PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
The USG Nigeria team and the implementing partner Harvard University (APIN+ Program) have split the
APIN+/Harvard activities between Harvard University and the indigenous partner APIN, Ltd. Therefore, the
activity narrative for Harvard that follows has been modified to reflect activities that will be performed
specifically by the efforts of Harvard through the APIN+ Program (Harvard) as opposed to APIN, Ltd (which
is submitting as a separate narrative under the name APIN). The narrative has also been updated to reflect
COP09 goals and targets. In addition, APIN Ltd will be taking over all activities for the following sites
previously supported by Harvard: Nigerian Institute of Medical Research (NIMR), Lagos University Teaching
Hospital (LUTH), Onikan Women's Hospital (OWH), and Mushin General Hospital (MGH). In accordance,
those sites, their activities and their respective patients are reflected in the APIN Ltd narratives. This
transition to building the capacity of the indigenous partner APIN Ltd will promote the long term
sustainability of the program.
NARRATIVE:
COP09 funding will support a comprehensive PMTCT program in line with the revised National PMTCT
Guidelines (2007) at 64 service outlets in 9 states (Benue, Borno, Ebonyi Enugu, Kaduna, Lagos, Oyo,
Plateau, and Yobe). This consists of 10 tertiary, 21 secondary and 33 primary sites. Opt-out testing and
counseling with same-day test results will be provided to all pregnant women presenting at antenatal care
(ANC) or labor and delivery (L&D). The current level of PMTCT testing and counseling uptake from women
presenting for ANC or L&D is 90%. All women are provided post-test counseling services on prevention of
HIV infection, including the risks of MTCT. They are encouraged to bring partners and family members for
on-site HCT. The program has a target of providing counseling and testing results to 65,500 women.
PMTCT prophylaxis will be provided to approximately 3,275 women in line with the national guidelines.
Infant follow-up care linked with PMTCT activities includes nutritional counseling and support, growth
monitoring, cotrimoxazole prophylaxis, HIV testing, and other preventative care services. It is estimated
that, of the infants tested for HIV infection, 131 will be HIV-positive; these infants will be referred to the
pediatric care and treatment program. Early infant diagnosis (EID) will be carried out using dried blood spots
(DBS) in line with the national EID scale up plan. This funding will support the ANC, lab, ARV prophylaxis
intervention to mothers and babies (not HAART), and personnel involved in PMTCT.
Through this program area, Harvard will provide linkages to other prevention, care and treatment services.
All ART-ineligible women will be placed on zidovudine from 28 weeks and or zidovudine and lamivudine
from 34 weeks until delivery and will be enrolled into palliative care services at the time they access PMTCT
services. Following delivery, mothers will be monitored in the care program, where services include on-site
enrollment or referrals for family planning and other reproductive health services. In addition, PMTCT
services are integrated into a system of maternal and child health services designed to promote maternal
and child health for all women. All ART-eligible pregnant women will be provided with ART through the adult
treatment program in line with the PMTCT guidelines. Children who become HIV-infected during the time
they are being monitored as part of the PMTCT program will be linked to the pediatric care and treatment
program. Those HIV-exposed children placed on single dose nevirapine at birth and zidovudine for 6 weeks
that remain uninfected at 18-months following the completion of ARV prophylaxis will be linked to the OVC
program for continued care services.
Counseling on infant feeding options will be conducted during the antenatal period, at L&D and/or at infant
follow-up visits using the National PMTCT and Infant Feeding Guidelines. Infant feeding counseling will be
performed in an unbiased manner and women will be supported in their choice of method. Clients will also
be counseled on the beneficial effect of couple/partner HCT/disclosure on adherence to infant feeding
choice. A follow-up team consisting of counselors and a home-based care (HBC) support group of PLWHAs
will assist in home and community tracking of HIV-positive mothers to provide nutritional support and
ascertain infant diagnosis.
A regular training program will be established at all sites to train and retrain 363 healthcare personnel
involved in the PMTCT program using the National PMTCT Guidelines. This includes non-laboratory
personnel who will be trained in HIV counseling and testing and traditional birth attendants (TBAs) using an
adapted curriculum in local areas near sites in PMTCT counseling. PMTCT counselors in the National
PMTCT Program will also be trained. Harvard will provide technical assistance for the development of the
National Infant Feeding Counseling Manual and will subsequently conduct a zonal training of trainers with
this manual.
During COP08, Harvard piloted a clinical quality assessment (QA) for PMTCT activities at 3 supported sites.
During COP09, Harvard will continue to conduct QA activities to improve quality of care in the PMTCT
program. The program will also continue to monitor and utilize electronic data captured through SI activities
to measure the quality of services provided as well as the associated patient outcomes and transmission
rates.
Harvard will partner with other implementing partners (IPs) in the implementation of the PEPFAR-Nigeria
local government area (LGA) coverage strategy in the program areas of PMTCT, OVC and TB/HIV,
designed to ensure the provision of PMTCT and TB/HIV services in at least one health facility in every LGA
of 6 identified states. In COP09, this will be expanded to Benue state. Per patient costs reflect the
expansion to at least 33 new sites and scale up as a part of this LGA coverage strategy. Under the
coverage strategy, these facilities are all linked with primary health facilities which provide HCT and
referrals for PMTCT services for HIV-infected mothers. Harvard will leverage FMOH, UNICEF and other IP
support in capacity building/training in identifying new PMTCT sites in its scale-up plans. Harvard will
strengthen the Benue state PMTCT committee as part of the LGA coverage strategy. Harvard will support
one quarterly PMTCT task team meeting as part of the support to the GON.
EMPHASIS AREAS
This activity will place major emphasis on the development of networks through expansion into more local
areas through a network of secondary or primary PMTCT clinics,with rural outreach to community
healthcare workers and TBAs involved in home delivery. All community workers and TBAs with whom
Activity Narrative: Harvard works are linked to tertiary health care facilities. In addition, major emphasis will be placed on
building organizational capacity in order to work towards sustainability of PMTCT centers and further
expansion of the Nigeria PMTCT program in conjunction with the Federal Ministry of Health and USG.
These system strengthening activities are led by local investigators at current PMTCT sites who participate
in new site assessments, overseeing QA/QI, capacity development and training for new PMTCT centers.
Minor emphasis is placed on performing targeted evaluations of PMTCT interventions to estimate the rate of
transmission with each of the ARV prophylaxis regimen used. Emphasis areas also include military
populations through support for PMTCT activities staff at 68 Military Hospital and Military Hospital Ikoyi,
Lagos.
POPULATIONS BEING TARGETED
In addition to providing PMTCT services for pregnant women that know their HIV infection status, this
program also targets women who may not know their HIV status and may be at greater risk for MTCT.
Furthermore, it seeks to target infants who are most at risk of becoming infected from an HIV-positive
mother during the antepartum, intrapartum and postpartum periods. Through the HCT program area,
Harvard seeks to target a broader group of adults by encouraging women to bring their partners and family
members in for HCT. Furthermore, training activities will train public and private health care workers on the
implementation of PMTCT protocols and HIV-related laboratory testing.
CONTRIBUTIONS TO OVERALL PROGRAM AREA
Through the PMTCT program, Harvard will provide HCT with test results to 65,500 pregnant women.
Additionally, treatment and prophylaxis will be provided to 3,275 pregnant women. Implementation of the
National PMTCT guidelines in 64 sites (new and continuing) contributes to the PEPFAR goal of expanding
ART and PMTCT services. Harvard is increasing the number of sites by adding secondary and primary level
sites in the radius of Harvard-supported tertiary care institutions. The tertiary centers will continue building
the network capacity and coverage in of target states. Counseling will encourage mothers to bring their
partners and family members for testing to reach discordant couples and in focused HCT programming.
This program is implemented in geographically networked sites to optimize training efforts and provide
collaborative clinic/lab services as needed. Harvard will train and retrain 363 health care personnel from the
PMTCT sites, including doctors, nurses, pharmacists and counselors. Training will build capacity at local
sites to implement PMTCT programs and provide essential treatment support to pregnant women with
HIV/AIDS. Capacity building efforts are aimed at future expansions of PMTCT programs. QA/QI will be
carried out through personnel training, data collection from sites for monitoring and evaluation and
supervisory visits from key program management staff, which may include representatives from the USG
and GON.
The program will increase gender equity by specifically targeting pregnant females for HCT and PMTCT
prophylaxis and their male partners for HCT. Data collection on PMTCT regimens provides a basis for
developing strategies to ensure that all pregnant women have access to needed and optimally effective
PMTCT services. This program addresses stigma and male norms and behaviors through the
encouragement of partner notification and bringing other family members in for HCT. Infant feeding
counseling, including on the appropriate use of exclusive breastfeeding or exclusive use of breast milk
substitute (BMS) where AFASS is available, will be in line with the National PMTCT Guidelines. Referrals to
income generating activities (IGAs) will also be provided to women as a part of palliative care and
counseling activities.
Additionally, as part of the PEPFAR sustainability building efforts, Harvard will provide technical assistance
and support for APIN Ltd. to assume program management responsibility for PMTCT activities. This will
include the implementation of a plan to transition site oversight, management and training over to APIN. The
goal of such efforts is to provide for greater assumption of responsibility for management and
implementation of PEPFAR programming by Nigerian nationals through an indigenous organization.
LINKS TO OTHER ACTIVITIES
This activity is linked to counseling and testing , OVC, adult and pediatric care and treatment, sexual
prevention, biomedical prevention, SI, human capacity development, health system strengthening, and
gender. Pregnant women who present for HCT services will be provided with information about the PMTCT
program and referred to the PMTCT program if they are eligible for these services. ART services for HIV-
infected infants and mothers will be provided through adult and pediatric treatment services. Basic pediatric
care and support, including support for chosen feeding option and TB care, is provided for all infants and
children through OVC activities. All exposed infants identified through PMTCT services will be linked to
these OVC services. Pregnant women are at high risk for requiring blood transfusions. Personnel involved
in patient care will be trained in universal precautions as a part of injection safety activities. Additionally,
these activities are linked to SI, which provides support for monitoring and evaluation of the PMTCT
activities and QA/QI initiatives.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13051
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13051 3227.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $2,850,000
Resources School of Public Track 2.0
Services Health Harvard SPH
Administration
6718 3227.07 HHS/Health Harvard University 4170 544.07 Track 2.0 $3,625,000
Resources School of Public
Services Health
3227 3227.06 HHS/Health Harvard University 2770 544.06 Track 1.0 $1,331,000
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
* Reducing violence and coercion
Health-related Wraparound Programs
* Child Survival Activities
* Malaria (PMI)
* Safe Motherhood
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $86,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Estimated amount of funding that is planned for Food and Nutrition: Commodities $186,675
Economic Strengthening
Education
Water
Table 3.3.01:
As we have now split the APIN+/Harvard activities between Harvard University and APIN, Ltd., our activity
narratives is amended to reflect activities that will be performed specifically by the efforts of Harvard through
the APIN+ Program as opposed to APIN, Ltd. (which has submited a separate narrative under the name
APIN). In addition, APIN will be taking over all activities of the Nigerian Institute of Medical Research
(NIMR), Lagos University Teaching Hospital, Onikan Women's Hospital, and Mushin General Hospital; thus,
those sites and their respective patients will drop out of the Harvard numbers and will be reflected in the
APIN narrative.
In COP09, Harvard will continue to provide sexual prevention programming activities in line with the overall
PEPFAR Nigeria goal of providing a comprehensive package of prevention services to individuals reached,
thereby improving the effectiveness of this messaging, through a balanced portfolio of prevention activities
including abstinence and be faithful messaging (HVAB) along with condoms and other prevention (HVOP).
By the end of COP08, Harvard will have assisted PEPFAR Nigeria in extending its reach of ABC services to
9 states, including Benue, Borno, Enugu, Kaduna, Lagos, Oyo, Ogun, Plateau and Yobe. Through its other
program areas, Harvard has a large population of HIV-positive clients to whom it is already providing age
appropriate ABC messaging and prevention with positives (PwP) services, which include STI screening and
management, condom provision, sexual risk reduction, disclosure, adherence, reduction of alcohol
consumption, and testing of sex partners and children in the HIV clinic setting. In addition, Harvard 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.
In COP09, Harvard will implement ABC activities at both the facility and community levels by utilizing the
minimum prevention package strategy as contained in the National Prevention Plan. This package includes:
community outreach campaigns; peer education; infection control activities; and STI
management/treatment. The goal of the program is to focus on targeted communities for saturation with
messages conveyed in multiple forums. Utilizing such 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 HVOP messaging on a regular basis and via at least 3 of the 4 strategies Harvard
will employ.
HVAB activities conducted at the local level by Harvard will be reinforced through national level mass media
campaigns by other USG partners, such as the successful Zip-Up campaign. HVAB messages promoting
abstinence, mutual fidelity, and addressing issues of concurrent and multiple sexual partnerships will be
balanced with condoms and other prevention messaging, where appropriate, and will be integrated with
treatment and care services at 66 sites and implemented by 2 stand-alone HCT providers.
Youth or young adults aged 15-24 years represent a key age group for HVAB activities, as they are the
highest prevalence age group (2005 ANC survey). In addition, the 2005 National HIV/AIDS and
Reproductive Health Survey (NARHS) demonstrated a low risk perception (28%) among the general
population and significant reports of transactional sex (11%) among young women aged 15-29 years.
Harvard will reach these beneficiaries through community awareness campaigns, peer education models,
and ‘peer education plus' activities.
Harvard collaborates with community-based organizations (CBO) and with persons living with HIV/AIDS
(PLWHA) support groups at its facilities and surrounding communities in other PEPFAR programming
activities. These support groups and CBO also serve as appropriate partners in the dissemination of ABC
messaging to other PLWHA using the peer education model, and to wider audiences through the peer
education plus model and community awareness campaigns. These support groups provide key community
linkages for prevention of mother-to-child transmission (PMTCT), palliative care and antiretroviral treatment
(ART) services. Support group activities will include the dissemination of prevention information for HIV-
infected individuals (funded under basic care and support [BC&S]), as well as community outreach to high
risk populations to encourage HCT and healthy behaviors, such as partner notification and condom use. For
HIV-negative individuals, trained counselors will provide education on HIV/AIDS transmission, risks, and
risk reduction strategies, including HIV testing. To address stigma issues and in compliance with the GIPA
principle, approximately 10 PLWHA from the pool of those receiving treatment at facilities who are living
openly and positively will be trained using the peer education model to disseminate ABC messages. They
will serve as peer educators to extended family members and members of their support groups. These
trained PLWHA will in turn reach individual cohorts of at least 10 other persons from among their social
peers. With 63 facilities (including PMTCT sites), this will serve as an effective tool for reaching individuals
in at least as many communities with balanced ABC messages.
A community awareness strategy will also be employed to serve the catchment areas of the hospital
facilities, which will be linked with community mobilization efforts promoting HCT. During static and mobile
HCT services, counselors will disseminate balanced ABC messages to recipient communities and clients
through focused, small-group discussions and interpersonal communication. The key messages that will be
conveyed are delay in sexual debut, secondary abstinence, mutual fidelity, prompt and complete treatment
of all STIs, and promotion of need to ascertain HIV serostatus through HCT.
Several Harvard sites target most-at-risk populations (MARPs), including outpatient STI patients, border
traders, military personnel, young male market agents, and motor mechanics. A prevention program for
young male market agents has been established in the Ibadan marketplace and implemented through the
Association for Reproductive Family Health (ARFH) NGO. HaltAIDS, a community based-NGO in the poor
community of Tudun Wada in Jos, has an established community HCT center, which currently provides
prevention messages, condoms and HCT to 150 community members per month. Prevention activities at
these clinics provide risk-tailored educational materials and distribute condoms. In addition to
comprehensive counseling on HIV prevention and risk reduction, HIV-infected individuals identified through
this activity are referred for palliative care and evaluation for ART eligibility. An emphasis on reaching high-
risk men also enhances prevention efforts and facilitates access to their partners. This funding will support
Activity Narrative: the implementation of behavioral interventions for MARP at stand-alone HCT centers, the development of
educational prevention materials developed by ARFH and HaltAIDS and referral for STD diagnosis and
treatment. Where appropriate, Harvard will build site capacity for STI syndromic management. Additionally,
in Jos, we collaborate with Mashiah Foundation, a faith based organization which provides palliative care
services for HIV-infected women and OVC. Mashiah also conducts mobile community outreach for HCT and
provides ABC prevention messaging to the populations that it serves.
Harvard will also use the peer education model to target job peers who are healthcare workers. Healthcare
workers at each site will be trained using established National peer education curricula and each will be
requested to form peer groups of approximately 10 members from the healthcare worker community for
dissemination of balanced ABC messaging. It is anticipated that these healthcare workers will continually
serve as conduits for age appropriate prevention messaging not only for their work peers, but also for their
social peers and all clients with whom they come in contact.
A focus of the program in COP09 will be continued improvement of the integration of prevention activities
into the HIV care and treatment settings. Healthcare providers and lay counselors in these settings will be
trained to appropriately deliver integrated ABC prevention messages and incorporate the messages into
routine clinic visits using IEC materials and job aids. An appropriate balance of ABC will be tailored to the
needs and social situation of each individual client in its presentation. Additionally, prevention activities will
be incorporated into other points of service in each health facility (general outpatient clinics, emergency
services, etc.), particularly into reproductive health services, including, family planning counseling, STI
management and counseling, and risk-reduction counseling. Harvard supported sites will integrate
prevention with positives (PwP) activities including: adherence counseling; syndromic management of STIs
in line with National STI control policy and guidelines; risk assessment and behavioral counseling to achieve
risk reduction; counseling and testing of family members and sex partners; counseling for discordant
couples; and IEC materials and provider delivered messages on disclosure. These interventions will be
implemented using the recently adapted HIV Prevention in Care and Treatment Settings Prevention
Package.
This funding will be also used to support the procurement and distribution of written prevention messages
and condoms. These materials will provide patients and clients with HIV prevention information using the
"ABC" model, including information about healthy behaviors, safer sexual practices, PMTCT, and condom
usage. Prevention messages will also include information about other STIs. Condoms will be offered to all
individuals at all sites and will be procured by Harvard from the Society for Family Health (SFH).
The target for the AB messaging campaign is 4,355 individuals. The target for the intensive campaign
activity in other prevention strategies is 35,106 individuals. Additional staffing and training of counselors will
also be provided by this funding, including a dedicated fulltime staff person. This activity will provide support
for training of 366 individuals in AB messaging and 324 in condom and other prevention promotion.
ABC programming emphasizes local organization capacity building, human capacity development, and
efforts to increase gender equity in HIV/AIDS programs. These activities also 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 components of the program.
Through ABC activities, we place major emphasis on community mobilization and participation as an
element of outreach for prevention efforts. We place major emphasis on training, infrastructure, and human
resources in order to build the capacity of counselors and providers in a full range of prevention strategies.
We also place emphasis on IEC as an essential element of outreach to high-risk populations, and on
developing networks for linking these activities to HCT, PMTCT, and other ART activities to serve as a
source of prevention information. Emphasis areas also include military populations (activities at 68 Military
Hospital and Military Hospital Ikoyi, Lagos).
These activities address gender equity issues by providing equitable access to prevention services for men
and women. In some cases, our activities seek to target men who may be at high risk for HIV in order to
promote condom use as a means of prevention and access to services for their sexual partners. Male-
targeted counseling seeks to address male norms and behaviors in order to encourage safer sexual
practices. Strong prevention programs that accommodate the array of societal and cultural norms can also
help reduce stigma and discrimination. Providing services at the community level will serve as an important
platform from which general HIV/AIDS information can be provided and risk reduction strategies discussed.
POPULATIONS TARGETED:
Key populations targeted are the healthcare community in treatment facilities, PLWHA, youth and adults
accessing HCT services, high-risk populations, and support group members and immediate families of
PLWHA. Other target populations include discordant couples, pregnant women and religious leaders.
Targeting these populations is important to encourage safe sexual practices, HCT, and other prevention
measures. Health care workers will also be targeted for training on the most effective prevention measures
for various risk groups.
CONTRIBUTION TO OVERALL PROGRAM AREA
These prevention activities are consistent with PEPFAR's goals for Nigeria, which aim to support a number
of prevention strategies as a comprehensive prevention package. In order to be maximally effective, the
prevention messages developed at different sites will be tightly targeted to various high-risk groups that they
serve. Furthermore, these activities are consistent with the PEPFAR 5-year strategy, which seeks to scale-
up prevention services, build capacity for long-term prevention programs, and encourage testing and
targeted outreach to high-risk populations. The establishment of networks and referral systems from
prevention efforts at the community level to PMTCT and HIV care and treatment will help facilitate the scale-
up of the overall program. Additionally, as part of our sustainability building efforts, Harvard will provide
technical assistance and support for APIN to assume program management responsibility for all ABC
activities. This will include the implementation of a plan to transition site oversight, management, and
Activity Narrative: training over to APIN. The goal of such efforts is to provide for greater assumption of responsibility for
management and implementation of PEPFAR programming by Nigerian nationals through an indigenous
organization.
LINKS TO OTHER ACTIVITIES:
ABC activities relate to HCT, by increasing awareness of HIV. They also relate to Adult Care and Treatment
and Pediatric Care and Treatment activities through dissemination of information by home-based care
providers and ultimately by decreasing demand on care services through decreased prevalence. Linkages
also exist to OVC programming by targeting OVC. These activities are also linked to TB-HIV activities in
that prevention messaging will be disseminated to individuals who are provided with HCT in a TB setting.
Through training of personnel, these activities also link to Human Capacity Development. As certain
activities focus on gender-related issues, this program area also links to Gender.
Continuing Activity: 15652
15652 15652.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $160,000
* Family Planning
Military Populations
Estimated amount of funding that is planned for Human Capacity Development $50,000
Table 3.3.02:
Continuing Activity: 13054
13054 9216.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $1,468,500
9216 9216.07 HHS/Health Harvard University 4170 544.07 Track 2.0 $635,000
Workplace Programs
Table 3.3.03:
The blood safety (HMBL) activity supports infrastructure and capacity development for blood safety training
and equipment, blood bank screening for HIV and other transfusion transmissible infections (TTIs: HIV,
HBV, HCV and syphilis), high-quality blood bank and transfusion practices, support of counseling and lab
personnel and their training on universal safety precautions (UP) and good lab practices, waste
management, and QA/QC for HIV serologic testing. At the end of COP08, capacity for high-quality blood
transfusion services at 7 Harvard-supported ARV centers will be increased through linkages between blood
banks at the sites and National Blood Transfusion Service (NBTS) Zonal Centers. In COP09, these same
sites will be supported for effective compliance with the National Blood policy. The policy emphasizes the
use of voluntary blood donors, screening for 4 TTIs with ELISA techniques before transfusion and centrally
coordinated blood banking services through the NBTS.
In COP09, Harvard will continue to work closely with the NBTS and Safe Blood for Africa Foundation
(SBFAF) in all aspects of its blood safety program. Harvard supports the NBTS' primary objective of
migrating fragmented hospital-based blood services to centralized NBTS-based blood services nationwide,
where a key feature of the program is a nationwide voluntary nonremunerated donor recruitment system
(VNRD). At Harvard-supported facilities, NBTS will provide TA for blood donation drives and SBFA will train
nurses and medical lab scientists in recruitment strategies to create repeat voluntary blood donors from
current family replacement donors. In this plan, Harvard will be instrumental in working with hospital
management and staff at all comprehensive sites to participate in the NBTS blood services program to
create support of blood donor organizers and to strengthen health facility and community focused blood
drive activities. All Harvard sites with blood transfusion services (7) will be technically supported so that
donors are screened with the national pre-donation questionnaire. Donors deferred after administration of
the questionnaire will be offered HCT using the National testing algorithm. Data on patients provided with
HCT through these activities will be captured through Harvard SI activities.
Linkages to NBTS Zonal Centers will occur through strengthening of ongoing collaborations. Harvard works
with secondary and tertiary facilities that do blood transfusions, some of which are already utilizing a
combination of ELISA and rapid tests for the 4 TTIs and are resistant to moving their current blood
screening practices to NBTS. Harvard, NBTS and SBFA will continue promoting the benefits of NBTS-
screening to the management and hematology departments of these facilities. Harvard will continue to
facilitate the development of an NBTS/hospital blood exchange programs at 7 health facilities that was
selected in COP08, based on supportive management, proximity to a zonal NBTS office, availability of
blood banking facilities, lab infrastructure and other resources. This linkage will include regular delivery of
donated blood to NBTS for screening along with a regular delivery of screened blood back to the facility. In
addition to collecting unscreened units, NBTS will deliver the requested order of screened units for blood
banking and use at the facilities to these 7 hospitals. NBTS will also provide monthly feedback on rates of
the 4 TTIs found by ELISA screening. It is expected that through the linkage with the NBTS blood banking
system, rapid testing in the blood donor setting will occur in emergencies only. The goal of the NBTS
hospital linkage is to limit emergency transfusion with rapid test kits to less than 20% of all transfusions in
the hospital. Harvard and its supported facilities will establish and coordinate a regular QA/QC program to
ensure that HCT in the blood donor setting meets national and international standards. It is expected that
these improvements in the donor screening and blood collection practices will result in the safe collection of
3,500 units of blood. 2,800 (80% of total units of blood) units of blood will be sent to NBTS for screening.
Harvard will identify appropriate staff (50) for training by SBFA who, in turn, will utilize standardized training
modules approved by NBTS and appropriate to the various levels of trainees. Subsequently, Harvard will
support a total of 140 doctors, nurses, and lab workers at supported sites to be trained via step down
training.
QA/QC activities will include site M&E and personnel trainings on proficiency in HIV testing, UP, and good
lab practices. All sites will be provided with copies of the National Blood Policy, operational guidelines for
blood transfusion, SOPs and job aids to support blood safety activities.
This activity will promote the principles of UP, such as the reduction of unnecessary exposure to blood,
accidental injury/contamination as well as the essential consumables and services that protect health care
workers (HCWs) from contracting infections, especially HIV. Harvard will support clinical meetings and
seminars of medical professionals to promote rational use of blood and blood products.
EMPHASIS AREAS:
HMBL activities emphasize upgrading the infrastructure of participating hospitals, laboratories, and blood
banks through training and minor renovations to effectively link up with the NBTS and contribute to the
nationally coordinated blood banking system. In order to develop human capacity, there will also be
emphasis on in-service training of lab workers and public health personnel in the implementation of
recruitment of voluntary non-remunerated blood donation and safe blood activities. This will also be
achieved through QA and supportive supervision of trained staff. SI will be emphasized in the collection of
data surrounding transfusions done at the site level. Lastly, this program will develop the capacity of local
organizations (blood banks in hospitals) to change the practice of fragmented hospital based services and
the use of paid/family replacement donors to participate in national blood safety activities. Awareness about
safe blood practices will be promoted in the communities and indirectly increase the number of volunteers
available for blood donations.
POPULATIONS BEING TARGETED:
HMBL activities target adults, specifically blood donors aged 18 and above. Additionally, it targets public
HCWs and laboratory workers for compliance with the national blood policy, training in HIV testing
techniques and proper UP in the handling of blood specimens.
CONTRIBUTION TO OVERALL PROGRAM AREA:
HMBL will provide support for 7 service outlets at tertiary health care facilities for improved blood screening
Activity Narrative: activities. Individuals will be trained in counseling and testing and blood bank safety protocols. Linkages will
be created with the NBTS. The emphasis on infrastructure building within this program is consistent with the
PEPFAR 5-year goal of providing technical assistance for the development of site-specific blood safety
policies, protocols and guidelines. Furthermore, it is consistent with the goal of ensuring a safe, effective
and nationally coordinated blood program that provides blood free of the four TTIs.
Additionally, as part of the program's sustainability building efforts, Harvard will provide technical assistance
and support for APIN to assume program management responsibility for HMBL activities. This will include
the implementation of a plan to transition site oversight, management and training over to APIN. The goal of
such efforts is to provide for greater assumption of responsibility for management and implementation of
PEPFAR programming by Nigerian nationals through an indigenous organization.
HMBL activities relate to activities in counseling and testing. All blood donors will be screened with donor
questionnaires and deferred donors provided with full HCT. The UP processes at the blood bank screening
centers also enhance blood bank workers' knowledge on best practices for high quality HIV testing and the
proper procedures for handling blood specimens throughout the blood banking protocol. TTI positive donors
are linked to care and treatment. HMBL activities also relate to activities in Adult Care and Treatment,
Pediatric Care and Treatment, PMTCT, TB/HIV, ART Services and OVC.
HMBL is linked to HMIN activities and to HLAB through the promotion of universal safety precautions, good
laboratory practices, and proper waste management for biohazardous materials. Both areas are linked to
Human Capacity Development (HCD) and Health Systems Strengthening (OHSS) by training workers and
building the overall capacity at the sites.
Continuing Activity: 13035
13035 6491.08 U.S. Agency for Family Health 6374 552.08 USAID Track $200,000
International International 2.0 GHAIN
Development
6710 6491.07 U.S. Agency for Family Health 4167 552.07 GHAIN $108,750
International International
6491 6491.06 U.S. Agency for Family Health 2771 552.06 GHAIN $225,000
Estimated amount of funding that is planned for Human Capacity Development $30,000
Table 3.3.04:
By the end of COP08, 450 health workers in 28 Harvard- and APIN-supported sites will have been trained in
injection safety. In COP09, Harvard will continue performing HMIN activities in 28 sites in 9 states (Benue,
Borno, Enugu, Kaduna, Lagos, Ogun, Oyo, Plateau, Yobe). This activity provides the initiation of an
intensive training program in injection safety practices for health care workers (HCWs) at the sites. As
Harvard scales up HIV/AIDS care and treatment activities, we aim to also build capacity to provide such
care in a medically safe environment. This includes education on appropriate practices to diminish the risks
of medical transmission and adoption of policies that address the risks of HIV medical transmission and
methods that can be used to mitigate these risks. In this vein, at all Harvard sites, a minimum package of
safe injection activities is provided, which includes needle disposal containers, vacutainers, and basic
educational materials for staff. Harvard also provides ongoing training efforts in universal protection (UP)
that have been a part of the continuing education of HCWs.
In COP08, trainings focused on scale-up to facility saturation, reaching workers from every section of the
hospital facility. In order to build the human resource capacity of each site for these activities, at least one
workshop on injection safety procedures was conducted in each site. Harvard collaborated with JSI/MMIS in
the development of the training plan and delivery of the training. Trainers trained by JSI/MMIS in COP08
with a standard curriculum developed and approved by the GON were utilized in step-down trainings for
other HCWs at these 28 sites. Workers who attended the workshop included physicians, nurses, laboratory
workers, community HCWs involved in Home Based Care (HBC), laundry workers, and administrative
personnel. Site-based waste managers and handlers were also provided with training on safe waste
management techniques. At this workshop, the protocol for safe needle handling and disposal was
reviewed. For COP09, Harvard will target HCWs at sites who were not provided with training during COP08.
As a part of the LGA coverage plan for Plateau State, secondary and tertiary health care facilities will be
targeted for training efforts. Trained personnel at these sites will engage in step-down trainings to build
capacity in this area for associated primary health care centers. A total of 280 people will be trained. The
funding for this activity will also support the procurement of color-coded bin liners for segregation of
infectious wastes and autoclave containers at 28 Harvard sites.
The funding will also support the distribution of educational materials and posters on injection safety for
relevant locations at all 28 sites. Harvard will collaborate with MMIS to distribute the educational materials.
Sites will be provided job aids and IEC materials to encourage behavior change and sustainability. Training
activities for each of the 28 sites will be accompanied by the sharing of safe injection SOPs at each site.
Supportive supervision will be provided to all the sites with technical support from MMIS. Harvard aims to
build networks among sites and involve the Plateau State Ministry of Health to allow the continued roll out of
training, services, and best practices in a sustainable manner.
For both HMBL and HMIN, UP materials will include personal protective equipment such as gloves, lab
coats, masks, and other essential consumables for each site. Additionally, each site will make provisions for
the referral of staff for access to post-exposure prophylaxis (PEP), as needed. PEP will be provided through
ART drug activities. Proper waste management will be encouraged at each site through the use of
biohazard bags and suitable sharps containers. Incinerators will be repaired or constructed as applicable.
Through HMIN activities, emphasis is placed on staff training and capacity development of Harvard-
supported sites. This activity will provide the basis for a workplace program through professional medical
associations that will ensure that the care and treatment of HIV-infected patients and safe handling of
specimens, with minimal risk to HCWs. In COP09, emphasis will also be on supportive supervision of these
sites to sustain the gains achieved in COP08 and appropriate health care waste management.
Stigma and discrimination has also been reported in healthcare settings in Nigeria. As HIV care and
treatment programs have been initiated, the training of all levels of HCWs in UP 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 also include military populations, through supportive supervision;
training/retraining for staff and renovation of the incinerator at 68 Military Hospital and Military Hospital Ikoyi,
All levels of HCWs that handle needles and/or blood from patients will be involved in the HMIN training
efforts. In addition, heads of service and administrators need to be aware of the policies put in place to limit
medical transmission of HIV. Furthermore, these activities will indirectly target the general population, who
will be provided with safer injection practices, which are designed to prevent transmission of HIV.
HMIN activities will contribute to the reduction of medical transmission of HIV and other blood-borne
diseases by following UP measures, as well as proper waste management. It will likely improve the quality
of health care and reduce stigma and barriers to comprehensive medical care for PLWHAs by addressing
concerns of HCWs and other hospital staff. As the overall program continues to scale-up, there will be an
increasing number of patients at each site with needs other than ART; well-trained staff in injection safety
will be a necessity. The adoption of practices and policies to address the risks of HIV medical transmission
is important for maintaining a high-quality comprehensive HIV/AIDS care and treatment program and in
preventing new infections.
Additionally, as part of our sustainability building efforts, Harvard will provide technical assistance and
support for APIN to assume program management responsibility for our HMIN activities. This will include
the implementation of a transition plan of site oversight, management and training over to APIN. The goal of
HMIN activities relate to activities in Adult Care and Treatment (HTXS and HBHC), Pediatric Care and
Activity Narrative: Treatment (PDTX and PDCS), PMTCT (MTCT), TB/HIV (HVTB), ART Services (HTXS) and OVC (HKID).
HCWs involved in these programs will benefit from the training program in HMIN and the adoption of safe
needle and needle stick injury policies and PEP protocol.
HMIN activities are also linked to HMBL and to HLAB through the promotion of universal safety precautions,
good laboratory practices, and proper waste management for biohazardous materials. Both areas are linked
to Human Capacity Development (HCD) and Health Systems Strengthening (OHSS) by training workers
and building the overall capacity at the sites.
Continuing Activity: 13053
13053 6818.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $200,000
6818 6818.07 HHS/Health Harvard University 4170 544.07 Track 2.0 $125,000
Estimated amount of funding that is planned for Human Capacity Development $42,000
Table 3.3.05:
ACTIVITY DESCRIPTION:
The SCMS objective is to support PEPFAR programs in Nigeria by providing increased access to quality
HIV/AIDS related commodities. SCMS activity under this program area covers the procurement but also the
shipment, distribution and delivery of medical supplies and equipments used in ARV services including
consumables and non medical supplies needed to run ARV services, as well as basic health care and
support related commodities for adults including other supply chain management related activities. It also
covers technical assistance (TA) and system strengthening (SS) activities provided to PEPFAR
Implementing Partners (IPs) and to the Department of Defense (DoD) to strengthen or build their supply
chain management capacity within their respective programs.
In COP09, SCMS will procure medical supplies and equipments used in ARV services and other
commodities used to extend and optimize the quality of life of HIV infected adults and their families for three
IPs and DoD. This also encompasses commodities for the prevention, management and clinical monitoring
of opportunistic infections (OI), except tuberculosis (TB), other HIV/AIDS related complications, including
malaria, and for the management of sexually transmitted infections (STIs). Example of such commodities
are pharmaceuticals (OI drugs, pain killers, opioids), insecticide treated nets, home based care kits, water
guard, gloves and therapeutic food. SCMS will also procure other medical and non medical supplies used in
treatment and basic health care and support services, including home-based care.
Through its continuous support to and strengthening of commodity security in PEPFAR care programs,
SCMS works towards ensuring uninterrupted availability of needed commodities to the target populations of
people living with HIV/AIDS and the general population through their families. This will be achieved by
assisting the IPs and DoD in quantification, forecasting of requirements and support for the development of
long term supply plans (considering in country stocks and anticipated consumption rates) for stock
management and delivery planning.
In COP09, SCMS will procure medical supplies and equipments used in ARV services, palliative drugs, care
and support commodities and provide requested technical assistance for three IPs and DoD, each of which
has allocated specific funds to SCMS for these services: DOD, $300,000 for Adult Care and Support and
$1,750,000 for Adult Treatment; Columbia University/ICAP, $150,000 for Adult Care and Support and
$675,000 for Adult Treatment; University of Maryland, $287,960 for Adult Care and Support; and URC,
$4,500 for Adult Care and Support and $45,000 for Adult Treatment. The budgets will cover the cost of
commodities as well as well as logistical and administrative services from the field office for the coordination
and management of the procurements undertaken by SCMS. The budget also supports the cost of TA and
SS.
SCMS will support the IPs and DoD in the following areas of the supply chain cycle: product selection in
accordance with the Federal Government of Nigeria's (FGoN) national treatment guidelines, marketing
authorization status (NAFDAC registration) and FGON importation regulation. SCMS will also be
responsible for ensuring that commodities procured meet eligibility criteria under the USG acquisition rules
and regulations including source and origin waivers and approvals by the US Food and Drug Administration
or other relevant stringent drug regulatory authorities.
SCMS will assist in quantification and forecasting of requirements and will support the development of long
term supply plans for stock management and delivery planning. SCMS will identify suitable sources of
supply both internationally and nationally. SCMS will work with IPs in Nigeria to locally procure products that
are either banned for importation or for which local procurement represents a key advantage in terms of
cost, delivery and/or associated services (i.e. maintenance service). SCMS will coordinate with the USG
team to ensure selected products are appropriately registered in Nigeria. For products not yet registered by
NAFDAC, SCMS will make suitable recommendations including waiver applications where appropriate.
SCMS will take the lead to communicate with manufacturers on registration gaps in Nigeria.
Currently, there are several challenges associated with the procurement of Opportunistic Infections (OI)
drugs. A number of key OI medicines are banned from importation into Nigeria and hence by default, need
to be procured from local manufacturers. However, the fact that none of locally manufactured products has
US FDA or similar stringent drug regulatory authority approval places the PEPFAR IPs in an untenable
situation. In COP 09, SCMS will work with the IPs and GoN to identify key OI drugs that are needed and
initiate the process of pre-qualification towards identifying local sources. SCMS will also work with GoN
towards defining the modalities for use of opioids for pain management by HIV/AIDS programs. SCMS
intervention in this area will ensure that required materials for palliative care are available for use of the
programs, thus improving the quality of life of PLWHA.
SCMS procurement leverages global spend to provide best value and offers clients certainty of competitive
prices and international quality standards. SCMS procurement strategy is articulated around buying
generics whenever possible, pooling procurement for HIV/AIDS care, prevention and treatment programs
across PEPFAR focus countries and negotiating long term contracts with suppliers. IPs and DoD's requests
for basic health care and support related commodities will be addressed to and coordinated with SCMS field
office directly.
SCMS will be responsible for the shipment of procured commodities into Nigeria through Abuja or other
points of entry as required. SCMS will take the lead and further streamline the customs clearance process
as appropriate including management of the CC1, CC2 or CC3 duty exemption forms. SCMS will coordinate
with the USG team to fulfill importation requirements and provide needed documentation to allow customs
clearance in an efficient and timely manner.
Where appropriate, commodities procured and imported by SCMS will be supplied through the SCMS
Regional Distribution Center (RDC) in Ghana. The warehousing of commodities in the RDC is a critical
component of the SCMS technical solution. The use of the RDC will significantly reduce lead times and
Activity Narrative: provide an important buffer between the supply from manufacturers and demands from the PEPFAR
programs in Nigeria. The RDC also ensure that shipment quantities do not overwhelm their recipients in
country, an increasing challenge in the context of program scale up. The RDC concept also brings an
increased flexibility in stock management thus reducing risk of stock obsolescence or need for emergency
replenishments, resulting in important savings. Finally, the RDC approach serves regional and national
sustainability, as the RDC is designed to be a commercially viable entity, available to other health (and non-
health) programs, whose benefit will last beyond SCMS. Where possible and appropriate, SCMS will road
freight from the RDC Ghana to Abuja; a mode of delivery that will provide significant savings over airfreight.
Delivery arrangements will be negotiated with URC, ICAP, UMD and DOD; SCMS will either deliver to a
central location or to point of services as needed. When local warehousing is needed SCMS will continue to
explore viable options make use of its recently acquired cross-docking facility and the long term warehouse
facility (which will be acquired in COP 09). For in country distribution where necessary, SCMS will
competitively source for and utilize the service of an efficient and safe in-country courier services operator.
SCMS provides TA and SS services in all areas of the supply chain including product selection,
quantification & forecasting, supply planning, procurement, warehousing, customs clearance and delivery.
In COP09, SCMS will provide TA and SS services to IPs including the training of individuals in the use of
the ProQ or Quantimed forecasting and Pipeline supply planning tools. SCMS will continue to provide TA
and SS services to DoD based on the recommendations that came out of a supply chain system's
assessment carried out in COP07. By providing training and supporting capacity building of local
organization, SCMS addresses the emphasis area of human capacity development.
SCMS will provide the USG team with regular reports on supplies and equipments as well as monthly
financial reports. In COP 09, Supply Chain Support Teams (to be made up of technical SCMS staff and
GoN or IP staff as appropriate) will be constituted by SCMS to work with the IPs in providing their trained
logisticians with the capacity to monitor and support the performance of the supply chains at various levels.
Using standardized indicators of logistics performance, the SCSTs will track performance of the supply
chains and together, act as an early warning system to identify impending or imminent supply chain
breakdowns and act to forestall these. By developing methodologies and tools for conducting these
activities, SCMS will work with GoN and IPs to establish and institutionalize this activity thereby building the
capacity to identify these problems and resolve them before service delivery is compromised. In addition, an
automated web based procurement tracking database will ensure that the USG team and IPs have
adequate visibility on SCMS procurement status by providing an easy access to accurate and up to date
information on procurement. Further procurement automation and harmonization will also be facilitated
through linkages with the LHPMIP system of SCMS.
In COP07, SCMS undertook, under DoD's request, a feasibility study for a Government Owned Contractor
operated (GOCO) warehousing facility to be used by HIV/AIDS Nigerian military and DoD programs. In
COP08, SCMS helped define detailed implementation workplan and responsibility for construction of the
warehouse, SCMS will provide technical oversight for the construction and managing the equipment of the
facility, while the NMoD will finance the construction of the facility, DoD will finance the equipment of the
warehouse through COP allocations to SCMS in the range of $750,000. The establishment of a GOCO, as
part of SCMS system strengthening to the host government's supply chain system, will bring a long term
solution contributing to the sustainability of the military HIV/AIDS programs in Nigeria. By providing training
and supporting capacity building of local organization, SCMS addresses the emphasis area of human
capacity development.
Under this program area, SCMS does not have targets of its own but supports PEPFAR IPs and DoD
reaching their care planned targets.
EMPHASIS AREA
Human capacity development.
Continuing Activity: 13055
13055 5369.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $5,065,000
6719 5369.07 HHS/Health Harvard University 4170 544.07 Track 2.0 $4,070,100
5369 5369.06 HHS/Health Harvard University 2770 544.06 Track 1.0 $2,573,000
Estimated amount of funding that is planned for Human Capacity Development $250,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $172,530
Estimated amount of funding that is planned for Water $664,486
Table 3.3.08:
As we have now split the APIN+ activities between Harvard School of Public Health and APIN, Ltd., our
activity narratives will be amended to reflect activities that will be performed specifically by the efforts of
Harvard through the APIN+ Program (Harvard) as opposed to APIN, Ltd (which will be submitting a
separate narrative under the name APIN). Narrative has also been updated to reflect COP09 goals and
targets. In addition, during COP09, APIN will be taking over all activities for Nigerian Institute of Medical
Research, Lagos University Teaching Hospital, Onikan Women's Hospital, and Mushin General Hospital, in
accordance, those sites and their respective patients will drop out of the Harvard numbers and be reflected
in the APIN narrative.
ACTIVITY DESCRIPTION
In COP08 Harvard provided comprehensive adult care and treatment (ACT) services in 36 sites. In COP09,
Harvard will provide high quality ARV and basic care and support services to eligible adult patients at a total
of 66 sites, including 23 comprehensive ART sites (10 tertiary and 13 secondary facilities) and 64 PMTCT
sites that also provide ART for HIV+ mothers and children identified through PMTCT services. Our ACT
sites are located in the 9 states of Benue, Borno, Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, and Yobe.
This activity will provide ART services to a total of 46,300 adults (9900 new) by the end of the reporting
period. Facility-based palliative care services will be provided to a total of 63,900 PLWHA; 17,600 ART-
ineligible and 46,300 ART-eligible). An additional 127,800 People Affected By HIV/AIDS (PABAs) will be
reached through the community and home-based care (HBC) of the PLWHA; therefore, it is expected that a
total of 191,700 people will access services. At our 21 secondary level PMTCT sites, there will also be ACT
provided for eligible pregnant women. Implementation of the PEPFAR-Nigeria LGA coverage strategy in the
program areas of PMTCT and TB/HIV, designed to ensure the provision of PMTCT and TB/HIV services in
at least one health facility in every local government area (LGA) of 6 identified states, will increase the reach
of ACT services as well into an additional 34 primary level facilities. As a part of the transition of
APIN+/Harvard PEPFAR activities to APIN, 4 Harvard COP08 Sites (LUTH, NIMR, OWH, and MGH), will be
supported by APIN in COP09. Harvard and APIN will collaborate in order to ensure a smooth transition of
clinical services.
Patients are identified through HCT services, including facility-based, mobile, and family-centered
strategies. All HIV-infected individuals are clinically pre-assessed for ART eligibility; ART-ineligible patients
are provided with continuous clinical monitoring and basic care and support services. ART-eligible patients
are provided with ART services, in accordance with a standardized programmatic protocol, which follows
the 2005 revised National ART Guidelines. All HIV+ patients are provided with palliative care services,
consistent with the Nigerian Palliative Care Guidelines. A network model of care will be used for service
delivery.
ART-ineligible individuals enrolled in care receive periodic follow-up to identify changes in eligibility status.
Scheduled physician visits for all patients are at 3, 6, and 12 months and every 6 months thereafter. ART
patients follow the same clinical visit schedule with more intensified monitoring and pick up drugs monthly.
At each visit, clinical exams, hematology, chemistry, viral load, and CD4 enumeration are performed when
indicated. All tertiary site labs perform the necessary lab assays. Secondary and primary sites with limited
lab capability send samples to an affiliated tertiary site lab for analyses. Electronic clinic and lab records
provide data for high-quality patient care and centrally coordinated program monitoring. As additional
medical needs of patients are identified through clinic visits, patients are provided with the services by
clinicians or referred for specialty care as necessary. HIV+ individuals are provided with cotrimoxazole
prophylaxis according to national guidelines. Diagnostics for common opportunistic infections (OIs) may
include: Candida albicans, protozoal infections, and gastrointestinal parasites. All HIV+ patients are also
symptomatically screened for TB and confirmed with laboratory and radiological diagnostics as indicated.
Harvard will support integration of syndromic management of STIs and risk reduction interventions into
care. All PLWHA will be provided with a basic care kit including clean water kits, ITN, and IEC materials on
prevention with positives (PWP). Pain management assessments will also be conducted by clinicians and
HBC providers and analgesics will be provided. Commodities distributed as a part of the palliative care
services are procured centrally through the APIN Abuja program office and Central Medical Stores in Lagos.
Distribution of commodities to individual sites is coordinated through supply chain mechanisms in place for
laboratory test kits and ART drugs. During COP09, Harvard will collaborate with SCMS for the procurement
and distribution of specified OI drugs.
All enrolled into care will receive risk assessment and behavioral counseling to achieve risk reduction.
These activities are provided through individual counseling and outreach by site PLWHA support groups.
Activities that focus on PWP include HCT for family members and sex partners, counseling for discordant
couples, counseling on healthy lifestyles and positive living, prevention messages, and IEC materials on
disclosure. Patients are also encouraged to refer family members for HCT. ART patients are provided ART
education and adherence counseling (EAC) prior to and during ART provision, which follows the National
Guidelines for Adherence Counseling and includes partner notification, drug adherence strategies and other
prevention measures. ART EAC is reinforced with PLWHA support groups at each site, which serve all
HIV+ patients and their families. ART patients are encouraged to have a treatment support partner to whom
he/she had disclosed status to improve adherence and to optimize care. Harvard also partners with
community based PLWHA support groups and CBOs to mobilize communities provide psychosocial support
to PLWHAs and their families, provide ART adherence counseling, and assist with patient follow-up and
HBC activities. Site HBC activities will be supervised by a hospital team.
Facility-based and community-based HBC teams partner to provide a continuum of HBC services
depending on client needs. When ART patients miss scheduled clinic visits or bed ridden clients are
reported by the community HBC team, the site HBC team provides follow-up according to a program based
SOP, utilizing a HBC kit provided to these outreach teams. The HBC includes ORS, bleach, cotton wool,
gloves, soap, calamine lotion, vaseline, gentian violet. The team will provide basic medical assessments of
signs and symptoms, basic nursing care, nutritional assessments and psychosocial support and make
appropriate referrals. HBC teams will also provide refills of cotrimoxazole, paracetamol, additional clean
Activity Narrative: water kits and additional ITNs to patients and their families.
All sites focus on the integration of adult care and treatment (ACT) services for all patients regardless of the
source of funding for different components of treatment (e.g. external funding sources for services or lab
commodities). At each site support is provided for the management of electronic data and patient medical
records for use in the provision of clinical care. TB diagnosis and treatment is provided to all patients via
facility co-location of DOTS centers and/or referral of HIV+ patients into ART from DOTS sites. ART-eligible
patients identified through HCT conducted for all TB patients at DOTS sites will be provided with ART.
Clinical staff at Harvard sites meet monthly for updates and training. The clinic coordinator and senior
clinical officer at each site is responsible approving drug regimen switching. As clinical training needs are
identified for new sites or new staff at existing sites, through APIN, Harvard provides training on regimen
switching and other relevant topics. In COP08, Harvard incorporated standardized quality indicators into a
comprehensive Quality Improvement (QI) Plan for the sites, which includes periodic external site
assessments and chart reviews as well as quarterly internal reviews, based on electronic databases. This
QI Plan has been harmonized with HIVQual activities for participating sites and will continue to be
implemented in COP09.
For patients enrolled through the GON National ART Program, we anticipate GON provision of 1st line ARV
drugs and PEPFAR support for ACT services. As patients require alternative or 2nd line drugs, they will
receive PEPFAR provided drugs. GON provision of 1st line drugs allows for additional ACT targets. Harvard
estimates that 3,981 additional adults will receive ART through the leveraging of GON drugs. Harvard will
partner with Clinton Foundation and Global Fund as appropriate to leverage resources for providing ARVs
to patients. The site investigators and project managers will actively participate in the GON National ART
program. Harmonization of data collection for M&E will be coordinated with USG and GON efforts. Harvard
has provided technical assistance and training expertise to the National ART program's training program,
which will continue in 2009. Harvard will continue to participate in the USG coordinated Clinical Working
Group to address emerging topics in ARV service provision and to ensure harmonization with other IPs and
the GON.
In addition, the program will identify, collaborate with and strengthen the capacities of support groups,
including AIDS Alliance and CBOs, to deliver palliative care services, including the provision of community
and HBC services such as domestic support, management of minor ailments, pain management, referral
services, and counseling services. Supported CBOs will provide a range of facility and HBC services,
including prevention for positives (balanced ABC messaging as appropriate), clinical care, prophylaxis and
management of OIs, lab support, adherence counseling, psychosocial and spiritual support, and active
linkages between hospitals, health centers, and communities. Through counselors and clinicians at all sites,
Harvard will provide referrals for TB, family planning, safe motherhood, and other wraparound services as
appropriate.
A total of 643 health care and non-health care workers will be trained in palliative care, including HBC, in
line with the National Palliative Care Guidance and the USG Palliative Care policy. This funding will also
support the personnel, clinic and lab services for training of 825 in ART Services. Harvard will support
policy development and implementation of task shifting to improve access to care and treatment services for
PLWHAs. Funding is also used to support renovations of physical infrastructure at expansion sites to build
physical capacity for the provision of ACT.
This program seeks to increase gender equity in programming through counseling and educational
messages targeted at vulnerable women and girls. Furthermore, through gender sensitive programming and
improved quality services the program will contribute to reduction in stigma and discrimination and address
male norms and behaviors by encouraging men to contribute to care and support in the families. Through
this program we will also target military populations, through ACT services provided at 68 Military Hospital
and Military Hospital Ikoyi, Lagos. We provide a focus on malaria and TB wraparounds through the
provision of ITNs, provision of malaria smears, TB screening and linkages to TB DOTS programs.
The clinical components of these activities target HIV-infected adults for care and treatment. The
operational elements of these activities (M&E, health personnel training, infrastructural supports, technical
assistance and quality assurance) target public and private program managers, doctors, nurses,
pharmacists and lab workers at PEPFAR sites. The expansion of care and treatment services to secondary
health facilities will increase access to necessary services in poor communities.
CONTRIBUTION TO PROGRAM
ACT activities are consistent with the PEPFAR goal of scaling up capacity to provide ARV drugs, care and
treatment services and lab support to serve more HIV+ people. Harvard will continue to support the
expansion of ARV services into more rural areas by strengthening a network of secondary or primary health
care clinics providing ART services that are linked to tertiary health care facilities. These networks will
ensure that facilities are able to develop linkages, which permit patient referral from primary health centers
and the provision of specialty care support. A tiered structure for ARV provision and monitoring established
in COP07 and COP08 provides a model for additional expansion efforts in COP09 in order to meet
PEPFAR treatment goals. The program will also contribute to strengthening human capacity through
training of health workers, community workers and PLWHAs and their families.
support for APIN to assume program management responsibility for our ACT activities. This will include the
implementation of a plan to transition site oversight, management and training over to APIN. The goal of
these efforts is to provide for greater assumption of responsibility for management and implementation of
Activity Narrative: LINKS TO OTHER ACTIVITIES
This activity is linked to ART drugs, OVC and Pediatric ART Care and Treatment for pediatric care, PMTCT
as the program will support 36 PMTCT sites, TB/HIV to provide ART to patients with TB, Lab to provide
ART diagnostics, HCT as an entry point to ART, and SI will provide the GON with crucial information for use
in the evaluation of the National ARV program and recommended drug regimens. This program is linked to
Continuing Activity: 13060
13060 6715.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $14,085,825
Table 3.3.09:
In COP09, the Harvard School of Public Health (Harvard) plans to move over four of its PEPFAR supported
sites to the indigenous partner APIN Ltd. (APIN). The sites include Lagos University Teaching Hospital,
Nigerian Institute of Medical Research, Onikan Women's Hospital, and Mushin General Hospital. The
activity narrative reflects the transfer of targets from Harvard to APIN. The activities will build on the
structure and systems put in place through Harvard. APIN will maintain a strong collaboration with Harvard
University.
In COP08 APIN Ltd. provided comprehensive pediatric care and treatment (PCT) services in one site. In
COP09, APIN will take over provision of high quality ARV and basic care and support services to eligible
pediatric patients in an additional five sites making a total of six sites; five comprehensive ART sites (two
tertiary and three secondary facilities) and one PHC located in two states of Lagos and Ogun. This will
provide ART services to a total of 1,050 children (700 new) at the end of the reporting period. Pediatric care
services will be provided to approximately 413 ART ineligible children and 1,050 ART eligible children for a
total of 1,550 pediatric PLWHA clients. People affected by HIV/AIDS (PABAs), including caregivers of
pediatric PLWHA, will be reached through community and home based care (HBC) services; therefore, it is
expected that a total of 4,650 individuals will access services (1,550 pediatric PLWHA and 3,100 PABA).
Patients are identified through PMTCT and HCT services, including facility-based, mobile, and family-
centered strategies. Through linkages with PMTCT services and pediatric wards at supported sites, early
infant diagnosis (EID) is performed for children <18 months utilizing dried blood spot (DBS) at secondary
and primary sites for transportation to two tertiary sites where DNA PCR is carried out.
All HIV-positive children are provided with care and support services in line with national guidelines and are
clinically pre-assessed for ART eligibility. ART-eligible children are provided with ART services in
accordance with a standardized programmatic protocol which follows the current National ART Guidelines.
All HIV-positive children are provided with basic care kits and care and treatment services, consistent with
the National Care and Treatment Guidelines. These services include clinical care (nursing care, pain
management, OI prophylaxis and treatment, nutritional assessment and support, end-stage care, and labs -
baseline hematology, chemistry, CD4 count baseline and follow-up, OI diagnosis, pregnancy test if
indicated), psychosocial and spiritual support, economic empowerment for caregivers, community HBC,
prevention with positives (PwP) and other prevention services. HIV-positive children are provided with
cotrimoxazole prophylaxis according to national guidelines. All HIVpositive children are also
Education on risk reduction interventions will be provided. All families of enrolled children will be provided
with basic care kits including water vessel, water guard, ITN, soap, ORS, latex gloves, and IEC materials.
Pain management assessment will also be conducted by clinicians and HBC providers and analgesics will
be provided. Any pediatric patient presenting with acute history of sexual assault will be provided with post-
exposure prophylaxis and psychosocial counseling services and monitored according to national guidelines.
APIN uses the hub and spoke model of care for service delivery and will continue to expand provision of
care and treatment services to the primary health centers.
ART-ineligible children that are enrolled in care will have periodic follow-up to identify changes in eligibility
status. Scheduled physician visits for all are at three, six, and 12 months and every six months thereafter.
ART patients follow the same clinical visit schedule with more intensified monitoring and appointments to
pick up drugs monthly. At follow-up visits, clinical exams, hematology, chemistry, CD4% enumeration and
viral load (when indicated) are performed. All tertiary site labs perform the necessary lab assays while
secondary and primary sites with limited lab capability send samples to an affiliated tertiary site. Electronic
clinic and lab records provide data for high quality patient care and centrally coordinated program
monitoring. As additional medical needs are identified through clinic and HBC visits, patients will be
provided with clinical services by clinicians or referred for specialty care as necessary. HIV-positive children
will be provided with a package of preventative care services, including cotrimoxazole prophylaxis according
to national guidelines, referrals for immunizations, growth monitoring and other child survival services. All
HIV-positive children will be also symptomatically screened for TB and confirmed with tuberculin skin test
(TST), laboratory and radiological diagnostics as indicated. HIV-positive children are also provided with
nutritional counseling and supplements, including multivitamins and Plumpy Nut as indicated. All HIV-
positive children are linked into the system of OVC services in order to ensure a continuum of care. The
Harvard Loss to Follow-Up (LTFU) utility will help in picking up children that might soon be lost to follow-up.
The list generated is sent to the LTFU team and support group to initiate a process of tracking and bringing
children back into care. APIN will continue to facilitate facility and community support group activities
focused on pre-ART patient retention. Home-based visits will be conducted to encourage children to
continue to access care and treatment. APIN will strengthen the linkage between facility and community
OVC services to promote retention of children.
Commodities distributed as a part of palliative care services are procured centrally through the Abuja
program office and Central Medical Stores in Lagos. Distribution of commodities to individual sites is
coordinated through supply chain mechanisms in place for laboratory test kits and ART drugs. During
COP09, APIN will collaborate with Harvard and SCMS for the procurement and distribution of specified
pediatric OI drugs.
All children enrolled into care will receive age-appropriate risk assessments and behavioral counseling to
achieve risk reduction. These activities are provided through individual counseling and outreach by site
PLWHA support groups. Caregivers are also encouraged to seek out HCT and refer other family members
for HCT. Caregivers for HIV-positive children are provided ART education and adherence counseling (EAC)
prior to and during ART provision, which follows the National Curriculum for Adherence Counseling. ART
EAC is reinforced with PLWHA caregiver support groups at each site, which serves all HIV-positive patients
and their families. APIN also partners with community-based PLWHA support groups and CBOs to mobilize
communities, provide psychosocial and spiritual support to PLWHAs and their families, provide ART
adherence counseling, and assist with patient follow-up and HBC activities.
Activity Narrative: Facility-based and community-based HBC teams partner to provide a continuum of HBC services
depending on client needs. When ART patients miss scheduled clinic visits or bedridden clients are
SOP, utilizing a HBC kit provided to these outreach teams. The HBC provider kit includes ORS, bleach,
cotton wool, latex gloves, soap, calamine lotion, petroleum jelly and gentian violet. The team will provide
basic medical assessments of signs and symptoms, basic nursing care, nutritional assessments and
psychosocial support and will make appropriate referrals. HBC teams will also provide refills of
cotrimoxazole, paracetamol, additional clean water kits and additional ITNs to patients and their families.
The HBC team is comprised of a clinician, nurse, counselor, social worker, volunteers and support groups
members
All sites focus on the integration of care and treatment services for all patients regardless of the source of
funding for different components of treatment (e.g., external funding sources for services or lab
commodities). At each site, support is provided for the management of electronic data and patient medical
facility co-location of DOTS centers and/or referral of HIV-positive patients into ART from DOTS sites. HIV-
positive patients identified through HCT conducted for all TB patients at DOTS sites will be referred to care
and treatment services.
Clinical staff at APIN and Harvard supported sites meet monthly for updates and training. As clinical training
needs are identified for new sites or new staff at existing sites, Harvard provides training on relevant topics
including regimen switching. In COP08, Harvard incorporated standardized quality indicators into a
comprehensive quality improvement (QI) plan for the sites, which includes periodic external site
assessments and chart reviews as well as quarterly internal reviews, based on electronic databases. APIN
Ltd. will support the training of 106 healthcare workers (HCWs) including primary health center HCWs to
provide care and treatment services to 1,550 HIV-infected children by the end of COP09, which includes
1,050 ART eligible children. A total of 1,550 children will be provided with PCT services. Funding is also
used to support renovations of physical infrastructure to build physical capacity to provide a child friendly
clinic environment and service.
For pediatric patients enrolled through the government of Nigeria (GON) ART Program, APIN anticipates
GON provision of 1st-line ARV drugs and PEPFAR support for other services. As patients require
alternative or second-line drugs, they will receive PEPFAR-provided drugs. APIN estimates that additional
children will be placed on ART through the leveraging of GON drugs. APIN will partner with Harvard and
Clinton Foundation as appropriate to leverage resources for providing ARVs to patients. The site
investigators and project managers will actively participate in the GON pediatric ART program.
Harmonization of data collection for monitoring & evaluation (M&E) will be coordinated with USG and GON
efforts. APIN has provided technical assistance and training expertise to the national pediatric treatment
training program, which will continue in COP09. APIN supported the development of the National Pediatric
Care and Support Guideline and Training curriculum.
In addition to providing training of site-based HCWs to improve care at supported sites, APIN will also fully
support the training of lab scientists working at GON and Global Fund supported sites in early infant
diagnosis techniques.
In addition, the program will identify, collaborate with and strengthen the capacities of support groups and
CBOs to deliver care and support services, including the provision of community and HBC services such as
domestic support, management of minor ailments, pain management, referral services, and counseling
services. Supported CBOs will provide a range of facility and HBC services, including PwP, clinical care,
prophylaxis and management of OIs, lab support, adherence counseling, psychosocial and spiritual support,
and active linkages between hospitals, health centers, and communities. Through counselors and clinicians
at all sites, APIN will provide referrals for TB, wraparound services and child survival programs as
CONTRIBUTION TO OVERALL PROGRAM
Care and treatment activities are consistent with the PEPFAR goal of strengthening capacity to provide
ARV drugs, care and treatment services and lab support to serve more HIV-positive children. APIN will
continue to support the expansion of services into more underserved areas by developing a network model.
These networks will ensure that facilities are able to develop linkages which permit patient referral from
primary health centers and the provision of specialty care as needed. A tiered structure for ARV provision
and monitoring established by Harvard provides a model for additional expansion efforts in COP09 in order
to meet PEPFAR treatment goals. The program will also contribute to strengthening human capacity
through the training of healthcare workers, community workers and HIV-positive children and their families.
Additionally, as part of PEPFAR sustainability efforts, APIN will continue to receive technical assistance and
support from Harvard as it assumes more program management responsibility for care and treatment
activities. This will include the implementation of a plan to transition site oversight, management and
training over to APIN. The goal of such efforts is to provide for greater assumption of responsibility for
The care and treatment components of these activities target HIV-positive children for care, clinical
monitoring and ART. The operational elements of these activities (M&E, health personnel training,
infrastructural support, technical assistance and quality assurance) target program managers, doctors,
nurses, pharmacists and lab workers at PEPFAR sites. The expansion of ART services to primary and
secondary health facilities will increase access to underserved areas.
Activity Narrative: APIN's major emphasis is on strengthening the capacity of healthcare workers to provide high quality care
and treatment services. Minor emphasis will be on child survival wraparound programming through the
provision of clean water kits, growth monitoring, nutritional support, treatment of OIs and other illnesses,
and counseling for caregivers on hygiene and nutrition for HIV-infected children. This program seeks to
increase gender equity in programming through counseling and educational messages targeted at girls and
boys. Furthermore, through gender sensitive programming and improved quality services the program will
contribute to reduction in stigma and discrimination and will address male norms and behaviors by
encouraging men to contribute to care and treatment in families.
Continuing Activity: 13057
13057 5415.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $2,235,000
6720 5415.07 HHS/Health Harvard University 4170 544.07 Track 2.0 $1,068,000
5415 5415.06 HHS/Health Harvard University 2770 544.06 Track 1.0 $200,000
Estimated amount of funding that is planned for Human Capacity Development $113,500
Table 3.3.10:
As we have now split the APIN+/Harvard activities between Harvard School of Public Health (Harvard) and
APIN, Ltd., our activity narratives will be amended to reflect activities that will be performed specifically by
the efforts of Harvard through the APIN+ Program (Harvard) as opposed to APIN (which will be submitting a
separate narrative under the name APIN). In addition, APIN will be taking over all activities for Nigerian
Institute of Medical Research (NIMR), Lagos University Teaching Hospital (LUTH), Onikan Women's
Hospital (OWH), and Mushin General Hospital (MGH); thus, those sites and their respective patients will
drop out of the Harvard numbers and be reflected in the APIN, Ltd. narrative.
In COP08 Harvard/APIN+ provided comprehensive pediatric care and treatment (PCT) services in 36 sites.
In COP09, Harvard will provide high-quality ARV and basic care and support services to eligible pediatric
patients at a total of 66 sites; of the 66, 24 are comprehensive ART sites (10 tertiary and 13 secondary
facilities and 1 primary health care facility) and 64 are PMTCT sites that also provide ART for HIV+ mothers
and children identified through PMTCT services. The sites are located in the 9 states of Benue, Borno,
Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, and Yobe and include 33 primary health care facilities in
Plateau State. This activity will provide ART and palliative care services to a total of 5,550 children (2,050
new) at the end of the reporting period. It is expected that through this program area, we will also reach a
total of 16,650 Through the community and home-based care (HBC) services in this program area, it is
expected we will reach 16,650 people affected by HIV/AIDS (PABAs), which includes caregivers of pediatric
PLWHA; therefore, it is expected that a total of 22,200 individuals will access services (5,550 pediatric
PLWHA and 16,650 PABA). At our 64 PMTCT sites, PCT will also be provided to HIV+ children.
Implementation of the PEPFAR-Nigeria LGA coverage strategy in the program areas of PMTCT and
TB/HIV, designed to ensure the provision of PMTCT and TB/HIV services in at least one health facility in
every local government area (LGA) of 6 identified states, will increase the reach of PCT services as well in
33 PHCs and 16 secondary level facilities. As a part of the transition of APIN+/Harvard PEPFAR activities to
APIN, 4 Harvard COP08 Sites (LUTH, NIMR, OWH, and MGH), will be supported by APIN in COP09.
Harvard and APIN will collaborate in order to ensure a smooth transition of clinical services at these sites.
centered strategies. Through linkages with PMTCT services and pediatric wards at our sites, early infant
diagnosis (EID) is performed for children <18 months utilizing DNA PCR at 6 tertiary level sites. Any young
girls that show signs of being raped will be provided with post-exposure prophylaxis and psychosocial
counseling services. The girls will be offered HIV monitoring services and enrollment if they become HIV+.
All HIV+ children are clinically pre-assessed for ART eligibility. Patients who are ART-ineligible are provided
with continuous clinical monitoring and basic care and support services. ART-eligible patients are provided
with ART services, in accordance with a standardized programmatic protocol, which follows the 2007
revised National ART Guidelines. All HIV+ patients are provided with palliative care services, which are
consistent with the Nigerian Palliative Care Guidelines. PCT services follow a family-centered model of
care, which seeks to provide access to HIV-related services for all caregivers, family members and other
PABAs. A network model of care will be used for service delivery.
status. Scheduled physician visits for all patients are at 3, 6, and 12 months and every 6 months thereafter.
ART patients follow the same clinical visit schedule with more intensified monitoring and pick up drugs
monthly. At each visit, clinical exams, hematology, chemistry, viral load, and CD4% enumeration are
performed. All tertiary site labs perform the necessary lab assays. Secondary and primary sites with limited
lab capability send samples to an affiliated tertiary site lab for analysis. Electronic clinic and lab records
provide data for high-quality patient care and centrally coordinated program monitoring. As needs for
additional medical needs are identified through clinic visits, patients will be provided with clinical services by
clinicians or referred for specialty care as necessary. HIV+ children will be provided with a package of
preventative care services, including cotrimoxazole prophylaxis according to national guidelines and
referrals to the National Vaccination Program for childhood vaccinations. Diagnostics for common OIs may
include: Candida albicans, protozoal infections, and gastrointestinal parasites. All HIV+ children will be also
symptomatically screened for TB and confirmed with TST, laboratory and radiological diagnostics as
indicated. HIV+ children are also provided with nutritional counseling and supplements, including
multivitamins, growth monitoring, and care for childhood illnesses. All HIV+ children and their caregivers will
be provided with a basic care package, including clean water kits, ITN, and IEC materials. Pain
management assessments will also be conducted by clinicians and HBC providers and analgesics will be
provided. All HIV+ children are linked into the system of OVC services in order to ensure a continuum of
care.
Commodities distributed as a part of these activities are procured centrally through the APIN+ Abuja
COP09, Harvard will collaborate with SCMS for the procurement and distribution of specific pediatric OI
drugs.
for HCT. Caregivers for HIV+ children are provided ART EAC prior to and during ART provision, which
follows the National Curriculum for Adherence Counseling. ART EAC is reinforced with PLWHA support
groups at each site, which serves all HIV+ patients and their families. Harvard also partners with community
based PLWHA support groups and CBOs to mobilize communities provide psychosocial and spiritual
support to PLWHAs and their families, provide ART adherence counseling, and assist with patient follow-up
and HBC activities.
Activity Narrative: depending on client needs. When ART patients miss scheduled clinic visits or bed-ridden clients are
gloves, soap, calamine lotion, petroleum jelly, gentian violet. The team will provide basic medical
assessments of signs and symptoms, basic nursing care, nutritional assessments and psychosocial support
and make appropriate referrals. HBC teams will also provide refills of cotrimoxazole, paracetamol, additional
clean water kits and additional ITNs to patients and their families.
All sites focus on the integration of PCT services for all patients regardless of the source of funding for
different components of treatment (e.g., external funding sources for services or lab commodities). At each
site, support is provided for the management of electronic data and patient medical records for use in the
provision of clinical care. TB diagnosis and treatment is provided to all patients via facility co-location of
DOTS centers and/or referral of HIV+ patients into ART from DOTS sites. HIV+ patients identified through
HCT conducted for all TB patients at DOTS sites will be referred to PCT services.
Clinical staff at Harvard sites meets monthly for updates and training. Each site has a clinic coordinator and
senior clinical officer who is responsible approving drug regimen switching. As clinical training needs are
identified for new sites or staff at existing sites, Harvard provides training on regimen switching and other
relevant topics. In COP08, Harvard incorporated standardized quality indicators for PCT into a
comprehensive Quality improvement (QI) plan, which includes periodic external site assessments and chart
reviews as well as quarterly internal reviews, based on electronic databases, at the Harvard PEPFAR sites
For pediatric patients enrolled through the GON ART Program, we anticipate GON provision of 1st-line ARV
drugs and PEPFAR support for PCT services. As patients require alternative or 2nd-line drugs, patients will
receive PEPFAR-provided drugs. GON provision of 1st-line drugs allows for additional PCT targets. Harvard
estimates that 500 additional children will be placed on ART through the leveraging of GON drugs. Harvard
will partner with Clinton Foundation as appropriate to leverage resources for providing ARVs to patients.
The site investigators and project managers will actively participate in the GON pediatric ART program.
Harmonization of data collection for M&E will be coordinated with USG and GON efforts. Harvard has
provided technical assistance and training expertise to the National ART Program's training program, which
will continue in COP09.
including AIDS Alliance and CBOs, to deliver pediatric palliative care and OVC services, including the
provision of community and HBC services such as domestic support, management of minor ailments, pain
management, referral services, and counseling services. Supported CBOs will provide a range of facility
and HBC services, including prevention, clinical care, prophylaxis and management of OIs, lab support,
adherence counseling, psychosocial and spiritual support, and active linkages between hospitals, health
centers, and communities. Through counselors and clinicians at all sites, Harvard will provide referrals for
TB, wraparound services and child survival programs as appropriate.
In addition to providing training of site-based HCWs to improve care at supported sites, Harvard will also
fully support the training of 300 lab scientists working at GON and GF supported sites in early infant
diagnosis techniques. This will serve to increase the access to EID services outside PEPFAR supported
sites. A total of 342 health care and non-health care workers will be trained in PCT services in line with the
National Pediatric ART Guidelines and the National Training Curriculum. This funding will support the
personnel, clinic and lab services for training of 377 people in ART services to cover monitoring of 5,550
pediatric patients at the end of COP09.
Through the provision of ITNs, provision of malaria smears, TB screening and linkages to TB DOTS
programs, we also provide focus on malaria and TB wrap-arounds. We will also provide emphasis on child
survival wrap-around programming, through the provision of clean water kits, growth monitoring, nutritional
supports, treatment of OIs and other illnesses, and counseling for caregivers on hygiene and nutrition for
HIV-infected children.
The care and treatment components of these activities target HIV+ children for clinical monitoring and ART.
The operational elements of these activities (M&E, health personnel training, infrastructural supports,
technical assistance and quality assurance) target public and private program managers, doctors, nurses,
pharmacists and lab workers at PEPFAR sites. The expansion of PCT to secondary health facilities will
increase access to necessary services in poor communities.
PCT activities are consistent with the PEPFAR goal of scaling up capacity to provide ARV drugs, care and
treatment services and lab support to serve more HIV+ children. Harvard will continue to support the
expansion of PCT services into more local areas by developing a network of secondary or primary health
and the provision of specialty care support and access to care in rural areas. A tiered structure for ARV
provision and monitoring established in COP07 and COP08 provides a model for additional expansion
efforts in COP09 in order to meet PEPFAR treatment goals. The program will also contribute to
strengthening human capacity through training of health workers, community workers and HIV+ children
and their families.
support for APIN to assume program management responsibility for our PCT Activities. This will include the
This activity is linked to ART drugs (HTXD), OVC (HKID), TB/HIV (HVTB) to provide ART to patients with
TB, Lab (HLAB) to provide ART diagnostics, HCT (HVCT) as an entry point to ART, and SI (HVSI) will
provide the GON with crucial information for use in the evaluation of the National ARV program and
recommended drug regimens. This program is linked to PMTCT services to optimize the follow-up on
children that become HIV-infected through their mothers. By training local personnel, we are also
contributing to the program area of Human Capacity Development (HCD). With our focus on helping young
girls, we also contribute to the Gender program area.
Estimated amount of funding that is planned for Food and Nutrition: Commodities $98,437
Table 3.3.11:
APIN Plus/Harvard sites will identify HIV infected patients through PMTCT, HCT centers and ART centers
and hospitals. These sites constitute a network of delivery points in nine states (Benue, Borno, Ebonyi,
Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe) and include tertiary teaching hospitals (11) and secondary
hospitals (24), for a total of 36 TB/HIV service delivery sites in COP08. APIN+, with other implementing
partners, will execute the PEPFAR-Nigeria LGA coverage strategy in Plateau and Lagos, ensuring the
provision of TB/HIV services in at least one health facility in every local government area (LGA) of these
states. This is an essential step toward universal access to TB/HIV services, and will focus on developing
programming at the secondary and primary level. All HIV-infected individuals are clinically pre-assessed for
eligibility for ART treatment; it is expected that 33,350 HIV positive clients will be screened for TB in COP08.
TB screening by sputum examination is conducted according to national guidelines. The 48,500
maintenance patients already on ART will also be monitored for TB. All HIV infected women (5,475) from
our 36 PMTCT sites will be assessed for ART eligibility and screened for TB. The TB clinics at 9 of our sites
are National TB centers offering the government DOTS program. At all of our associated DOTS clinics, we
will implement HCT for 10,000 clients presenting to the DOTS center; it is expected that 5,000 of these will
have TB. In all, it is expected that 16,550 TB/HIV HIV/TB co-infected patients will be identified and will
receive treatment for TB and be linked to APIN+ ART clinics for evaluation of eligibility for ART and
provision of treatment and palliative care.
NIMR is the National Tuberculosis Reference Laboratory and will provide an important resource to other
APIN+ sites in strengthening their capacity for TB diagnosis and cross-training of health care workers in
TB/HIV. TB services provided at these clinics will be integrated with ART services and HCT in order to
promote the development of a comprehensive system of care for individuals with HIV/TB co-infection. This
will be part of the 500 health care workers in both HIV and TB clinical and laboratory settings to be trained
in COP08. APIN+ TB/HIV program officers and facility staff will be provided with formal TB/HIV training to
enhance their productivity, including retraining on x-ray diagnostic skills for clinicians and retraining on good
sputum specimen collection and laboratory AFB sputum smear diagnosis for laboratorians. A dedicated TB
program officer provides TB expertise to all APIN+ sites and is responsible for training efforts and reporting
of TB patients to the NTPLCP.
APIN+ will prevent nosocomial transmission of TB to HIV+ patients through such measures and principles
such as basic hygiene, proper sputum disposal, and good cross ventilation at clinics. Facility co-location of
TB/HIV services is preferred to clinic co-location. The national guidelines on TB infection control on co-
located sites will be implemented in all sites. Patient and staff education on infection control measures will
be routinely carried out to ensure program success. APIN+ will upgrade facilities as needed through
infrastructure support such as basic renovations, upgrading equipment and procuring supplies and
consumables (e.g. sputum containers).
To date, more than 30% of APIN+ clinic attendees present with pulmonary tuberculosis. Depending on
clinical status, many patients will be treated for TB prior to receiving ART, following the NTBLCP Guidelines.
Concurrent ART and TB treatment follows the National guidelines of d4T+3TC+EFV (800mg). All co-
infected patients with CD4 values <200 cells/mm will receive cotrimoxazole. INH prophylaxis therapy will
only be provided on a case by case basis following the NTBLCP guidelines. Five hundred HIV+ patients are
estimated to be given IPT. The TB DOTS sites will be supported to provide holistic patient care according to
National and IMAI guidelines.
APIN will also continue to work with GON in providing support for the Federal Public Health Laboratory,
which was developed into a national reference lab in COP07. TB diagnostic capacity will include culture,
PCR, and sequencing for resistance testing. At NIMR, APIN will provide technical assistance in the
implementation of MDR-TB and XDR-TB surveillance activities in Nigeria.
Pursuant to the State LGA coverage plan, APIN+ will work with secondary sites in 17 LGAs of Plateau and
Lagos states. Secondary sites will be linked with two tertiary care sites for specialty care and are fed by
patient referrals from primary health care centers. To ensure continuous availability of drugs and
commodities in supported sites, APIN will partner with the USG PEPFAR team to strengthen logistics
management within the states where it works.
CONTRIBUTION TO OVERALL PROGRAM:
The provision of TB diagnostics and treatment within participating ART facilities is consistent with the
PEPFAR goal of ensuring that all facilities offering ART develop the ability to diagnose TB and provide
nationally accepted DOTS sites within their facility. There will a deliberate attempt to locate HCT in DOTS
centers so as to increase detection of co-infected TB/HIV patients. At these facilities, APIN estimates that it
will provide clinical treatment for TB to 16,550 patients with HIV/TB co-infection either prior to or during their
ART therapy, thus contributing significantly to the 2008 PEPFAR goals. At all APIN+ sites referral to TB
DOTS sites that are either co-located or within short proximity will be provided. The provision of TB
diagnosis and treatment, infrastructure building and health care personnel training under this program will
work towards building and maintaining Nigerian National tuberculosis treatment capacity, which is
consistent with the PEPFAR 5-year strategy.
This activity also relates to activities in HCT (5424.08), Care & Support (5369.08), ART Services (6715.08),
PMTCT (3227.08) and OVC (5415.08). Through this activity linkages between participating treatment sites
and the National Tuberculosis Reference Laboratory will be provided. Additionally, linkages to potential
patient populations through outreach initiatives, HCT activities, and ART services will improve utilization of
care opportunities created through PEPFAR funding. This activity is linked to care and support and ART
services because TB diagnosis and treatment are provided as a part of patient palliative care and support at
sites which also provide ART. A high TB co-infection rate has a major impact on ART management.
This activity targets adults and children with HIV and TB co-infection by providing a mechanism for critically
Activity Narrative: important TB diagnosis and treatment both prior to the initiation of ART and also during the course of ART
therapy. Newly enrolling ART patients will be prescreened for TB in COP08 and TB that develops in
patients that are currently on ART therapy will be diagnosed and treated. All HIV infected pregnant women
participating in APIN+ PMTCT programs will also be eligible for TB diagnosis and treatment under this
program.
Emphasis areas include local organization capacity building, and health-related wrap around activities.
This activity will increase gender equity by focusing on strategies which seek to reach an equitable number
of co-infected men and women. Furthermore, it seeks to provide additional focus on support for pregnant
women who have TB/HIV. Through data collection and patient surveillance from this activity, APIN will be
able to show the breakdown of men and women who are accessing TB diagnostics and treatment services.
Outreach activities and patient counseling also seek to address stigma and discrimination and increase
access to information, education and TB diagnosis and treatment for women and girls with HIV.
Continuing Activity: 13056
13056 3222.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $2,175,000
6713 3222.07 HHS/Health Harvard University 4170 544.07 Track 2.0 $1,903,000
3222 3222.06 HHS/Health Harvard University 2770 544.06 Track 1.0 $764,000
Estimated amount of funding that is planned for Human Capacity Development $200,000
Table 3.3.12:
Since APIN+/Harvard activities have been split between Harvard and APIN, Ltd., the Harvard narratives will
be amended to reflect activities that will be performed specifically by the efforts of Harvard through the
APIN+/Harvard Program (Harvard) as opposed to APIN, Ltd (which will be submitting a separate narrative
under the name APIN). The narrative has also been updated to reflect COP09 goals and targets. In
addition, APIN will be taking over all activities for Nigerian Institute of Medical Research (NIMR), Lagos
University Teaching Hospital (LUTH), Onikan Women's Hospital (OWH), and Mushin General Hospital
(MGH); in accordance, those sites and their respective patients will drop out of the Harvard numbers and be
reflected in the APIN narrative.
In COP09, Harvard will conduct OVC activities at 65 sites in 9 states (Benue, Borno, Enugu, Kaduna,
Lagos, Ogun, Oyo, Plateau, Yobe). These OVC sites constitute a network of delivery points including 10
tertiary teaching hospitals, 21 secondary hospitals and 34 primary health care facilities. Harvard will identify
HIV-infected and -affected OVC through PMTCT, HCT, and ART centers, as well as HBC activities and
hospitals as entry points into OVC services. Most at risk children will be enrolled into the OVC program
through a family-centered approach using a vulnerability and need assessment checklist and Child Status
Index (CSI). Those children identified through an HIV-positive adult family member or caregiver (PMTCT
client, adult treatment or adult care and support client) will be offered HCT. Harvard will strengthen the
coordination of PMTCT, ART and OVC services for a seamless movement of HIV-infected and -uninfected
children across the various services. The experience gained from the initial rounds of this activity will assist
in more efficient implementation of OVC activities in the new centers. In addition, Harvard will provide OVC
services to HIV-negative children whose parents or caregivers had or have HIV/AIDS.
Expansion to 33 sites will include the addition of primary health facilities in all the LGAs in Plateau State
following the state coverage strategy. While many of the Harvard-supported original PMTCT sites are
classified as secondary or community-based in nature, the expansion sites in Plateau State and elsewhere
represent a continuation of the overall movement from tertiary to secondary and primary sites, as these new
sites are virtually all secondary or community-based. In addition, active PMTCT programs at 64 sites will
identify HIV-exposed infants who will require PCR diagnosis and clinical assessment to determine ART
eligibility.
Harvard will provide OVC services to 1,875 HIV-negative children (1,012 males and 863 females) whose
parents or caregivers had or have HIV/AIDS (including babies born to HIV-infected mothers and identified
through our PMTCT activities). OVC will receive multiple services through Harvard activities. Harvard will
provide preventive care services for OVC, include ensuring that children receive all scheduled childhood
immunizations, growth monitoring and other child survival interventions according to the national policy.
Preventive care kits will be distributed to all caregivers of children supported under this activity; kits include
multivitamins, clean water kits, ORS (with guidance on preparation and use), water guards and bed nets. All
OVCs are also provided with nutritional counseling, assessments and support, psychosocial support, and
referrals to other wraparound services based on identified needs such as economic empowerment for
caregivers and legal protection referrals. During COP09, Harvard will work with Mashiah Foundation in Jos
to provide educational support for some OVC, which will include educational materials (books, sandals,
bags, and uniforms) as well as pay tuition for education in government-approved schools. Harvard will
prioritize partnering with USG-supported wraparound services in states where the activities are co-located
with Harvard. Harvard will target adolescent OVC through outreach efforts and link them with appropriate
services.
Harvard will partner with persons living with HIV/AIDS (PLWHA) support groups to provide outreach to OVC
and their families and caregivers through psychosocial and spiritual support, stigma reduction, risk reduction
and basic child health education including identification of danger signs, nutritional demonstration and
verification of appropriate use of basic preventive commodities. Harvard will work with PEPFAR and other
donors to identify sources to leverage therapeutic nutritional support commodities. The program will build
the capacity of the OVC support groups through training and mentoring to develop more innovative means
of addressing OVC issues such as recreational, psychosocial, economic empowerment, and life skills.
Harvard will also explore partnerships with other OVC providers in the communities in which it works for
potential synergy of activities in the spirit of proper networking.
Monitoring and evaluation of all aspects of the OVC program will be conducted as a part of the SI activities,
which will include the use of the Child Status Index (CSI) tool. Harvard collects electronic data on patient
care, which is used for site and program specific evaluation of services provided to OVC. In addition, the
progress of children benefiting from educational support will be monitored through registers and their school
records; follow-up services with school administrators, teachers and OVC caregivers will be coordinated by
program staff. These data are used to conduct program evaluations and provide feedback to site
investigators on a quarterly basis. On-site data managers will conduct monthly evaluations. Harvard will
develop and implement an internal QA/QI program to provide feedback to sites on performance and identify
best practices and areas for strengthening and support.
This funding will also support training for 342 healthcare providers and caregivers of HIV-infected and -
affected OVC and volunteers on OVC services. Healthcare providers to be trained include pediatricians,
general duty medical doctors, pharmacists, counselors and nurses in the area of OVC services. Training in
this area will be coordinated with FMOH and USG following the National Guidelines on OVC. These
activities will strengthen the capacity of sites to provide comprehensive OVC services to 1,875 children
(excluding the 6,750 receiving pediatric HIV care and support services). Training of caregivers will be done
through community- and home-based programs with support groups and home-based care providers.
Harvard will advocate and support the state Ministry of Women Affairs in building their capacity to provide
oversight and reporting functions for OVC programs. Harvard will participate in the development of the
national OVC training curriculum and other instruments.
Activity Narrative: EMPHASIS AREAS:
Emphasis is placed on training through activities focused on training healthcare providers and caregivers in
the care of HIV-infected and affected OVC. These activities will also place an emphasis on the development
of networks and referral systems in order to support the development of a comprehensive system of care
through links to community PLWHA support groups and PMTCT, HCT, TB/HIV and ART sites. Emphasis
areas include military populations, through support for OVC served by our sites at 68 Military Hospital and
Military Hospital Ikoyi, Lagos.
These activities seek to target OVC who have been exposed to HIV through pregnancy and breastfeeding
from HIV-infected mothers through the identification of exposed infants from PMTCT programs. We will also
identify OVC from other areas as targets for supportive pediatric care and family outreach. Outreach
initiatives also seek to target mothers and family members of HIV-infected OVC and their siblings, including
PLWHA, to ensure comprehensive family psychosocial support. Caregivers of OVC are also targeted to
encourage HCT for potentially exposed children. Harvard also targets caregivers by providing them with
preventive care packages
New/Continuing Activity: New Activity
Continuing Activity:
Estimated amount of funding that is planned for Human Capacity Development $220,446
Estimated amount of funding that is planned for Food and Nutrition: Commodities $3,645
Estimated amount of funding that is planned for Education $27,000
Table 3.3.13:
This activity provides comprehensive counseling and testing services (HCT) to at-risk individuals, delivered
through 14 service outlets (11 comprehensive Harvard sites with ART and PMTCT services and 3 stand
alone HCT centers) in 9 states (Benue, Borno, Enugu, Kaduna, Lagos, Ogun, Oyo, Plateau and Yobe). This
is a decrease from the 40 active sites at the end of COP08, which reflects the transfer of 4 sites (LUTH,
NUMR, Onikan and Mushin) to APIN and a consolidation of activities in this program area for COP09. When
including TB sites, Harvard will reach 13,000 individuals (4,810 males and 8,190 females) that will receive
HIV counseling & testing (HCT) and receive their results; when excluding TB sites, the number to be tested
is 8,500 (3,145 males and 5,355 females). Targeted populations include most-at-risk populations (MARPs),
clients presenting to the health care facilities, blood donors, and family members of PLWHA. Provider-
initiated HIV testing is utilized as an additional strategy to reach clients at the health care facilities. Harvard
and APIN Ltd will collaborate in order to ensure a smooth transition of HCT services.
In COP09 the Harvard HCT site and community level activities will stress: (1) providing technical
assistance, particularly in identifying most at risk persons in need of HCT, and (2) working with sites to
identify and obtain additional resources (from the GON, other donors, Global Fund, etc.) to provide
commodities and increase uptake of HCT services in all points of service in the facilities. As a result of the
necessary shift in resources to maintain care and treatment activities, there is a reduction in funding and
targets for HCT services from COP08 to COP09. Harvard will phase out HCT services at 23 previously
supported HCT service delivery sites. In anticipation of this and in order to minimize the potential impact on
the availability of services, Harvard will also work with these sites during COP08 to evaluate the opportunity
to seek out other sources of funding for these activities.
Individuals identified as HIV-positive at stand-alone HCT clinics will be referred for palliative care, PMTCT
and ART services as appropriate. Those identified as positive at Harvard comprehensive sites will be
referred to PMTCT and ART clinics for treatment and palliative care services. Prevention for HIV positive
individual will be incorporated into HCT activities including offering and promotion of HCT for family
members and sex partners, counseling for discordant couples, counseling on healthy lifestyles and positive
living, prevention messages and IEC materials on disclosure. Harvard sites use family counseling sessions
and "love letter" strategies to encourage partners of HIV-infected patients to access HCT so that couples
receive HIV counseling and testing together. Counselor training will include couple HIV counseling and
testing (CHCT) to strengthen this program. Pediatric patients that are identified at testing points of service
will be enrolled into the Harvard supported OVC program and ART as necessary. HCT will also be offered
to patients receiving TB services at each of the Harvard sites throughout TB/HIV program activities. HCT is
offered to blood donors as per Blood Safety activities.
Harvard will use the National "Heart to Heart" logo at supported HCT sites so as to reflect the integration
within the national program. Through these activities, 3 stand-alone HCT service outlets are also maintained
which provide HIV testing as well as pre- and post-test counseling and condom distribution. At all HCT
outlets, patients are provided with Information, Education & Communication (IEC) materials on HIV
prevention and referrals for ART services and palliative care as appropriate. The materials will address HIV
prevention using the "ABC" model, providing information about healthy behaviors, safer sexual practices,
STI prevention, PMTCT, and condom usage.
HCT services are also provided in community settings in conjunction with projects in Lagos, Plateau and
Oyo states that serve specific MARPs including: outpatient STI patients, bar workers, sex workers, border
traders, military personnel, fashion designers, and motor mechanics. Mobile HCT services will be used to
reach these populations. Activities targeting these populations are linked with Harvard sites to provide
referral linkages to PMTCT, Palliative HIV/TB and ART services depending on eligibility for ART.
Condoms will be made available at all HCT sites in conjunction with the delivery of ABC messages. The
Society for Family Health (SFH) will supply condoms. Training of 100 individuals in counseling and testing
will use the new national serial testing algorithm and will educate trainees on appropriate counseling
messages specific to the different high-risk groups with which they work. Refresher training will be provided
during the year for counselors, particularly after final revision of the national training curriculum. HIV testing
is performed with rapid test assays and same day results are given. Following HIV diagnosis with the
national testing algorithm, immunoblot confirmation will be provided during assessment for ART in line with
the national algorithm. This is done by HIV laboratories at Harvard supported comprehensive ART centers.
To meet up with the increased demand for services, non-laboratorians, including nurses, counselors and lay
counselors will be trained to provide counseling and testing services in one visit using finger prick. These
will be supervised by laboratory scientists and quality of testing would be ensured by proficiency testing and
quarterly supervisory visits. The UCH Virology lab will establish and coordinate a regular QA/QC program to
insure that HIV serologic testing at HCT centers meets national and international standards. This lab will
also ensure coordination of HIV testing SOPs and provide regular training for new lab personnel. The USG
team will be providing Harvard with rapid test kits that will be managed by the pharmacy logistics team in
Lagos and stored and distributed from the APIN central medical stores warehouse. Harvard will continue to
Activity Narrative: harmonize the logistics process with GON Logistics Management Information System (LMIS) and Inventory
Control System (ICS) activities.
These activities will also address gender equity issues by providing equitable access to HCT services for
men and women. In some cases, the activities seek to target men who may be at high risk for HIV in order
to provide a mechanism for HCT as a means of prevention and access to services for their sexual partners.
Male targeted counseling seeks to address male norms and behaviors in order to encourage safer sexual
practices. Counseling also seeks to address sexual norms and issues of HIV related stigma and
discrimination. Through this program, Harvard will also target military populations through HCT services
provided at 68 Military Hospital and Military Hospital Ikoyi, Lagos.
TARGET POPULATIONS:
These activities target adults for HCT, particularly those from most at risk populations, as described above.
Targeting these populations is important to encourage utilization of HCT services and provide ART
treatment for eligible HIV infected individuals. Counseling provided through these activities also seeks to
target PLWHA who are newly diagnosed by encouraging them to bring their partners and other family
members in for HCT. In addition, target populations include orphans and vulnerable children.
Harvard HCT activities are consistent with the PEPFAR 2009 goals for Nigeria, which aim to increase
uptake of HCT by supporting HCT centers, which are linked to treatment and care services, to target
MARPs. By continuing to support and build the capacity of HCT centers and provide linkages to treatment
and care centers, these activities will be able to meet the increasing utilization of these services, expected
to result from HCT outreach initiatives identifying infected individuals. The network of HCT centers linked to
HIV services and care will provide a sustainable network for infected and affected individuals in Harvard's
catchment areas.
Additionally, as part of the sustainability building efforts, Harvard will provide technical assistance and
support for APIN Ltd to assume program management responsibility for HCT Activities. This will include the
This activity also relates to activities in Adult Care and Treatment, Pediatric Care and Treatment, Sexual
Prevention, TB/HIV, OVC, Human Capacity Development, and Gender. Through these activities, Harvard
has incorporated a number of currently funded HCT prevention programs (i.e., Gates Foundation) to provide
access to a broad range of palliative care, support and ART services. This network of community, research-
based and tertiary care institutions should provide sustainable and high quality HIV and related services to
the communities served. Furthermore, both primary and satellite Harvard sites are linked in order to provide
laboratory and specialty care support, as related to the HCT activities.
Continuing Activity: 13058
13058 5424.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $1,087,000
6721 5424.07 HHS/Health Harvard University 4170 544.07 Track 2.0 $950,000
5424 5424.06 HHS/Health Harvard University 2770 544.06 Track 1.0 $400,000
Estimated amount of funding that is planned for Human Capacity Development $4,500
Table 3.3.14:
Track 1 and 2 funds are combined for this activity.
narratives will be amended to reflect activities that will be performed specifically by the efforts of Harvard
through the APIN+ Program (Harvard) as opposed to APIN, Ltd (which will be submitting a separate
narrative under the name APIN). Narrative has also been updated to reflect COP09 goals and targets. In
(MGH), Harvard will support the management of the Central Medical Stores (CMS) for both Harvard and
APIN supported sites. In accordance, those sites and their respective patients will drop out of the Harvard
numbers and be reflected in the APIN narrative.
This funding will specifically support the procurement of antiretroviral (ARV) drugs. Through these activities,
Harvard will provide ARV drugs for 51,850 patients (46,300 adult and 5,550 pediatric) at 24 Harvard sites in
nine states (Benue, Borno, Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). These sites include ten
tertiary level comprehensive antiretroviral treatment (ART) sites serving pregnant women, adults and
children, 13 secondary level sites and one primary health care center that provide only pediatric ART. Nine
of ten tertiary level ART sites are also supported by the government of Nigeria (GON) with 14% of patients
receiving GON provided drugs. We also provide prevention of mother to child transmission (PMTCT)
services at 33 additional primary health care level PMTCT sites and eight secondary level PMTCT sites. At
all sites Harvard will provide the ART prophylaxis options and triple drug regimens for eligible pregnant
women consistent with the national guidelines. Thus, a total of 65 Harvard sites will be providing ARV drugs
through ART or PMTCT services. As part of the transition of Harvard PEPFAR activities to APIN Ltd, four
Harvard COP08 Sites (LUTH, NIMR, OWH, and MGH), will be supported by APIN in COP09. Harvard and
APIN will collaborate in order to ensure a smooth transition of clinical services. ARV drugs for such sites
will be provided by APIN and supply chain management mechanisms will be coordinated by both APIN and
Harvard to ensure proper tracking and stocking of needed pharmaceutical stocks. Harvard will continue to
directly purchase drugs for Harvard sites, and supply chain activities will continue through the existing
system, which is managed by APIN, with strategic technical support from Harvard.
All drug orders are based on projections of patient numbers as determined by annual forecast conducted in
August 2008 in conjunction with the Harvard / APIN Ltd country team, SCMS and USG Logistics Technical
Working group. The determining factors were rate of patient enrollment, weight class of patients affecting
drug dosage, gender, rates of toxicity, and rates of failure. Our rates of drug ordering and estimation of
buffer stock needs have been informed by our experience with lengthy and variable order to delivery times,
global shortages (e.g. BMS and Merck), splitting of most orders, delays in NAFDAC registration and lengthy
clearance of drugs in country. As a result, our drug forecasts and orders had been adjusted to
accommodate with an increase in buffer stocks. This year, we have buffer stocks for approximately 3-5
months for all of the requisite PMTCT, first and second line ARV drugs. Based on patient baseline data,
fixed dose combinations (FDC) of CBV+EFV/NVP will be used for first line regimen; patients with anemia or
Hepatitis B/C will be placed on TDF+FTC+NVP/EFV. Other first line alternative regimens and second line
regimens will be dictated based on individual patient data or history. FDC and generic drugs will be used
preferentially. Currently 7% of patients on ART are on second-line and 93% on first line regimens. Drug
usage updates are provided to all Harvard investigators by email on a monthly basis.
APIN Ltd. will purchase the drugs in accordance with USG, FDA and National Agency for Food and Drug
Administration and Control (NAFDAC) regulations as well as with the 2007 National Standard Treatment
Guidelines. In COP09, APIN Ltd. will continue to collaborate with the Clinton Foundation for the receipt of
second line adult and all the pediatric drugs. Harvard will also work closely with the Government of Nigeria
to leverage resources for the sites supported by both PEPFAR and GON. All purchases of Truvada
(TDF/FTC) and ZDV-3TC-NVP Fixed Dose will be procured via pooled procurement mechanism by SCMS
in line with OGAC's recommendation. The rest of the drugs will be purchased via IDA and other
procurement mechanisms. Drugs will be shipped to Harvard Central Medical Stores (CMS) in Lagos, from
where they will be distributed to sites in accordance with the internal supply chain management system,
which is collaboratively managed by APIN Ltd. and Harvard. Harvard maintains a subcontract with Fed-Ex
to provide monthly distribution to all site pharmacies. An electronic bin card system is utilized to track and
monitor drug stores and the distribution.
APIN Ltd. has developed SOPs for supply chain management, drug usage, drug regimen tracking, drug
distribution, warehouse storage, waste management and individual pharmacy site management. These
SOPs are also used for procurement and distribution of OI drugs and certain lab supplies and test kits.
Capacity building and training for the CMS at NIMR and individual site pharmacies is ongoing
collaboratively with APIN and Harvard. to support pharmacy management and implementation of the
National ART Program. Harvard is participating in the ART harmonization process with the GON. The goal
of these harmonization activities is to facilitate the pharmacies' ability to scale up capacity as patient
utilization of ART increases. Assessments of all facilities to determine infrastructure needs have been
conducted in COP07 and COP08 and will continue to be conducted in COP09 for new sites. These site
capacity assessments have been the basis for efforts to strengthen the supply chain management system
for new sites. Ongoing assessments ensure sustainability of pharmacies and supply chain management at
the sites. All site pharmacists have participated in regular training sessions and work with site data
managers in providing regular supply chain information electronically to the APIN central pharmacy. The
computerized supply chain information system linked through APIN to patient clinical records also provides
reporting data for monitoring and evaluation (M&E) at each site. In COP08, additional logistician and supply
chain management staff were hired to provide additional support in the implementation of the supply chain
management system.
Our long-term goal is to support a sustainable supply chain management system for ART that incorporates
Activity Narrative: and bolsters existing Nigerian institutional structures and is harmonized with the GON activities. Continued
collaboration with GON procurement efforts contribute to this goal. Implementation of the PEPFAR-Nigeria
LGA coverage strategy in the program areas of PMTCT and TB/HIV, designed to ensure the provision of
PMTCT and TB/HIV services in at least one health facility in every local government area (LGA) of 6
identified states, will help guiding the ongoing site expansion for ART and PMTCT. As part of that plan,
secondary health care facilities covering all 17 LGAs in Plateau state will be targeted for pharmacy support
and drug distribution. As expansion of ARV drug services is prioritized to rural areas, Harvard will
strengthen existing referral channels and support network coordinating mechanisms. Each new site will be
visited by a team of technical staff from APIN and Harvard as well as other sub-partners. Pharmacy and
logistics management procedures will be assessed and be part of the site development plan.
Recommendations for drug storage, equipping of pharmacies and minor renovations are considered. All
Harvard pharmacists have completed the IDA ARV training program. Pharmacists hold meetings on a
quarterly basis and training updates are provided. Pharmacists and their data entry staff also participate in
the electronic data tracking system; regular training in computer entry and database management are also
provided by in-country and US-based program management staff.
Emphasis areas include military populations, through support and training for pharmacy staff and
counselors at 68 Military Hospital and Military Hospital Ikoyi, Lagos.
The primary target of these activities are health care workers, including program managers doctors, nurses,
and pharmacists who are involved in the drug procurement and distribution process. Furthermore, by
building mechanisms for drug procurement, these activities seek to target PLWHA, both adults and children,
who are in need of or already receiving ART care.
Through these activities we will have provided ARV drugs to 51,850 patients at 24 ART service outlets at
the end of the reporting period. In addition, we have scaled up our PMTCT activities with 64 points of
service providing access to PMTCT services for 3275 HIV-infected pregnant women. Through these
activities, we will continue to strengthen the structure of our ARV drug procurement system, as described
above, in accordance with PEPFAR goals in order to ensure cost effective and accountable mechanisms for
drug procurement and distribution. Furthermore, efforts to build local capacity through infrastructure building
and training mechanisms are consistent with PEPFAR 5-year goals to enhance the capacity of supply chain
management systems to respond to rapid treatment scale-up. Additionally, through procurement via SCMS,
we seek to provide support to efforts to build harmonized national capacity related to drug procurement and
distribution.
support for APIN to assume program management responsibility for our ARV Drugs activities. This will
This activity also relates to activities in TB/HIV, Adult Care and Treatment, Pediatric Care and Treatment,
Strategic Information, and Human Capacity Development. Through this activity, we will maintain significant
linkages with PMTCT and Adult and Pediatric Care and Treatment through the procurement of ART drugs
for individuals served by these programs. Additionally, we will develop and maintain linkages to TB/HIV
activities, with expansion focusing on co-locating ARV sites with existing DOTS sites. The supply chain
management system will serve to provide drugs to ART sites that are providing TB services in conjunction
with ART services. SI activities will provide crucial information for M&E as well as efficacy of the drug
regimens, which may impact drug procurement decision-making.
Continuing Activity: 13059
13059 9888.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $7,154,288
Table 3.3.15:
Track 1 and Track 2 funding will be combined for this activity.
narrative under the name APIN). The narrative has also been updated to reflect COP09 goals and targets.
In addition, APIN will be taking over all activities for Nigerian Institute of Medical Research (NIMR), Lagos
(MGH), in accordance, those sites and their respective patients will drop out of the Harvard numbers and be
This activity provides maintenance of activities at the National Central Public Health Reference Lab
(NCPHRL) and HIV labs at 10 tertiary and 20 secondary health facilities in Plateau, Oyo, Borno, Yobe,
Lagos, Enugu, Kaduna, and Benue States, for a total of 31 labs. In addition, we will expand the capacity of
labs at primary health facilities throughout Plateau and Oyo states (HIV testing). All of our 10 major tertiary
level labs and the NCPHRL have capabilities for haematology, automated chemistry analyzers, and laser-
based lymphocyte subset enumeration. Seven of these facilities, in Lagos, Oyo, Plateau, Benue, Kaduna,
Enugu, and Borno states, will also have PCR technology (68 Military Hospital, UCH, JUTH, ABUTH, UMTH,
FMC Makurdi, UNTH). During COP09, we will transition the management and support of laboratory
activities at NIMR, LUTH, OWH, and MGH over to APIN.
Harvard will continue to work with GON in developing the NCPHRL into a national reference lab, a project
identified by the MOH as a priority. This lab will serve national HIV QC/QA needs and with 2-3 additional
Harvard-supported labs, will serve as a national laboratory training center. This lab's capacity will include
standard HIV assays, flow cytometry for CD4 enumeration, clinical chemistries, hematology, and TB culture.
In addition, we will continue to strengthen existing labs by providing backup equipments to major tertiary
sites in geographically isolated areas to avoid interruption in service. Equipment maintenance is coordinated
through assistance from a consultant trained in the maintenance of freezers and bio-safety cabinets and
through the manufacturers for other items.
By the end of COP09, HIV rapid testing will be performed at the HCT centers with the labs providing
supervisory roles. All 23 adult ART sites will have western blot capacity to confirm HIV status. Mashiah
Foundation (an additional pediatric ART site) does not have western blot capacity. Rather these tests are
conducted at JUTH and results are then transmitted to Mashiah for use in patient care. Western blots are
conducted on all patients as a part of the determination of eligibility for ART. HIV serology, hematology,
chemistries, and CD4 enumeration will be supported at all secondary hospitals with referral to the tertiary
labs for PCR diagnostics and viral loads. Primary health care facilities are closely partnered with secondary
and tertiary care facilities, allowing for baseline and periodic evaluation with full lab monitoring. The primary
facilities and feeder sites provide limited lab monitoring with basic clinical chemistry, haematologic and CD4
assays. We will also provide screening for STIs, including syphilis and chlamydia at all of our sites. Our labs
with infant PCR diagnostic capabilities will continue to assist other PEPFAR IPs, using dried blood spots
(DBS) to transport specimens from distant satellite sites. For these sites, DBS are transported to sites with
PCR capacity via shipment with FedEx or DHL. Results are transmitted back utilizing electronic databases
and registers, using secure methods. Testing and results are completed within 2-3 weeks. Harvard will
support the PEPFAR-Nigeria LGA coverage strategy (PMTCT and TB/HIV).
We are currently screening for TB by sputum and/or pulmonary X-ray at all ART sites. We will evaluate the
use of PCR diagnosis of TB at selected tertiary sites in COP08; this will help to guide programmatic
decisions regarding its use in COP09. In COP09, we will enhance TB diagnostic capacity at high volume
sites at tertiary care institutions with fluorescent microscopy. Funding in this area will be used for the
procurement of fluorescent scopes, conversion kits for light microscopes, reagents for staining and training
of laboratory staff in the use of this equipment.
Standardized lab protocols have been developed to accompany the PEPFAR clinical protocol and
computerized lab results link to patient records. The protocols include provisions for the disposal of
biomedical waste in accordance with good lab practices. Quality assurance/quality control (QA/QC) policies
have been developed and detailed annual assessments of all lab activities are conducted. Quarterly QA/QC
lab site visits are conducted by the Harvard project management team and use a standardized assessment
tool developed in Nigeria by the Lab Technical Working Group (LTWG). Results from the proficiency testing
and site visits will be sent into a centralized system within Nigeria, developed and supported by the
PEPFAR LTWG. EQA for lab tests was established in COP06 and is operational for CD4, HIV, HCV and
HBV serology, chemistries, VL and HIV PCR diagnostics through individual lab registration with UK-NEQAS
and CAP. All labs performing PCRs will participate in the CDC's DBS DNA PCR proficiency program (EID
QA). Regular lab training allows for the development of high-quality lab standards in our PEPFAR labs; this
has been networked to our secondary and primary labs with specific tailoring to the needs and skills at each
level. Biannual trainings are provided on specific techniques/topics integrating lab QA/QC, good lab
practices and biosafety. Competency monitoring/evaluations and refresher trainings will be provided within
individual labs. Harvard provides support for a dedicated training lab at University College Hospital -
Ibadan, which serves as a training facility for laboratory activities in all areas. We also provide support for a
training lab at Jos University Teaching Hospital (JUTH), which is a comprehensive hand-on training center
with lecture room capacity and personnel skilled in training. The JUTH lab provides training in all areas,
with special focus on rapid testing and CD4 enumeration. We will also provide training for engineers at sites
in the maintenance of laboratory equipment in order to improve lab equipment maintenance capacity at
tertiary care institutions. Post-exposure prophylaxis (PEP) protocols have been implemented at each of our
labs; supported under our ART drugs activities. Harvard has supported international laboratory ISO 9001
certification for NIMR which is working toward international accreditation and in COP09 will seek
international certification for 2 additional labs and local accreditation for 10 other labs.
We provide support for 152 lab staff persons (based at sites), responsible for implementation of lab
Activity Narrative: protocols, data entry and performance of lab tests. In addition, we provide support for 11 staff who provide
technical assistance to sites, 8 of whom are at Harvard in Boston. The additional 2 lab support staff persons
and one consultant are supported through APIN, Ltd. in Abuja, and provide sites with ongoing technical
assistance in logistics management, general management of lab activities, troubleshooting maintenance
issues. Lab support staff from Harvard is primarily responsible for technical assistance on lab start-up,
QA/QI, and lab certification. In COP09, we will continue our efforts to employ laboratory technical staff for
lab training and QA.
A laboratory information system (LIS) will be implemented at sites, with appropriate capabilities, to
streamline the capture of lab data, minimize transcription errors and facilitate data entry and results output.
We will continue to participate in LTWG monthly meetings to ensure harmonization with other IPs and the
GON, including the development of a common lab equipment platform (appropriate for each lab level).
Procurement of lab reagents is structured in two ways. Reagents available in Nigeria are procured directly
by the sites from specific distributors. Labs are advised to maintain a 3-month reagent buffer. Most reagents
needing importation, such as viral load, CD4 and western blot kits, are ordered at Harvard and shipped to
the APIN Central Medical Stores warehouse in Lagos and a 3-month reagent buffer is maintained. Harvard
coordinates with APIN for supply chain management of reagents and lab test kits. PEPFAR funding
supports procurement of lab equipment, generators and water purifiers necessary for lab work. Equipment
costs for tertiary labs can be high in the first year, but represents significant infrastructure development.
Secondary and primary labs, including HCT facilities, have lower start up costs. Maintenance costs include
minimal renovation costs for some labs, replacement of small lab equipment and training costs for additional
personnel. As further regional networks are developed around these centers of excellence, training, lab and
clinical support will be provided to secondary and primary points of service.
This program seeks to address gender equity by building the capacity of labs at affiliated sites to conduct
testing related to PMTCT. Increased lab capacity will permit the sites to provide equitable treatment for both
women and men. Through this program we will also target military populations, through support and training
for medical lab scientists at 68 Military Hospital and Military Hospital Ikoyi, Lagos.
This program targets public and private health care workers with training to maintain high quality lab
standards.
These activities contribute to the goal of maintaining high-quality services as the PEPFAR program
expands. Harvard will perform 931,173 tests in COP09, including HIV diagnosis and tests for disease
monitoring, including CD4 enumeration, PCR diagnosis of infants and VL. In addition, we seek to train 650
lab staff members in COP09. Harvard will provide training at their supported training facilities to a large
number of non-Harvard and non-PEPFAR supported medical lab scientists. Training lab staff will assist in
building the human resource capacity of our sites to provide sustainable lab support to sites providing high
quality HCT and ART treatment. Seven labs at tertiary care hospitals will have the capacity to perform early
infant diagnosis (EID) by HIV DNA PCR. These labs are also linked to PMTCT sites, to provide a
mechanism for EID as a part of the PEPFAR supported national scale-up plan (consistent with 2009
PEPFAR objectives for Nigeria). Harvard will partner with the GON and Clinton Foundation for procurement
of EID test kits and specimen collection supplies. Through linkages with APIN, the NIMR PCR lab will
provide QA support for the EID program in the Southern half of Nigeria (through retesting). Through a tiered
system of labs at tertiary, secondary and primary sites we are able to ensure that patients at community
based primary facilities are provided with a full complement of lab monitoring as a part of ART treatment
and care. Our training activities include management and competency training, which seeks to build
sustainability. We have provided training to lab workers through the MOH ART training program at NIMR.
Lab workers from all 36 states and the FCT are invited to participate on a biannual basis at the JUTH site.
Support for the training of additional lab workers is provided through APIN at NIMR, and is conducted in
coordination with Harvard lab training activities. Two of our sub-partner sites are actively involved in lab
training for the MOH training program (JUTH and UCH) resulting in 100 indirect targets without budget
allocation.
support for APIN to assume program management responsibility for our Lab Infrastructure activities. This
will include the implementation of a plan to transition site oversight, management and training over to APIN.
The goal of such efforts is to provide for greater assumption of responsibility for management and
These activities relate to activities in PMTCT, Counseling & Testing, Palliative Care TB/HIV, Adult Care and
Treatment , Pediatric Care and Treatment, OVC, SI, and Human Capacity Development. Our labs are
crucial in providing adequate HIV diagnostics in PMTCT, HCT, OVC, Palliative care and ART services.
Furthermore the lab provides other diagnostics such as OIs. As a part of this activity, we seek to build
linkages between labs and our patient care sites in order to ensure that lab information is fed back into
patient records for use in clinical care. Our SI (HVSI) activities provide support in M&E, including data
management of testing results. In training local staff, we are building human capacity and strengthening the
overall health system.
Continuing Activity: 13061
13061 6716.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $6,624,810
Estimated amount of funding that is planned for Human Capacity Development $350,000
Table 3.3.16:
As we have now split the APIN+ activities between Harvard University and APIN, our activity narratives will
APIN+ Program (APIN+/Harvard) as opposed to APIN (which will be submitting a separate narrative under
the name APIN). In addition, APIN. will be taking over all activities for Nigerian Institute of Medical
Research (NIMR), Lagos University Teaching Hospital (LUTH), Onikan Women's Hospital (OWH), and
Mushin General Hospital (MGH); in accordance, those sites and their respective patients will drop out of the
Harvard numbers and be reflected in the APIN, Ltd. narrative.
COP08 NARRATIVE UPDATED TO REFLECT COP09 ACTIVITIES AND TARGETS:
In COP09, Harvard will provide support to 66 sites (10 tertiary, 21 secondary, 34 primary, and Mashiah
Foundation). The activities include: data management and data quality, monitoring and evaluation (M&E),
health management information systems (HMIS) and operational research studies in all Harvard sites and
the Central Public Health Laboratory. Funds will also be utilized to continue building the capacity of site staff
in the above areas in order to promote effective use of data to improve services and programs and to
influence policy. In addition, a major goal in the coming year is to further achieve sustainability by further
transferring data expertise to APIN by Harvard personnel. Harvard will work with APIN to assure effective
use of paper-based and electronic data systems, including the use of the web-based portal for data
reporting (LHPMIP), where feasible (i.e. electronic databases in place). Technical assistance will also focus
on the promotion of the one National HIV M&E system with reference to the "three ones". In collaboration
with Harvard, a database specialist, IT specialist, an M&E Officer and an M&E Consultant from the APIN
staff will assist the sites with on-site clinical, pharmacy, laboratory and project reporting. In line with the
PEPFAR-Nigeria indigenous capacity-building strategy, Harvard and APIN will strengthen local capacity at
primary, secondary and tertiary health facilities as well as centrally through further building the expertise of
those at APIN, Ltd. A major goal of our activities this coming year is to further: 1) build M&E capacity at the
local level by ensuring that there are dedicated M&E officers at all facilities and/or points of service. 2)
promote increased utilization of data in evidence-based decision making; 3) evaluation of clinical outcomes
and intervention efforts; 5and 4) evaluation of program outcomes.
Our program uses a relational database system that is linked by a unique patient ID number and contains
data required for patient management and monitoring (PMM). The electronic database is functional and
fully harmonized to the GON PMM forms to allow for full integration and harmonization into the broader
Nigerian national health information system. The database will be strengthened to track linkages for
prevention-care-treatment or the continuum of HIV services. Throughout the transition of activities from
Harvard to APIN, we will continue to use the APIN+/Harvard forms and databases which were developed
under COP funding to Harvard in previous grant years. The APIN+/Harvard forms collect clinical visit,
pharmacy pick-up, laboratory assessment, toxicity, virological/immunological failure and discontinuation
information for adult and pediatric care and treatment as well as PMTCT services. At present, OVC data are
collected using GON registers, but we are working to develop electronic forms, which are fully harmonized
with the GON forms which will allow for more efficient reporting. The program has also developed a number
of utilities to maximize the efficient use of data for improved patient management, data quality, reporting and
program management. This includes a treatment response utility, which provides a graphical display of
patients' CD4 counts, viral loads, and drug pick-up history, as well as a loss to follow-up utility, which serves
as an early warning system for patients that miss drug pick-ups. Information is generated and used for site
and program-specific evaluation of services, such as assessment of CD4 counts, viral load, adherence, and
loss to follow-up.
Harvard provides computer hardware and software support to sites as services are being maintained. SOPs
are in place to govern data entry, security, management and reporting based on the ARV treatment and
care protocol. Refinement of instruments and databases is ongoing to accommodate program reporting
requirements from Harvard, USG and the GON. The PMM forms are stored in the patient hospital folders
and kept in locked file cabinets. National registers are also in use at Harvard supported sites. Data from
PMM forms and relevant registers are entered into the databases by trained data entry staff at the
respective sites. The data are then uploaded to a password protected web server, accessible to authorized
personnel and data managers at the Nigerian sites, APIN and Harvard. Data managers prepare timely
reports for GON and USG using the electronic databases. Facility-based data are reported using a
harmonized national reporting system. The Boston and APIN data management team and the APIN M&E
officer provide regular feedback on data collected and on reports to the sites. Site M&E committees are in
place to implement an annual M&E plan; M&E results are fed back to the sites to promote systems
improvement.
Harvard will continue to improve its good working relationships with state-level M&E staff through regular
communication, on-site monitoring activities, active work at capacity-building, championing the "Three
Ones" at the state level, and participation in routine state-level monitoring and reporting events that include
non-Harvard supported sites in the states. These actions are designed to encourage state M&E officers'
participation in strategic information activities and to expand their capacity in data collection, management,
reporting and strategic utilization. This involvement will build the capacity of the state-level staff and
promote sustainability. The SI team of APIN and Harvard will continue to participate actively in the National
M&E technical workgroup (TWG) and the USG-Nigeria SI TWG and respond to the goals of the one
national reporting system.
In COP08, Harvard further built our internal quality improvement (QI) initiative, designed at collecting
qualitative and quantitative data regarding indicators on the provision of adult, pediatric and PMTCT
services at each site. The QI activities were developed with significant input from APIN and Harvard as well
as colleagues in Botswana and Tanzania. In COP09, Harvard anticipates scaling up these activities to
conduct assessments at sites that started HIV care and treatment activities during COP08 as well follow-up
assessments on sites that were assessed in COP07. In order to continually improve and monitor data
quality, each site will be visited regularly by APIN and Harvard M&E staff throughout COP09 and; on-site TA
and supportive supervision will be provided. Regular inter-site interactions will be encouraged, facilitated by
APIN and Harvard personnel. In COP08, all supported sites constituted M&E committees; these committees
Activity Narrative: meet to evaluate the site M&E data and use the information towards improving quality of care and making
evidence-based clinical decisions. During COP08 and going into COP09, sites will work on fully developing
QA/QI committees to conduct quarterly reviews of quality of care. During COP09, we will continue to
encourage and monitor the activities of the site M&E and QA/QI teams. We are also working on developing
a database utility that will allow the sites to quickly pull out data on patients that are lost to follow-up,
showing signs of toxicity or failure, or that may require other focused attention, to further improve quality of
care. Finally, HIVQUAL using additional QI indicators is being implemented in five selected Harvard-
supported sites, with eventual implementation at all Harvard and APIN+ sites within two years.
In COP09, 384 individuals will be trained in database management, monitoring and evaluation (M&E),
surveillance, and HMIS. The trainees will include some state and LGA staff. The APIN central office will
conduct 5 training sessions centrally. In addition, regional data management trainings for personnel working
with medical records and patient data will be conducted on a regular basis. Data management and M&E
modules are incorporated into respective technical training for other disciplines such as clinicians, nurses,
pharmacists and laboratory staff etc.
These activities emphasize monitoring, evaluation, and reporting through data collection, data analysis, data
use and data dissemination. Emphasis is placed on strategic information, human capacity development and
local organization capacity-building.
This activity will highlight gender issues by providing gender disaggregated data on patients accessing
HIV/AIDS related services. Through this analysis, we will be able to contribute to national surveillance on
utilization of HIV services and impact of HIV intervention on both sexes. This data will be essential to the
development of outreach, treatment programs and education to reach an equitable number of men and
women.
TARGETED POPULATIONS:
The SI activities target program managers and M&E officers including state and local M&E officers, site
coordinators and principal investigators to provide them with skills and tools for programmatic monitoring
and evaluation. The data collection and management components of these activities target medical record
staff, data staff, and other health care workers who are involved in the implementation of these processes.
Lastly, the M&E and capacity-building efforts target implementing organizations, including private,
community-based and faith-based organizations involved in the provision of ART, HCT, BC&S, TB/HIV and
PMTCT services.
CONTRIBUTIONS:
SI activities supported by Harvard are consistent with the 2009 PEPFAR goals to build indigenous capacity-
building in the area of SI. Harvard SI activities are consistent with these goals in that funding will be used to
strengthen local capacity in the area of database management, data analysis, data use, M&E and QA/QI.
Harvard will also provide SI support to its local administrative office, central pharmacy and warehouse.
support for APIN to assume program management responsibility for the SI Activities. The goal of such
efforts is to provide for greater assumption of responsibility for management and implementation of
These activities are linked to PMTCT, OVC, TB/HIV, HCT, ART, Basic Care & Support Services, SI, HCD,
and Gender. In M&E activities, Harvard will link to the National M&E TWG and Nigeria Medication Event
Monitoring System (MEMS). Additionally, through the provision of IT support and data management
personnel, APIN+/Harvard will provide linkages between all supported sites as related to data sharing and
HIV surveillance in PEPFAR program areas. Through operational research studies, APIN+/Harvard will
collaborate with the FMOH, other GON representatives, NNART committee and the NIAID/NIH.
Continuing Activity: 13062
13062 3226.08 HHS/Health Harvard University 6378 544.08 HHS/HRSA $1,900,000
6717 3226.07 HHS/Health Harvard University 4170 544.07 Track 2.0 $845,000
3226 3226.06 HHS/Health Harvard University 2770 544.06 Track 1.0 $500,000
Estimated amount of funding that is planned for Human Capacity Development $150,000
Program Budget Code: 18 - OHSS Health Systems Strengthening
Total Planned Funding for Program Budget Code: $11,991,301
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
As PEPFAR programming segues into the next five year period, the USG/Nigeria team will increasingly shift programming focus
to issues around a sustainable, Nigerian-led HIV/AIDS response. This shift will entail a new focus on larger issues around health
systems strengthening and a continuing effort to provide strategic supports in the areas of capacity building and policy advocacy
to ensure that the Nigerian response will meet the growing demands.
Since the inauguration of the new administration under President Yar'Adua a year ago, a number of changes in leadership among
key federal line Ministries have occurred, many of which have challenged some of the policy and capacity building efforts
undertaken during COP08. However, there have also been some key policy and systems-level achievements. Of particular note
is the growing interest and activism seen at the State level, with increasing signs of effective leadership at that level, particularly
with regard to supports for OVC programming and for harmonized monitoring and evaluation. The National Assembly has also
shown signs of increasing leadership in the HIV response, as evidenced through the development of a strategic workplan for the
Committee on HIV/AIDS/TB and Leprosy, which was developed with partner inputs. The drafting of an Islamic Policy for
HIV/AIDS was another key development this year, which builds further on the advocacy and leadership efforts among the faith-
based community.
Looking at the COP09 plan of action, the PEPFAR program will be working to address weaknesses in the activities addressing
stigma, as discrimination continues to limit peoples' ability and willingness to seek out services and supports. Policy work will
continue to improve the recognition of rights for marginalized populations (victims of trafficking, members of sexual and other
minority groups, disinherited women, etc.) in order to reduce their vulnerabilities and improve their access to targeted services. A
cross-cutting focus on gender will also be a key initiative, with a revitalized Gender Technical Working Group leading the way.
The increased emphasis on children's issues across the board, in prevention, care, and treatment,, will also link in with capacity
building efforts to ensure the appropriate policy environment and leadership initiatives within the health care system to promote
baby/child/adolescent-friendly and appropriate services. The continuing close partnership with the Global Fund, through technical
assistance, participation on the Country Coordination Mechanism, and via common implementing partners, will further enhance
strategic alignments of investments for accelerated results and longer-term sustainability.
Specific activities will continue from previous years to strengthen the capacity of host country government institutions, such as the
Federal Ministry of Health, the Federal Ministry of Women Affairs and Social Development, and the Ministry of Defence, to plan,
manage, and implement HIV programs, including national procurements and logistics systems. Local partner organizations, who
are critical for the sustainability of the program and for the reach into underserved communities, will continue to receive tailored
organizational capacity supports, particularly for management, leadership, and policy development. The USG team, in
partnership with the other members of the National Technical Working Groups, which include members of governmental and
PEPFAR implementing partner organizations, will provide strategic leadership for the development and utilization of policy
documents, which will subsequently translate into guidance and job tools across all the programmatic areas of PEPFAR.
Looking to the next five years, , there is a far better appreciation among Nigerian policymakers and development partners of the
total need in this country and the challenges of filling the gap between available funding and the scope of the projected need. The
size of Nigeria and its federal nature with 36 autonomous and heterogeneous states and a Federal Capital Territory, with limited
trained human capital, all contribute to the numerous challenges in meeting the needs of those affected and infected by HIV. The
financial commitments of Nigeria at the federal level have gradually improved, while state governments have been taking tentative
steps to assigning complementary resources. Major new initiatives are being designed, with the support of key donors, to link
capacity and resources. The USG and other development partners are working with the lead GON agency, the National Agency
for the Control of AIDS (NACA), in developing a Joint Financing Arrangement (JFA) to codify one common workplan, national
strategy, monitoring and evaluation systems, and budget. The PEPFAR/Nigeria compact strategy will provide another framework
for enhancing this partnership and allow for strengthening of the strategic supports to the health system overall.
Table 3.3.18:
