quality improvement and supportive

supervision.

ACTIVITY DESCRIPTION:

In Nigeria today, only a small percentage of single use disposable syringes are available for use at health

care services centers. This creates a threat of HIV/AIDS transmission through the reuse of syringes which

may contain trace quantities of infected blood or through the risk of needle stick. In order to eliminate this

threat, the Government of Nigeria has set a mandate for 100% single use autodisable disposable syringe

adoption by mid-2009. It is anticipated that the majority of these will be produced domestically by current

syringe manufacturers.

Nigeria currently consumes approximately 600 million syringes per year. The major procurers of syringes in

Nigeria include the Ministry of Health, World Health Organization, UNICEF, and teaching hospitals. With the

Government of Nigeria behind the conversion, it is anticipated that each of these institutions will begin

procuring only single use disposable syringes. There is also unmet demand in the West Africa region.

Major supplies of syringes to Nigeria come from abroad. There are two sites currently producing single use

disposable syringes in Nigeria. The first is in Calabar and has a maximum capacity of 90 million annually.

The plan for this facility is to scale up to 160 million in the near future. The second site is in Port Harcourt

and will be completed soon. It will have a capacity of 150 million with the goal of scaling up to 350 million in

the near future. These two facilities alone could be producing over 500 million by 2009.

This program aims to facilitate a comprehensive assessment of potentials for domestic production of auto-

disable syringes. This assessment will determine demand and supply for single use disposable syringes in

2009 and afterwards; assess the financial viability and competitiveness of domestic syringe production;

analyze the barriers to increased domestic production of syringes (financial, technical assistance, risk, etc);

and understand the points of leverage where donor money can facilitate greater production of quality, single

use disposable syringes through the cultivation of public-private partnerships.

Upon completion of this assessment, USAID's PEPFAR team, in partnership with local manufacturers,

banks, and procuring organizations, will design an intervention aimed at meeting the Government of

Nigeria's mandate. Possible solutions include: the establishment of a credit guarantee program through

USAID's Development Credit Authority (DCA) to facilitate financing for the procurement of necessary

manufacturing equipment; the leveraging of contacts from the Foreign Commercial Service to link local

manufacturers with equipment manufacturers in the US willing to provide credit, technical assistance, and

Activity Narrative: design services directly; the facilitation of advance contracts to secure orders for future production;

increased private sector investment for renovation and expansion of current facilities matched with the

provision of technical assistance; and increased private sector investment matched with awareness

campaigns intending to encourage increased use of single use disposable syringes.

CONTRIBUTION TO OVERALL PROGRAM AREA.

This program will inform the design of any PEPFAR-supported intervention and will enable PEPFAR Nigeria

to contribute to the overcoming of existing barriers which discourage the private sector from meeting future

demand for single use disposable syringes. It would also contribute substantively to NACA's 5-year Strategy

Framework implementation and contribute to the prevention of 1,145,545 new HIV infections by 2010 in line

with the PEPFAR global achievement of the 2,7,10 goals.

LINKS TO OTHER ACTIVITIES

This activity also relates to activities in HIV Counseling and Testing, Laboratory, Palliative Care, TB/HIV,

ART Services, Blood Safety and OVC and the adoption of utilization of single syringe and needle stick

policy of GON, all which are aimed at improving the safety for workers involved in these other programmatic

activities.

EMPHASIS AREAS

Major emphasis is placed on public - private partnership development for Domestic Production of

Disposable Syringe.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Workplace Programs

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.05: