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: 30 new points of service added. Early
infant diagnosis (EID) is referenced and reader is referred to Pediatric Care and Treatment narrative.
ACTIVITY DESCRIPTION:
Utilizing a network model with PMTCT care centers linked to secondary and tertiary "hub sites" that provide
more complex PMTCT care and lab testing, in COP09 125,000 pregnant women will receive PMTCT
counseling & testing and receive their results. A total of 136 PMTCT sites will be supported (106 sites
established by the end of COP08 and 30 sites added by the end of COP09). Sites are located in 23 states:
Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano,
Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, and Sokoto. ACTION will pay
particular attention in Nasarawa state as the Lead IP to support the development and implementation of the
PMTCT LGA (local government area) coverage strategy that ensures there is at least one PMTCT point of
service in each LGA. The scale up of ACTION-supported PMTCT services in COP09 will be focused at
ANC sentinel sites including the primary health center level.
PMTCT stand alone points of service in the network are linked to adult and pediatric ARV care through
utilization of a PMTCT consultant coordinator in each network based at the hub site, network referral
standard operating procedures (SOPs), monthly PMTCT network meetings, and incorporation of team
approaches to care in all training and site monitoring. Through this SOP, HIV-positive pregnant women who
require HAART are linked to an ARV point of service. Particular emphasis is placed on the involvement of
community health workers who are the primary source of care for women in the pre and post-partum period
and are integral to a program that seeks to engage women where they seek care. This program will work
closely with the care and support team to maximally engage community based PMTCT and ARV linkages.
In addition to receiving PMTCT services, each HIV-positive pregnant woman will be referred to OVC
services in order to facilitate care for all of her affected children.
Opt-out testing and counseling with same day test results will be provided to all women presenting for ANC
and untested women presenting for labor and delivery. All women are provided pre-test counseling services
on prevention of HIV infection including the risks of MTCT. Partner testing is offered as part of PMTCT
services or through referral to on-site HCT centers where available. A step down training of couple
counseling and a prevention with positives (PwP) package will be utilized in all sites. This will provide an
opportunity to interrupt heterosexual transmission, especially in discordant couples and will facilitate partner
involvement in care, treatment and support. Master trainers for HCT will train labor and delivery staff in the
use of HIV rapid tests for women who present at delivery without antenatal care.
An anticipated 6,625 HIV-positive pregnant women will be identified and provided with a complete course of
ARV prophylaxis (based on ACTION's current program prevalence of 4.5% and loss to follow up). HIV-
positive women will have access to lab services including CD4 counts without charge. This will be available
on-site or within the network through specimen transport. Women requiring HAART for their own health care
are linked to a network ARV center. For the anticipated 2/3 of women not requiring HAART, the current
Nigerian PMTCT guidelines recommended short course ARV option will be provided which includes ZDV
from 28 weeks or ZDV/3TC from 34/36wks, intra-partum NVP, and a 7-day ZDV/3TC post-partum tail.
Women presenting in labor will receive SDNVP and a 7-day ZDV/3TC post-partum tail. All HIV-positive
women will be linked post-partum to an HIV/ARV point of service, which will utilize a family centered care
delivery model whenever feasible, co-locating adult and pediatric care and providing a linkage to family
planning services. Women frequently face barriers to facility-based treatment access as a result of demands
on them for childcare and to contribute to the family economic capacity. To address this, mobile clinic
outreach as described in the adult care and treatment narrative will be integrated at the community level to
bring PMTCT services to women who otherwise will opt-out of care and treatment.
HIV-positive women will be counseled pre- and post-natally regarding exclusive breast feeding with early
cessation or exclusive breast milk substitute (BMS) if AFASS using the WHO UNICEF curriculum adapted
for Nigeria. Couples counseling or family member disclosure will be utilized to facilitate support for infant
feeding choices. Consistent with national policies on importation of infant formula and recent concerns
regarding appropriate use of BMS, ACTION will not utilize EP funds to purchase BMS. As part of OVC
programming ACTION will provide safe nutritional supplements including safe weaning for exposed infants
as well as water guard, bed nets and other home based care items. HIV-positive women will be linked to
support groups in their communities, which will provide both education and ongoing support around infant
feeding choices, early infant diagnosis (EID), ART, adherence and PwP. PLWHA are currently employed at
ACTION-supported ARV points of service as treatment support specialists. The use of dedicated treatment
support specialists for PMTCT in the clinic and community will be expanded based upon the successful
"Mothers to Mothers" model in Southern and East Africa. This will ensure that HIV-positive women remain in
care throughout pregnancy and receive appropriate services for herself and her infant.
Infant prophylaxis will consist of single dose NVP with ZDV for 6 weeks in accordance with Nigerian
National PMTCT Guidelines. Cotrimoxazole suspension is provided to all exposed infants pending a
negative virologic diagnosis. Ten regional laboratory centers for DNA PCR have been established by
ACTION. Testing of infants will be carried out using dried blood spot (DBS) specimen collection. ACTION
will actively participate in the national early infant diagnosis initiative by providing DNA PCR testing of dried
blood spots (DBS) at ACTION-supported labs. The source of DBS samples will include ACTION and non-
ACTION supported PMTCT sites. A systematic coordinated approach to program linkages will be
operationalized at the site level and program level including linkages to adult and pediatric ART services,
OVC services and basic care and support. Quality monitoring will be undertaken through site visits using an
existing assessment tool and routine monitoring and evaluation indicators.
ACTION will train an average of 10 HCWs from each of the 30 new sites in COP09 sites including
community-based health workers in the provision of PMTCT services and infant feeding counseling. The
revised and updated national PMTCT training curriculum and the infant feeding curriculum will be utilized.
Under COP08, ACTION has adapted and piloted a modified version of the PMTCT National Curriculum for
traditional birth attendants (TBA), which focuses on HCT and referral of HIV-positive women. ACTION
Activity Narrative: piloted this with 20 TBA in COP07 and 50 in COP08. ACTION will expand this to additional an 100 in
COP09, targeting TBAs based on a community needs assessment that has been carried out in COP08
identifying points of deliveries for women in the community. Site-based step down trainings will be carried
out in conjunction with the Ministry of Health (MOH) utilizing Master Trainers that were trained on infant
feeding in COP08. There will be a minimum of 10 trainees per new site for a total of 300. Thus, the total
direct training target is 400. ACTION will continue to collaborate with the government of Nigeria (GON) and
the Clinton Foundation to increasing access to early diagnostic services for infants. This activity is described
under Pediatric Care and Treatment.
In addition to routine monitoring and evaluation activities, ACTION will contribute to a Multicountry PHE that
will evaluate best practices and document best program models for increasing the number of HIV-positive
pregnant women who receive HAART. The aim is to identify which models of ART service delivery to
pregnant women result in the best uptake for PMTCT and maternal treatment interventions.
CONTRIBUTIONS TO OVERALL PROGRAM AREA:
This activity will provide counseling & testing services to 125,000 pregnant women, and provide ARV
prophylaxis to 6,250 mother and infants pairs. This will contribute to Nigeria's goal of increasing PMTCT
coverage by 80% by 2010 and the EP goal of supporting this effort.
LINKS TO OTHER ACTIVITIES:
This activity is linked to adult and pediatric care and treatment, OVC, laboratory infrastructure, condoms &
other prevention, AB, and SI where action will continue to provide TA for the National PMTCT MIS. PwP
counseling will be integrated within PMTCT care for HIV-positive women. The basic package of care
provided to all HIV-positive patients will be available to HIV-positive pregnant women. ACTION lab staff will
ensure that HIV testing provided within the PMTCT context is of high quality by incorporating PMTCT sites
into the laboratory QA program. ACTION will collaborate with UNICEF in the support of PMTCT services at
some sites, leveraging resources without duplication and creating a more sustainable service support
structure.
POPULATIONS BEING TARGETED:
This activity targets pregnant women who will be offered HCT, HIV-positive pregnant women for ARV
prophylaxis, infant feeding counseling and family planning. The exposed infants will be offered prophylaxis
and early infant diagnosis services. Family members will have access to prevention, care and support
services.
EMPHASIS AREAS
The key emphasis area is training, as most supported personnel are technical experts. A secondary
emphasis area is commodity procurement as ARVs for prophylaxis and laboratory reagents for infant
diagnosis will be procured. Another secondary emphasis area is network/ referral systems as networks of
care will be supported, which are critical to ensuring quality of care at the PHC level, identifying women in
need of HAART, and ensuring access to HAART within the network. In addition, partners and PABAs will be
identified for linkage to care and support services. This activity also addresses gender since treatment will
be provided to women and will focus on family centric issues including male involvement in PMTCT
programming.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13106
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13106 3257.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $3,550,000
Disease Control & Maryland 2.0 Univ
Prevention Maryland
6768 3257.07 HHS/Centers for University of 4184 632.07 Cooperative $4,545,798
Disease Control & Maryland Agreement
Prevention
3257 3257.06 HHS/Centers for University of 2778 632.06 UTAP $1,165,000
Disease Control & Maryland
Emphasis Areas
Health-related Wraparound Programs
* Child Survival Activities
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $350,000
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 $253,125
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
AB targets have been adjusted per notional targets for 2009 and C&OP targets have been adjusted per
notional targets for 09. There will be an increase in number of motor park service points from 6 to 12, and
new Bio Behavioral Surveillance data is cited.
ACTION COP 09 sexual prevention activities will continue to provide prevention services to 9,545 youth and
young adults (4772 males and 4773 females) through Abstinence/Be Faithful (AB) activities and 46,364
individuals through condoms and other prevention (C&OP) activities. ACTION will implement its AB
programming activities in line with the overall PEPFAR Nigeria goal of providing a comprehensive package
of prevention services to individuals through a balanced portfolio of AB prevention activities. Through the
involvement of ACTION as a partner in this activity, PEPFAR Nigeria will extend its reach with AB services
into focused communities in six states (Plateau, FCT, Benue, Kaduna, Kano and Edo). In COP08, ACTION
reached over 10,000 individuals using a combination of abstinence and/or being faithful prevention
messaging approaches. A key age group for AB activities is youth/young adults aged 15-24 years, as this is
the highest prevalence age group. Many young adults are in tertiary educational institutions where they can
be accessed for appropriate AB messages. Through its other program areas, ACTION reaches a large
population of HIV-positive adults, adolescents and children through care and treatment services. HIV-
affected partners and family members of these clients will also be reached with prevention with positives
(PwP) services.
ACTION will focus AB activities at tertiary educational institutions (polytechnical schools and universities)
located in cities where individuals reached with AB messages who test positive can be referred or linked to
care and treatment facilities, as necessary. ACTION will work principally at educational institutions but will
have spill over to the community through a combination of multiple strategies in line with the Government of
Nigeria/U.S. Government (GON/USG) minimum care package. These will include: community awareness
campaigns specifically focusing on small group discussions (SGD) organized within departments; a school
based approach that will leverage existing curricula developed jointly by the Federal Ministry of Education
and the Society for Family Health; and peer education plus activities focusing on drama groups. The
curriculum will be used to train lecturers and guidance counselors to provide AB messages routinely in their
teaching. Peer education plus activity dance drama groups will perform in the targeted institutions. These
dramas will have culturally and age group relevant scripts written by a professional consultant using input
from the SGD. Content will be piloted for acceptability and accurateness of the messages before
performances are carried out at these institutions. ACTION will continue to collaborate with the International
Institute of Christian Studies (IICS), an NGO that has worked with the Nigerian Federal Ministry of
Education and has implemented effective AB services in secondary schools in Nigeria.
Activities conducted at the local level by ACTION will be reinforced through national mass media campaigns
by other USG partners, such as the successful Zip-Up campaign. AB messages will be balanced with
condoms and other prevention messaging, where appropriate and will be integrated with other PEPFAR
program area services in proximal areas. The goal of the program is to saturate targeted communities with
messages conveyed in multiple fora. Utilizing such a methodology, a large number of people will be
reached with messages received via one method or another, but the target group will be those individuals
that will have received AB messaging on a regular basis and via the three strategies ACTION will employ
(community awareness campaigns, school based programming and peer education plus activities). The
target for this intensive AB messaging campaign is 9,545 individuals. A total of 500 persons made up of
teachers, guidance counselors, school health care workers, and peer educators will be trained to conduct
effective prevention interventions inclusive of AB messaging from 166 outlets. Another focus of the
program in COP09 will be improvement of the linkages between appropriately balanced ABC services,
condoms and other prevention activities, HIV counseling and testing, and HIV treatment activities. The
incorporation of HIV AB messages by lecturers who have access to this age group on a regular basis will
institutionalize the AB services. In addition, prevention activities will be incorporated into points of health
care service in each institution, including family planning counseling, sexually transmitted infection
management and counseling, and risk-reduction counseling.
ACTION will also provide C&OP activities for 46,364 most-at-risk persons (MARPs; 23,182 males and
23,182 Females) and support 60 community based condom outlets in locations frequented by MARPs, such
as bars, brothels and truck stops in addition to the hospital based outlets co-located at HCT/antiretroviral
treatment (ART) clinics. Sites are located in states that have been selected based on the National ARV
Scale-Up Plan with the goal of universal access. ACTION will build on COP08 successes to expand
prevention services and linkages to wraparound services (e.g., family planning). At the health care facility
level this will complement prevention with positives (PwP) activities supported under basic care and support
programming. Prevention services will take place in community settings, including: skills development
centers, truck stops, markets, and OVC centers targeting out-of-school youth. ACTION will complement
mobile HCT with prevention services by supporting NGOs to establish HCT and other prevention program
sites at locales where transactional and intergenerational sex are common, using five mobile HCT vans
based out of ACTION regional offices. The 2007 Integrated Bio Behavioral Surveillance Survey (IBBSS) for
Nigeria revealed an alarming National HIV Prevalence of 37.4 and 30.2 for brothel and non-brothel-based
female sex workers. ACTION will expand prevention programs in collaboration with experienced community
-based organizations (CBOs) and peer educators to reach commercial sex workers (CSWs) and other
individuals along the Benin-Lagos transport corridor, including truck drivers and those who engage in
transactional sex at overnight motor parks. It is anticipated that seroprevalence among this group exceeds
20%. The number of targeted truck stops will be increased from 6 to 12. ACTION also targets out-of-school
youth via community centers and organized activities supported through OVC programming. Condoms and
other prevention programming will be balanced with AB prevention messaging for youth in these settings.
In COP09, ACTION will build on COP08 activities at the community level utilizing a combination of
strategies, including community outreach campaigns, peer education models, and sexually transmitted
infection (STI) screening, management, and treatment. Peer education strategies will focus on Greater
Involvement of People with HIV/AIDS (GIPA). The goal of the program is to cover target communities with
messages conveyed in multiple fora so as to reach the specific target groups with C&OP messaging on a
Activity Narrative: regular basis via the three key strategies employed (community outreach campaigns, peer education
models, STI screening/management/treatment). ACTION employs a dedicated program officer to oversee
these prevention activities.
ACTION will enhance services for MARPs testing HIV-negative by coupling post-test counseling with
targeted behavior change interventions that address individual risk. Individual counseling will include
abstinence/mutual faithfulness messages, promotion/instruction regarding correct and consistent condom
use, information education communication (IEC) materials, and linkages to family planning services.
Community outreach through collaboration with PLWHA support groups will ensure that IEC materials and
counseling messages are culturally acceptable. Group counseling will be carried out in supportive settings
to discuss and promote HIV prevention behaviors, including avoidance of STIs, recognition and seeking
early treatment for STI symptoms, and reduction of alcohol/illicit drug use. Condom promotion and
distribution will be coupled with prevention information about abstinence and mutual faithfulness, behavioral
change communication, and risk reduction education using peer educators. Sixty stationary condom
distribution points at locales frequented by MARPs (such as bars serving truck drivers) will be established
and maintained along with those situated within ART facilities.
Building on the successful models employed in COP 07 and 08, mobile HCT vans will be utilized for the
provision of syndromic STI services in conjunction with HCT services targeting truck stops and night spots
frequented by MARPs. This service will be provided by community heath extension workers (CHEWs)
following standard operating procedures for syndromic STI management and will include treatment for
syphilis, gonorrhea, and chlamydia. Program staff will work with sites to ensure appropriate linkage/referrals
to STI care.
PwP strategies targeting HIV-positive persons will also be included in this package of services for MARPs
using approaches and materials developed through USG Nigeria. ACTION will support risk reduction and
safer sex promotion activities among HIV-positive clients, partners, and members of their households. The
comprehensive package of prevention interventions will include provider and counselor delivered prevention
messages, family planning counseling, STI management and treatment, and testing of partners and
children. Lay counselors and peer educators will be mobilized for more in-depth counseling on key
prevention issues such as: sexual risk reduction, disclosure, adherence, reduction of alcohol consumption,
and partner testing. Condoms and information on proper condom use will be available to all patients
attending ACTION supported ARV clinics. ACTION 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.
Site/regional level trainings for CHEWS in STI syndromic management will be carried out by ACTION
program staff. Peer educators and PLWHAs will be trained by ACTION program staff and CBO
subcontractors using a curriculum developed by SFH focusing on truck stop and commercial sex settings as
well as a manual on interpersonal communications jointly developed by ACTION and SFH. General training
will include risk stratification, disclosure and couple counseling, proper condom use, and syndromic STI
management training for health care workers. The direct training target is 380 persons.
ACTION AB activities emphasize integration of prevention activities with treatment and care services. Use
of the community awareness campaigns, school based programs, and peer education plus activities
(community drama, dance events, etc.) allows dissemination of AB messaging, including integration with
condom messaging, from socially-credible sources of information (educators, healthcare workers and
related populations of PLWHA). This program will contribute to the global HIV/AIDS strategy by reaching
11,480 people with AB messaging and 5,740 people with abstinence only messaging in a comprehensive
approach. As high risk and "bridge" populations contribute to HIV transmission, C&OP activities will support
the Nigerian Federal Ministry of Health (FMOH), and emergency plan goal of reducing new infections and
thus decreasing the overall disease burden of HIV in Nigeria by enhancing HCT with targeted prevention
messages and interventions. Targeted efforts to promote correct and consistent condom use and STI
management for MARPs can reduce the risk of HIV infection. The activities will also address issues of
stigma and discrimination through the education of individuals and communities.
AB and C&OP activities relate to HCT, basic care and support (through dissemination of information by
home based care providers), OVC programming (through specific targeting), and SI. A challenge of this
program is to successfully link identified HIV-positive individuals with services. The populations being
targeted often do not access services via traditional treatment venues. The program will create a means to
strengthen linkages and will identify through the hub and spoke model innovative strategies for creating
access to treatment in convenient venues. Targeting MARPs will help to identify persons who need referral
into care, ARV services and prevention for positives counseling, which will be an important component of
post-test counseling of HIV-positive persons as part of HCT services and the basic package of care.
Balanced prevention messages targeting behavior change will complement HCT for all, irrespective of HIV
status. OVCs will be taught family life and sexual initiation delay/abstinence negotiation skills.
POPULATIONS TARGETED:
AB will be targeted at youth (particularly university and polytechnic students), teachers, and adults
accessing HCT services, while C&OP targets MARPs (commercial sex workers and their clients, prisoners,
out-of-school youth, and mobile populations such as truck drivers). The other major focus is school-based
youth. ACTION will provide technical assistance to SFH in the training of doctors, nurses, other health care
workers in the public sector as well as PLWHA and peer educators who will focus on the special prison
population, which faces additional stigma.
EMPHASIS AREAS:
Activity Narrative: Emphasis will be on human capacity development for AB and C&OP activities, promote a rights based
approach to prevention among positives and other vulnerable members of society and equal access to
information and services. Reduction of stigma and discrimination are also key features of the program.
Community development through linkages with CBOs and PLWHA support groups are also emphasized.
Continuing Activity: 15651
15651 15651.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $287,000
Estimated amount of funding that is planned for Human Capacity Development $24,500
Table 3.3.02:
Continuing Activity: 13109
13109 9210.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $1,735,500
9210 9210.07 HHS/Centers for University of 4184 632.07 Cooperative $1,117,000
Table 3.3.03:
Activities will be focused on supportive supervision of 32 hub sites to encourage linkage with NBTS Zonal
Centers and adoption of NBTS recommended practices as well as on-site refresher training complementing
training provided by NBTS and SBFA.
AIDS Care and Treatment in Nigeria (ACTION) will support the USG effort to assist the Nigerian National
Blood Transfusion Service (NBTS) in the development of a nationally-coordinated blood program to ensure
a safe and adequate blood supply by supporting 32 hospital blood banks to utilize screened blood from
NBTS Zonal Centers for their transfusion needs. These activities will be facilitated through the provision of
laboratory consumables and supplies, supportive supervision, and on-site refresher training utilizing
curricula developed by NBTS and Safe Blood for Africa Foundation (SBFA). For their emergency
transfusions as an interim measure, sites will be supported to utilize the NBTS standard donor screening
questionnaire, provide full HCT services to deferred donors, and encouraged to screen all emergency
donors for the four transfusion transmitted infections (TTIs) (HIV I and II, syphilis, hepatitis B, and hepatitis
C) in accordance with NBTS policies. The blood banks will also be supported to carry out proper universal
precautions, good laboratory practice, waste management, and QA/QC for all serological testing.
Approximately 32 facilities supported by ACTION and carrying out blood transfusion services will be
supported to utilize the NBTS donor screening questionnaire, provide pre-donation counseling, and
implement standardized blood collection methods. Safe injection program area resources will be leveraged
to facilitate proper universal precautions and waste management.
In COP09, ACTION will work closely with NBTS and SBFA in all aspects of its blood safety program.
ACTION will support the NBTS in implementing its primary objective of migrating fragmented hospital-based
blood services to centralized NBTS-based blood services nationwide. A key feature of this program is the
development of a nationwide voluntary donor recruitment system. ACTION will work with NBTS Centers to
implement blood drives at supported facilities and surrounding communities. To assist in the development of
efficient national coordinated and centralized donor recruitment, blood screening, and distribution systems
in accordance with the Nigerian National Blood Transfusion Policy, the four selected ACTION sites involved
in the provision of blood transfusion services and supported as model blood banks in COP08 will be
followed up to sustain blood safety activities. Blood banks will be supported to professionally screen and
bleed donors. These blood units will be sent to NBTS centers for screening with ELISA techniques for the 4
TTIs. NBTS will return safe blood units to the model blood banks and give return data on the rate of TTI on
the screened blood units. A total of 9600 units of blood is targeted for the hospital linkage program in these
4 blood banks.
Recognizing that the transition to full reliance upon the NBTS Centers for all blood products will take some
time, sites will be supported to follow NBTS policy in the identification and collection of blood from all donors
including blood for emergency transfusions. Procedures for emergency donors at the site will mirror NBTS
Center procedures to the extent possible. This will include the use of the NBTS donor screening
questionnaire for all donors deferred as necessary based on responses, and the provision of standard HCT
services to deferred donors using the National HIV rapid testing algorithm. In order to maintain high quality
laboratory results, ACTION will include the blood bank in its laboratory QA/QC program that involves on-site
quarterly monitoring and retraining as well as selective retesting and proficiency panels for all serologic
testing.
This activity will promote the principles of Universal Safety Precautions, such as the reduction of
unnecessary exposure to blood, accidental injury/contamination as well as the essential consumables and
services that protect health care workers from contracting infections, especially HIV. Proper waste
management will be encouraged through the use of biohazard bags, suitable sharps containers, and the
use of incinerators. In addition, each site will have in place a Post-Exposure Prophylaxis (PEP) protocol
and starter kits in the event of an occupational exposure (described under the ARV services narrative).
Staff will be trained at sites by SBFA who in turn will utilize standardized training modules that are
appropriate to the various levels of trainees and approved by NBTS. In order to avoid double counting,
training targets are counted under the SBFA blood safety narrative. ACTION will complement this activity
during supportive supervision visits to the 32 supported sites by providing refresher training for 3 staff per
site for a total of 96 direct training targets. Clinical seminars for medical doctors on appropriate use of blood
will also be supported.
Activities in this program area will support PEPFAR and GON goals to avert new infections through
ensuring that all blood transfused at selected facilities are HIV free by instituting safe blood activities at all
sites. Screening for TTIs will provide information on prevalence among blood donors and guide future policy
formulation on TTI screening. ACTION activities will support the implementation of GON operational
guidelines for blood transfusion practice in Nigeria and actualization of a well coordinated and centralized
blood supply system in the country, while the QA program will serve as a mechanism to measure and
evaluate the success of the intervention strategy.
This activity is linked to HCT as deferred donors will be provided with full HCT services. This activity is also
linked to infection control activities under injection safety as a post exposure prophylaxis policy will be
instituted, universal precaution supplies including safe disposal containers will be provided, and training will
be conducted. Linkages to laboratory infrastructure also exist. Strategies for HIV positive donor referral to
clinical ARV facilities will promote treatment access goals and provide encouragement of donors to have
HIV testing done. SI will support data gathering related to blood donations.
The target populations are blood donors, laboratory workers, physicians and blood donor organizers at
Activity Narrative: public facilities who will be the focus of capacity development and voluntary blood donations.
An emphasis area for this activity is organizational capacity building as capacity around blood donor drives
and blood banking services in facilities are strengthened. This activity will increase awareness and build
skills around safe blood issues at facility and community levels. It is expected to also promote awareness
about safe blood practices in the communities and to indirectly increase the number of volunteers available
for blood donations.
Continuing Activity: 13107
13107 3258.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $315,000
6769 3258.07 HHS/Centers for University of 4184 632.07 Cooperative $400,000
3258 3258.06 HHS/Centers for University of 2778 632.06 UTAP $190,000
Estimated amount of funding that is planned for Human Capacity Development $19,000
Table 3.3.04:
78 sites, as supported during COP08, will be maintained. These sites provide direct medical service (either
PMTCT or ARV or Adult/Pediatric C&S). Emphasis in COP09 will be supportive supervision of these sites
and health care waste management. Training activity principally addressing infection control and proper
waste management will focus on the retraining at existing sites due to limited funds.
In COP08, ACTION supported 78 sites in 23 states (Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers,
Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger,
Ogun, Osun, Plateau, Sokoto) with injection safety programming. In COP09, ACTION will continue to
collaborate with JSI/MMIS to provide safe injection programming to 78 ACTION-supported sites in the 23
states. In COP08, JSI provided initial training and seed commodities to sites, while ACTION provided step
down training and ongoing commodity procurement and management for all sites. An ACTION program
officer is dedicated to the oversight of this program area with the support of regionally based medical and
nursing program officers. The focus of this activity is to reduce exposure to blood borne pathogens,
particularly HIV, and the incidence of medical transmission of these pathogens.
Health care workers targeted for this activity included physicians, nurses, community health extension
workers (CHEWs), laboratory workers, and waste handlers. In COP08, ACTION supported follow-up and
step down site level trainings to physicians and nurses from the inpatient wards, clinics, labor and delivery,
and the surgical theaters. In addition, HCT counselors performing rapid tests, laboratory scientists, blood
bank staff, and waste handlers were trained. Training topics included BCC strategies to reduce
unnecessary medical injections, safe injection practices, proper handling and disposal of syringes and
sharps, infection control policies and practices, universal precautions, use of personal protective equipment
(PPE), protocol for post-exposure prophylaxis (PEP, see ART services), and appropriate waste segregation,
handling, and disposal. Standard curricula and IEC materials developed by JSI/MMIS and approved by the
GON were utilized. In addition, training materials developed in the context of the OVC program that address
issues of stigma and irrational fear related to "fear of contagion" were included with the goal that informed
health care providers and CHEWs will help inform others in the health care and community setting of what
the true risks are rather than the widely held beliefs prevalent in the community that contribute to
stigmatization. A total of 240 health workers and waste handlers will be trained in COP09. Sites were also
provided with job aids and IEC materials to encourage behavior change and sustainability. Emphasis in
COP09 will be supportive supervision of injection safety activities and implementation of appropriate
healthcare waste management. A follow-up of trainees and on site retraining based on performance
evaluation at sites will be the focus. IHVN will ensure that sites implement infection control plans including
waste management practices which were developed in COP08. Master trainers will be used to facilitate
supportive supervision at these sites.
ACTION will continue to provide personal protective commodities and will take on the new role of logistic
supplier of recurrent stocks of injection safety commodities for all sites. ACTION will supply color coded bin
liners for waste segregation and universal precaution supplies including gloves, eye shields, boots, and
aprons. Commodities and disposables will be procured, warehoused, and distributed by ACTION. They will
be provided to sites based upon a pull system using a site level inventory control system linked to the
ACTION warehouse logistics management information system. The current system can be easily
harmonized with a national or PEPFAR-wide logistics management information system and inventory
control system once implemented. ACTION will intensify advocacy so that the sites will be able to take over
procurement of some of the commodities. In addition, ACTION will support safe health care waste
management by supporting construction or repair of existing incinerators at sites.
This activity will contribute to the reduction of medical transmission of HIV and other blood-borne diseases
by following universal precaution measures, as well as proper waste management. It will likely improve the
quality of health care and reduce stigma and barriers to comprehensive medical care for PLWHA by
addressing concerns of health workers and other hospital staff. Overall this will contribute to the USG goal
for Nigeria of the prevention of 1,145,545 new HIV infections by 2010 in Nigeria.
This activity is linked to laboratory services, PMTCT, ART services , blood safety, HCT, and SI. Health care
workers involved in these programs will benefit from the training program in injection safety and the
adoption of a safe needle, needle stick policy, and PEP protocol, all which will improve the safety for
workers involved in these other programmatic activities.
Doctors, nurses, laboratory scientists, other health care workers and waste handlers are targeted for
training and services in the public sector.
KEY LEGISLATIVE ISSUES ADDRESSED:
This activity addresses issues of stigma and discrimination as the services will reduce stigma and
discrimination associated with HIV status in the health care facility setting.
The emphasis area for this activity is training as nearly all supported personnel are technical experts who
focus on development of training materials, SOPs and the provision of training at the site level. A secondary
emphasis area is commodity procurement as supplies for safe disposal will be procured and supplied.
In COP07, ACTION supported 46 sites in 13 states (Anambra, Edo, FCT, Nassarawa, Kogi, Niger, Kano,
Cross Rivers, Bauchi, Benue, Rivers, Delta, and Lagos) with injection safety programming. In COP08,
ACTION will collaborate with JSI/MMIS to provide safe injection programming to 106 ACTION-supported
sites in 23 states (Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo,
Activity Narrative: Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto). In
COP06 and COP07, JSI procured commodities for all sites while ACTION and JSI divided sites by state in
the provision of training and commodity management. Under COP08, JSI will provide initial training and
seed commodities to all sites, while ACTION will provide step down training and ongoing commodity
procurement and management for all sites. An ACTION program officer is dedicated to oversight of this
program area with the support of regionally based medical and nursing program officers. The focus of this
activity is to reduce exposure to blood borne pathogens, particularly HIV, and the incidence of medical
transmission of these pathogens.
Health care workers targeted for this activity include physicians, nurses, community health extension
workers (CHEWs), laboratory workers, and waste handlers. JSI will be responsible for conducting initial
training at the site level; this will include both the training of new sites and the retraining of existing sites.
ACTION will support follow-up and step down site level trainings to train an average of 8 additional staff per
site for a direct training target of 848. Physicians and nurses from the inpatient wards, clinics, labor and
delivery, and the surgical theater will be targeted. In addition, HCT counselors performing rapid tests,
laboratory scientists, blood bank staff, and waste handlers will be trained. Training topics will include BCC
strategies to reduce unnecessary medical injections, safe injection practices, proper handling and disposal
of syringes and sharps, infection control policies and practices, universal precautions, use of personal
protective equipment (PPE), protocol for post-exposure prophylaxis (PEP, see ART services), and
appropriate waste segregation, handling, and disposal. Standard curricula and IEC materials developed by
JSI/MMIS and approved by the GON will be utilized. In addition, training materials developed in the context
of the OVC program that address issues of stigma and irrational fear related to "fear of contagion" will be
included with the goal that informed health care providers and CHEWs will help inform others in the health
care and community setting of what the true risks are rather than the widely held beliefs prevalent in the
community that contribute to stigmatization. Sites will also be provided job aids and IEC materials to
encourage behavior change and sustainability.
While JSI, the main procuring IP will provide a seed stock of all commodities, ACTION will continue to
provide personal protective commodities and will take on the new role of logistic supply of recurrent stocks
of injection safety commodities for all sites. ACTION will supply color coded bin liners for waste segregation
and universal precaution supplies including gloves, eye shields, boots, and aprons. Commodities and
disposables will be procured, warehoused and distributed by ACTION. They will be provided to sites based
upon a pull system using a site level inventory control system linked to the ACTION warehouse logistics
management information system. The current system can be easily harmonized with a national or PEPFAR-
wide logistics management information system and inventory control system once implemented. In addition,
ACTION will support safe health care waste management by supporting repair of existing incinerators at
sites.
This activity is linked to laboratory services (3256.08), PMTCT (3257.08), ART services (3255.08), blood
safety (3258.08), HCT (5426.08) and SI (3253.08). Health care workers involved in these programs will
benefit from the training program in injection safety and the adoption of a safe needle, needle stick policy
and PEP protocol, all which will improve the safety for workers involved in these other programmatic
activities.
Continuing Activity: 13108
13108 6821.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $350,000
6821 6821.07 HHS/Centers for University of 4184 632.07 Cooperative $122,000
Workplace Programs
Estimated amount of funding that is planned for Human Capacity Development $16,000
Table 3.3.05:
Adult ARV Narrative: 22 PMTCT sites will be upgraded to provide treatment services. Training targets
revised. More emphasis on HIVQual and Clinical QA/QI.
Care and Support Narrative: 22 PMTCT sites will be upgraded to provide care services. Training targets
revised and highlights use of Master Trainers from 07 and 08 Health System Strengthening programming.
Increased emphasis on basic care kits, PwP, home based care and management of acute malnutrition.
Narratives merged.
ACTION will provide Care and Support Services to 113,000 HIV+ adults and support services to an
additional 226,000 persons affected by AIDS (PABAs) as well as ARV services to 70,953 adults (7,953
new). In COP08 ACTION supported Adult Care and Treatment services at 78 sites (including 42 smaller
secondary hospitals or Primary Health Care Centers (PHC) and DOTS satellite sites using the Hub & Spoke
model. In COP09, ACTION will continue to provide services in these 78 sites and will upgrade 22 PMTCT
sites, the majority of which are small secondary hospitals or comprehensive primary health centers (PHC) to
Adult Care and Treatment satellites so that comprehensive services including ART will be provided in a total
of 100 sites. These sites will be located in 23 states (Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers,
Ogun, Osun, Plateau, Sokoto). Sites are chosen jointly with the GON to complement the national scale-up
plan being supported by Global Fund (GF) and other IPs. Services at PHC satellite sites are provided using
three different strategies to ensure quality of care and network linkages: physician and lab assistant team
travels from the "hub" site on selected days; nurse-managed PHCs/DOTS with nurses trained using the
IMAI national curriculum; and physician/lab assistant team utilizes mobile site/van equipped with CD4 and
basic lab equipment to visit PHCs on selected days. An alternative model employs a physician or nurse-led
team with transport of samples back to the hub site for lab testing. The vast majority of these sites will also
provide Pediatric Care and Treatment services. PMTCT stand-alone points of service (POS) link to adult
and pediatric ARV care through utilization of a network PMTCT coordinator based at the hub site. A specific
referral SOP is used to ensure that HIV+ pregnant women who require HAART for their own care are linked
to an ARV point of service.
In COP 09, ACTION will continue to provide clinical services (pain assessment and management,
laboratory, OI prophylaxis/management, nutritional assessment/therapy) with Basic care kits plus at least
two other services in the domains of HBC, psychosocial, spiritual, PwP and preventive services to all
PLWHA enrolled into care. Lab services will include CD4, hematology, blood chemistry, LFT, OI and
pregnancy testing if indicated. CD4 count follow-up will be provided at least every 6 months to monitor for
change in status. Access to appropriate TB diagnostics and linkages with DOTS programs described under
TB/HIV are also provided. Screening for hepatitis B, malaria and urinalysis are supported for all HIV+
persons if indicated. The nutritional status of PLWHA will be assessed at the initial clinical contact and at
follow-up visits. If diagnosed with malnutrition, food by prescription consisting of a ready to mix soya based
supplement fortified with multivitamins will be provided and referrals/linkages to wraparound services
providing other nutritional therapy will be given. All PLWHA will be provided with a Basic Care Kit including
ITN, water guard, water vessel, soap, ORS sachets, latex gloves, condoms and IEC materials on self care
and prevention of common OIs. Prevention with positive services provided to PLWHA include condoms and
information on use, counseling on reduction of high risk behaviors, abstinence messages, discordant couple
counseling and syndromic management of STIs. A standard formulary is provided to sites to treat common
opportunistic infections and malaria.
Community HBC will be provided in each of the 32 network catchments areas ACTION supports. This is
overseen by a team comprising of community HBC nurse, health extension workers and volunteers. This
activity will be linked to primary prevention and HCT programs emphasizing the home based approach to
these other programs and ensuring family engagement in HBC. In addition to HBC for those requiring
classic "palliative care" interventions, Community HBC providers support ART adherence in the home
setting through education and addressing adherence barriers. This program utilizes volunteers, peers and
buddy systems and pill boxes as reminders for effective drug adherence. Community support system of
PLWHAs is also used to ensure adherence and tracking defaulters will be sustained. HBC providers focus
on linkage to services, ensuring that clients in need of hospital care gain access to care and linking family
members to OVC, PMTCT, community immunization, family planning, and TB DOTS services. These
activities will be linked to the patient's medical care source as the supervising community home based care
nurse/PHC extension worker will work under the medical direction of the site physician.
PLWHA and PABAs will be afforded linkages to psychosocial support through participation in PLWHA
support groups and individual counseling operational at all points of service. Emphasis on support group
activities that encourage participation for pre-ART clients will be supported. The function of PLWHA support
groups is strengthened by an ACTION program officer with a counseling background who works with the
support groups to improve their programs and to ensure linkages between points of service and
communities. Services to be provided to PABAs at the clinic and community levels include: promotion of
HCT; HIV prevention education including balanced ABC services as appropriate; psychosocial support
through on-site counselors; and participation in support groups designed for family members focusing on
prevention of transmission, stigma/discrimination reduction, support for infected family members by serving
as a treatment partner to enhance adherence. It is anticipated that many PABAs will be reached in the
communities rather than clinic settings through the community HBC program which will provide HCT
access, linkages to HIV care and other services, peer support and facilitation of home care to PLWHA by
PABAs.
ACTION care and treatment services are in line with current GON guidelines. ACTION supported the
update of the national care and treatment guidelines and will continue to participate actively in National
Care and Treatment Guideline Committees. All sites are supported to employ treatment support specialists
- PLWHA who participate in patient education, client advocacy, and home visits to track defaulters. A new
SOP to enhance adherence services has been developed and piloted in a number of sites in COP08. This
SOP creates a mandatory patient education/preparation before commencement of therapy and ongoing
adherence within the health facility and a back up follow up using Treatment Partners and community
Activity Narrative: support. Additionally, sites receive training, a standard SOP, and emergency prophylaxis starter kits for post
-exposure prophylaxis to address occupational HIV exposure of health care workers.
ACTION uses ART expertise to ensure high quality care using a two-pronged didactic and experiential
training approach. Using expert staff from established POS as resource persons, site staff will participate in
central or regional trainings on ARV care, adherence counseling, and/or pharmacy SOPs. All training will
include approaches for prevention for positives integrated into the clinic and community setting. Adapted
IMAI manuals will be used to step down trainings for secondary, PHC and DOTS sites. The training plan for
COP09 to support this scale up using the National training curriculum includes the training of 30 Master
Trainers from established ARV sites who will work with ACTION. Additional training plans include a
HIVQUAL training (see below) for the QA/QI Committee Chair at each of 32 hub sites and an Adherence
Refresher site based training for 10 staff at each of 32 hub sites. Thus the training target focused on ART
care is 30 Master Trainers, 200 site staff, 32 QA/QI and 320 adherence counselors for a total of 582.
ACTION will support HBC refresher trainings at 32 sites (or networks) to strengthen existing and new
networks with community & primary care facilities for a total of 32 trainings for 10 providers each (subtotal
320). Standard training curricula for healthcare and community workers, developed by ACTION to include
specific modules on pediatric home based care will be utilized. To enhance sustainability, ACTION will
support retraining for existing COP08 site nurses using nurse Master Trainers from the Health System
Strengthening program area. ACTION will support step down trainings at each ART point of service in order
to encourage ongoing in-house HIV continuing education program (220 nurses will participate in refresher
training). Thus the total training target focused on Care and Support is 540. These training will facilitate
task shifting and ACTION will support the GON in developing policies related to this.
Bedside teaching is also a component of ongoing education. IHV/UMD adult and pediatric HIV care
specialists are posted in Nigeria as preceptors. ACTION has developed 3 regional training centers which
are equipped with training venues adjacent to large clinical care facilities where best practices are modeled.
A clinical training center in Abuja provides a model clinic that integrates physician, nurse, treatment support,
pharmacy and community outreach teams to provide experiential training in a holistic model clinic setting in
order to demonstrate feasible and functional strategies bridging community to care. ACTION supports 4
regional training labs that will train lab scientists working at GON and GF-supported sites in ARV lab
monitoring including good lab practices, HIV rapid testing, automated CD4, hemogram and chemistries.
This will serve to increase the quality and sustainability of ARV services outside of PEPFAR-supported
ACTION in COP08 participated in the National HIVQUAL pilot and then expanded upon these clinical QA/QI
indicators to conduct quarterly comprehensive QA/QI assessments jointly with all sites providing ART
services. Deficiencies identified are discussed with the site QA/QI committee and ACTION staff and an
improvement plan implemented. Training needs identified are addressed by the IHVN Training Dept. In
COP09, ACTION will continue this process collaboratively with the sites, USG and GON. Based on gaps in
knowledge identified the Training Department refines/updates training materials for new and ongoing
training activities. ACTION will also facilitate and actively support onsite standardized HMIS using GON
forms and National electronic platforms and will provide onsite assistance with data management and M&E
to guide quality improvement measures. ACTION will also participate in the yearly care and treatment
evaluation jointly conducted by GON/USG.
Sites are supported to carry out renovations to ensure clinic facilities are adequate and particularly that
pharmacy store and dispensing areas are able to store ARVs and other HIV care drugs and commodities
consistent with manufacturer guidelines. Care and treatment drugs and commodities are procured through
SCMS, and other local mechanisms.
At the end of COP09 ACTION will be providing ART services to 70,953 people, contributing to
GON/PEPFAR targets for Nigeria.
This activity provides services which are a high priority for the 2-7-10 Emergency Plan strategy by providing
a basic package of care services to all HIV+ adults and PABAs. The services are consistent with the current
Guidelines for Palliative Care in Nigeria and the USG Palliative Care Policy as well as the Nigerian
Guidelines for Antiretroviral Therapy. ACTION will build the skills of over 1000 care providers thus
contributing to national sustainability plans.
Using the Hub-and-Spoke model in site selection leverages resources and improves referrals between
tertiary, secondary and primary health care facilities. This activity is linked to drugs, HCT, HVOP, OVC,
TB/HIV, PMTCT, Lab, and SI. Services are co-located with TB DOTS centers and TB/HIV linkages will be
strengthened; all HIV infected patients will be screened for TB using the National algorithm. ACTION will
also provide onsite assistance with data management and M&E to guide quality improvement. HCT
targeting MARPs is established proximate to ARV POS. Using a network model, linkage to ARV services for
HIV+ women identified through PMTCT and HIV-infected infants are in place. Quality lab services supported
by an ACTION-facilitated lab QA program are available at comprehensive sites while manual lab methods
or specimen transport systems will be established for primary health center satellites. Sites have been
chosen to maximize linkages with national TB DOTS sites and to provide services for HIV+ pregnant
women identified through PMTCT.
Populations targeted are adults living with HIV/AIDS and PABAs, TB patients, OVC, persons in prostitution,
and pregnant women. Doctors, nurses, other health workers (public sector) as well as people living with
HIV/AIDS and caregivers of PLWHA are targeted for training.
Emphasis areas include human capacity building as capacity development for sustainability is a key focus.
Local organization capacity building and TB-related wraparound programs are another focus.
Activity Narrative:
Continuing Activity: 13110
13110 3259.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $5,346,000
6770 3259.07 HHS/Centers for University of 4184 632.07 Cooperative $4,249,931
3259 3259.06 HHS/Centers for University of 2778 632.06 UTAP $1,923,750
Estimated amount of funding that is planned for Human Capacity Development $366,500
Estimated amount of funding that is planned for Food and Nutrition: Commodities $75,000
Table 3.3.08:
Continuing Activity: 13115
13115 3255.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $17,603,375
6766 3255.07 HHS/Centers for University of 4184 632.07 Cooperative $12,945,300
3255 3255.06 HHS/Centers for University of 2778 632.06 UTAP $7,961,922
Table 3.3.09:
FY08 CollaborativeNigeriaNG.08.0201Multi-countryCARTEvaluation of Interventions to Reduce Early
Mortality among Persons Initiating ART in Emergency Plan Countries
New/Continuing Activity: New Activity
Continuing Activity:
Estimated amount of funding that is planned for Public Health Evaluation $327,175
This activity has been revised to include Pediatric ARV services, Pediatric Care and Support and Early
Infant Diagnosis in a single narrative. Increase in number of sites by 20.
ACTION will provide care and support services and lab monitoring to 10,500 children out of which 8,000
(2,450 new) will be on ART in COP09. In COP08, ACTION supported pediatric ARV services at 70 sites (33
tertiary or large secondary hospital "hub" sites, 37 smaller secondary hospitals or primary health care
centres (PHC)) using the hub-and-spoke model. In COP09, ACTION will continue to provide services in
these 70 sites and will upgrade 20 PMTCT sites, the majority of which are small secondary hospitals or
comprehensive PHCs to ARV satellites so that pediatric care and treatment will be provided in a total of 90
sites. These sites will be located in 23 states (Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta,
Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun,
Osun, Plateau, Sokoto). Sites are chosen jointly with the GON to complement the national scale-up plan
being supported by Global Fund (GF) and other IPs. Services at PHC satellite sites are provided using three
different strategies to ensure quality of care and network linkages: physician and lab assistant team travels
from the "hub" site on selected days; nurse-managed PHCs/DOTS with nurses trained using the national
curriculum; and physician/lab assistant team utilizes mobile site/van equipped with CD4 and basic lab
equipment to visit PHCs on selected days. An alternative model employs a physician or nurse-led team with
transport of samples back to the hub site for lab testing. The choice of best model will depend on which one
provides timely and high-quality results with good patient adherence. In all models of community outreach, a
portable pharmacy is employed to deliver ARVs and OIs drugs to patients at the community level.
Pediatric care and treatment services will be expanded to all supported tertiary and secondary hospitals and
selected PHCs. At larger sites, ACTION will provide temporary salary support to facilitate the hiring of
additional pediatric ARV dedicated medical officers. Sites will be required to absorb the funding of these
positions in the main hospital budget within one year. ACTION staff participate actively in National ARV
Guideline Committees. Guidelines for adults and pediatrics were updated in 2007 for consistency with WHO
2006 guidelines. A corresponding National ARV standard operating procedure (SOP) has been developed.
ACTION ARV services are in line with GON guidelines.
Health care services will include access to free lab monitoring for all HIV-infected children including: CD4
count, hematology, and chemistry. The basic health care package, which will be available to all of the HIV-
infected children as well as HIV-exposed infants receiving services, includes: access to appropriate TB
diagnostics and linkage with GON sponsored DOTS programs described under TB/HIV, instruction for
parents/caregivers in appropriate water purification and provision of basic care kits (water guard, water
vessels, soaps, Vaseline, latex gloves, ITNs, IEC materials, ORS) provision of cotrimoxazole prophylaxis,
diagnosis and treatment of malaria, and symptom management including provision of pediatric formulations
of antidiarrheals/antihelminthics/analgesics/antipyretics. In addition, a standard formulary will be provided to
sites to treat common OIs.
Point of entry into care and treatment include PMTCT, EID, HCT at every pediatric points of service within
health care facilities and communities through HBC. Community home based care (HBC) for children is in
need of scale-up in Nigeria. ACTION has updated its HBC curriculum to include modules on HBC for
children. HBC for children will be linked to HBC for adults and provided in all 32 network areas under
COP09, so that at least 40 children per network or a total of 1,280 children receive pediatric specific HBC.
This is overseen by a team comprising of community HBC nurse, health extension workers and volunteers.
This activity will be linked to primary prevention and HCT programs emphasizing the home-based approach
to ensure that family members at risk including other children in the household are tested and counseled.
This strategy supports family engagement in HBC and identifies family members in need of HIV care. In
addition to HBC for those children requiring classic "palliative care" interventions, home based care staff
support parents with ART adherence for children in the home setting through education and addressing
adherence barriers. Home based care staff focus on linkages to services, ensuring that clients in need of
hospital care are able to access this care and linking family members to PMTCT, community immunization,
family planning, and TB DOTS services. ACTION will continue to utilize different models depending on site
preference including supplementing site staffing with dedicated home based care staff or developing
agreements with local NGOs/CBOs/FBOs to provide this service. Extension workers will be preferentially
recruited from the PLWHA support group membership. HBC will be linked to the child's medical care source
as the supervising community home based care nurse/PHC extension worker will work under the medical
direction of the site physician.
Access to food and nutrition support is a major need for children. Leveraging support from the Clinton
Foundation, ACTION will provide comprehensive nutritional support for OVCs through the provision of
fortified cereals, Kwashi-pap and PlumpyNut, targeting HIV-infected children as well as HIV-exposed infants
weaning after exclusive breast feeding. This will include nutritional assessment (growth monitoring through
charting and plotting) and counseling as well as multivitamins/mineral supplementation. In the provision of
nutritional supplements, ACTION will build the capacity of care givers by providing raw materials and
instructions so that Kwashi-pap can be prepared by them at home. ACTION will prioritize partnering with
USG-supported wraparound services in states where it is co-located with these activities.
ACTION has worked to strengthen psychosocial support for children by improving the quality of counseling
available for HIV-infected children at points of service through training focused on developmentally
appropriate adherence counseling of children. In COP09 ACTION will expand this training to new sites. The
curriculum includes formal child development, socialization, limit setting, pediatric counseling, diagnosis
disclosure, grief and loss, and adherence to medications. These trainings will include not only HBC and
facility-based providers, but will also focus on improving psychosocial support for OVC in orphanages.
ACTION partners with community OVC providers including the Sisters of the Poorest of the Poor, the
Anglican Church and the Mothers Welfare Group in provision of OVC services to OVC in their homes and to
OVC in orphanages. Through these partnerships this step down training will ensure improved provision of
psychosocial services not only to OVC in their homes but also to OVC in orphanages who are awaiting
family placement.
Activity Narrative: Leveraging support from the Clinton Foundation for test kits and specimen transport, Early Infant Diagnosis
(EID) will be supported through the pediatric care and treatment program area and available at PMTCT
POS under COP09 to improve the identification of HIV+ children for linkage into care and treatment
services. Nine regional laboratory centers for DNA PCR have been established by ACTION with an
additional one planned for COP09. Testing of infants will be carried out using dried blood spot (DBS)
specimen collection. ACTION will actively participate in the national early infant diagnosis initiative by
providing DNA PCR testing of DBS at ACTION-supported labs. The source of DBS samples will include
ACTION and non-ACTION supported PMTCT sites. A systematic coordinated approach to program linkage
will be operationalized at site and program levels including linkages between adult and pediatric ART
services, OVC services and adult and pediatric basic care and support. Quality monitoring will be
undertaken through site visits using an existing assessment tool and routine monitoring and evaluation
indicators.
ACTION uses care and treatment expertise to ensure high quality care using a two-pronged didactic and
experiential training approach. Using expert staff from established points of service, ACTION will conduct
training to develop the capacity of 15 pediatric care experts who will serve as regional master trainers. Ten
regional trainings will then be conducted to train 200 site staff in pediatric HIV care. In addition to ARV
management and institution based care, these trainings will include specific modules on adherence support
in children based upon the national curriculum. Bedside teaching is also a component of ongoing education.
IHV/UMD adult and pediatric HIV care specialists are posted in Nigeria as preceptors. In addition, a
preceptor program brings volunteer physicians with extensive HIV experience from other US and European
institutions, and also uses expert on-site staff as preceptors. ACTION has developed three regional training
centers which are equipped with training venues adjacent to large clinical care facilities where best
practices are modeled. A clinical training center in Abuja provides a model clinic that integrates physician,
nurse, treatment support, pharmacy and community outreach teams to provide experiential training in a
holistic model clinic setting in order to demonstrate feasible and functional strategies bridging community to
care. Additional trainings planned include 32 site-based trainings in pediatric care and support and home
based care to train a total of 160 persons, and five central/regional-based trainings in Early Infant Diagnosis
to training an additional 100 persons. Thus, the training targets are 264 ARV focused and 260 care and
support focused trainings. This training will facilitate task shifting and ACTION will support the GON in
developing policies related to this. ACTION will work in collaboration with the USG/GON to ensure adequate
supervision of all sites.
ACTION supports four regional training labs (described under ARV Lab). These facilities will train additional
lab scientists working at GON and GF-supported sites (i.e., non-PEPFAR supported sites) in ARV lab
In COP08 ACTION participated in the National HIVQUAL pilot and then expanded upon these clinical QA/QI
indicators for pediatric care and treatment. Deficiencies identified are discussed with the site QA/QI
committee and an improvement plan is then implemented. In COP09, ACTION will continue this process
collaboratively with the sites, USG and GON. The ACTION QA program has site level clinical QA
coordinators assigned at each POS who perform structured periodic chart reviews that are incorporated into
the QA assessment process using indicators developed as part of the National HIVQUAL Program. Site
level CareWare aggregated data is evaluated and feedback provided. ACTION supports the training of
medical officers in IAPAC and GALEN certification as HIV specialists and other clinical staff in expanded
support roles under the treatment team concept. Based on gaps in knowledge identified, the training
department refines/updates training materials for new and ongoing training activities. ACTION will also
facilitate and actively support onsite standardized HMIS using GON forms and national electronic platforms,
and will provide onsite assistance with data management and monitoring and evaluation to guide quality
improvement measures.
Sites are supported to carry out renovations to ensure clinic facilities are child and adolescent friendly and
that pharmacy stores and dispensing areas are able to store ARVs consistent with manufacturer guidelines.
ARVs are procured as described in the ARV drugs narrative. ACTION will partner with Clinton Foundation
and GF as appropriate to leverage resources for providing ARVs to patients. In this scenario, ACTION
provides pharmaceutical commodity management and ensures access to alternative first line and second
line ARVs, pediatric formulations, and wraparound services including lab monitoring and high quality clinical
care. Coordination with the FMOH to plan site targets will ensure a single comprehensive HIV care program
although there may be multiple ARV sources. Additionally, sites receive training, a standard SOP, and
emergency prophylaxis starter kits for post-exposure prophylaxis to address occupational HIV exposure of
health care workers.
By adhering to the Nigerian National ART service delivery guidelines and building strong community
components into the program, this activity will contribute to achieving global PEPFAR treatment targets and
will also support the Nigerian government's universal access to ART by 2010 initiative. ACTION will build
the skills of at least 720 care providers thus contributing to national sustainability plans.
Care and treatment services are offered to HIV positive infants and children living with HIV/AIDS. Doctors,
nurses, and pharmacists are targeted for training in both the public and private sectors. Health workers and
laboratorians at non-PEPFAR supported sites will be targeted by offering dedicated central ARV training.
An emphasis will be placed on human capacity development through training and local organization
capacity building.
Continuing Activity: 13112
13112 5417.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $2,359,000
6771 5417.07 HHS/Centers for University of 4184 632.07 Cooperative $1,706,190
5417 5417.06 HHS/Centers for University of 2778 632.06 UTAP $309,725
Estimated amount of funding that is planned for Human Capacity Development $113,500
Estimated amount of funding that is planned for Food and Nutrition: Commodities $984,375
Table 3.3.10:
Table 3.3.11:
ACTION will continue to support 92 sites and implement services at an additional 8 secondary health
facilities for a total of 100 facilities. References to LGA coverage strategy will be removed. References to
PHEs have been removed. TB laboratory diagnostics section is updated.
In COP08, ACTION supported integrated TB/HIV services at 92 sites and will continue to support these
sites in COP09 and implement services at 8 additional secondary health facilities sites for a total of 100
sites in 23 states (Akwa Ibom, Anambra, Bauchi, Benue, Cross River, Delta, Edo, FCT, Gombe, Imo,
Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto).
ACTION will support TB/HIV management using the global strategy of the 3-Is. Intensified TB case findings
among HIV positive patients will be carried out through TB screening of all 123,500 HIV positive clients.
The integrated management of HIV/TB co-infected patients at ACTION points of service (POS) will remain a
major focus. TB screening and diagnosis follows the national algorithm and is in line with national
guidelines. At ARV POS, patient record forms have been modified to prompt for TB screening indicators
and site level training of health workers is on utilization of symptom history including chronic cough, fever,
weight loss, or night sweats to prompt referral for TB evaluation. Chest x-ray is supported for sputum
negative patients and for candidates for INH prophylaxis. ACTION has collaborated extensively with the
National TB and Leprosy Control Programme (NTBLCP) to conduct a feasibility pilot of INH prophylaxis for
HIV-infected patients. Eligible TB/HIV patients will also receive Cotrimaxozole Preventive Therapy (CPT)
according to National Guidelines. ACTION will support IPT for all eligible patients in the ART program. The
TB DOTS sites will be supported to provide holistic patient care according to national guidelines. In addition,
HIVQUAL will be utilized as a clinical quality indicator and improvement strategy at sites. ACTION M&E staff
support the national surveillance program by ensuring that sites properly report incident TB cases to
Federal Ministry of Health (FMOH)
Under COP09, ACTION will support HIV counseling and testing (HCT) for 5,500 clients being evaluated for
TB at 100 DOTS points of service. Of these, it is expected that 2,000 of those getting HCT will have TB. It is
expected that 20% of HIV-infected adults and children initiating ART will be coinfected with TB and that all
HIV-infected patients in care will be screened for TB at least yearly. Thus, ACTION will reach at least 2,000
TB/HIV co-infected patients with TB treatment. Infection control at health centers is a priority to limit
nosocomial transmission of TB to HIV+ patients. Basic hygiene, proper sputum disposal, and good cross
ventilation at clinics will be promoted. Facility co-location of TB/HIV services is preferred to clinic co-
location. National guidelines on infection control for co-located sites will be implemented at all sites.
ACTION has previously supported the GON in carrying out preparatory HCT trainings for DOTS staff at the
National TB and Leprosy Training Centre (NTBLTC) in Zaria. In COP09, DOTS staff at targeted centers will
be trained on the National testing algorithm using the National HCT training curriculum. Training will be
conducted by ACTION HCT program staff or ACTION regional HCT master trainers. Two staff per site will
be trained for a direct training target of 220. All clients presenting to DOTS centers will receive HIV pre- and
posttest counseling with rapid testing carried out using an opt-out approach to provide same day results.
Those testing HIV+ will be referred for further evaluation and care to an ARV POS within the network.
Regionally based ACTION HCT program officers will ensure referral linkage for DOTS stand alone sites.
TB culture capacity has been developed at an ACTION supported NTBLTC in Zaria using the Bactec
system. ACTION will support the National MDR TB management program. ACTION will continue to
maintain its membership in the National TB/HIV working group and the MDR-TB committee and will
continue to be actively involved in national TB/HIV planning, implementation, monitoring and supervision.
ACTION will also have a particular emphasis on provision of technical assistance to the national working
groups to ensure that the MDR-TB laboratory supports are appropriate for the Nigerian context. Due to the
safety concerns for the microscopic observation drug susceptibility (MODS) assay by CDC and WHO,
ACTION will work with CDC Nigeria to pilot the PCR based HAINS Assay, a molecular method for rapid
diagnosis of TB and INH/Rifampicin drug resistance at Zaria and some selected PCR facilities. ACTION has
already established the superiority of the LED based microscopes on auramin stained direct sputum
smears. For COP09, ACTION will roll out this technology at its sites, DOTS centers within its sites and
mobile labs following adequate training in the technology at the NTBLTC Zaria. ACTION will also coordinate
with Global Fund supported initiatives in the roll out of TB culture capacity in Nigeria to maximize regional
availability. An additional 50 staff will be trained in the use of LED microscopy to enhance sputum smear
TB detection for a total of 270 trained laboratorians.
ACTION will also work with SCMS in country to procure equipment and supplies, and $127,500 was
allocated to SCMS for this support. Commodity management of HIV test kits and supplies will be provided
by ACTION using the current regional distribution system. ACTION will upgrade facilities through
infrastructure support such as basic renovations, upgrading equipment and procuring supplies and
consumables. ACTION will strengthen the pharmacy services at supported TB DOTS sites to improve
forecasting and avoid stock outs and will work with sites to recognize if stock outs are due to facility level or
government level TB logistics issues.
Training and support to improve the quality and integration of TB/HIV services are consistent with FMOH
and emergency plan priorities. Activities will be carried out collaboratively with FMOH and state MOH to
promote sustainability through capacity development and integration into the health sector system. COP09
activities will focus on sustainability of the national training program and the national model facility for
laboratory diagnosis and clinical care with a decreasing dependence upon ACTION technical expertise and
a focus on the training of a cadre of Master Trainers.
HCT targets in this section are not included in the testing target in the HCT narrative and those in the HCT
narrative do not overlap with these targets. This activity is linked to HCT, BC&S, OVC and ARV services,
Activity Narrative: Lab , and SI. ACTION will expand HIV treatment access to community venues including DOTS centers, an
approach that will also strengthen treatment adherence for both TB and HIV and articulate TB and ARV
services to promote seamless transition from TB to HIV treatment and care. The collaboration with the
NTBLTC will also include training to ensure that HCT is available at all DOTS POS. Linkages to TB
diagnosis and treatment is an important component of adult BC&S and OVC services. Linkage to ARV
services and proper management of patients requiring ARV and TB medications is a focus.
TARGET POPULATIONS:
Persons at risk, including household members, people who have documented TB, OVC, pregnant women
and PLWHA are targeted. Screening of close household members for both HIV and TB will promote a public
health strategy reaching populations at risk with diagnosis and services. ARV services are offered to HIV+
infants/children and adults with TB. Doctors, nurses, laboratory workers community outreach workers, GON
staff, and DOTS staff are targeted for training in both the public and private sectors.
Emphasis areas include construction and renovation, human capacity development, local organization
capacity building, and TB related wraparound programs. This activity focuses on the issue of wraparound as
the activity relies upon non-PEPFAR TB funding and promotes linkages with HIV-specific programs to
ensure that comprehensive services are available to TB/HIV co-infected persons.
Continuing Activity: 13111
13111 3254.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $2,243,680
6765 3254.07 HHS/Centers for University of 4184 632.07 Cooperative $3,260,300
3254 3254.06 HHS/Centers for University of 2778 632.06 UTAP $920,020
* TB
Estimated amount of funding that is planned for Human Capacity Development $54,000
Table 3.3.12:
In addition to 10,500 HIV infected or exposed children served in the Pediatric Care and Support program
area, ACTION will reach 14,000 (7,000 males and 7,000 females) HIV-infected and/or affected children
under OVC. IHVN will train 600 providers/caregivers in COP09. The Narrative has been rewritten
completely to focus on this scale up of OVC services.
ACTION has previously focused its OVC services on linkage between medical points of care and
community based OVC providers, providing three core services to over 10,000 HIV-infected, exposed, and
affected children in COP08. In COP09, ACTION will utilize OVC funding to focus on rapid scale-up of OVC
services across the country at the community level, ensuring comprehensiveness and a renewed emphasis
on education and nutrition service components and improving quality of care. ACTION will provide OVC
services to 14,000 HIV infected and affected children including adolescents in 23 states (Akwa Ibom,
Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina,
Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto). ACTION supports Pediatric HIV care
and support in 30 networks at 90 medical points of service. ACTION will continue its collaboration with the
State Ministry of Women Affairs (SMOWA) in the 23 states to build capacity of its focal person especially in
advocacy for OVC services in each state. Through OVC programming, ACTION will support an OVC
network coordinator in each of the 30 networks and engage a community OVC provider in each of the 30
networks to ensure that at least three core services are provided to all OVC in the network as well as
linkage of all OVC to services not provided directly by ACTION ensuring comprehensive quality services.
The focus of this OVC scale up will be HIV affected children living without adequate adult support, living
outside of family care, or living in a situation where they are marginalized, stigmatized, or discriminated
against.
The OVC Network Coordinator in each network will identify children in need of OVC services through
contact with families at points of medical service and community engagement. The Coordinator will ensure
that OVC are linked to needed medical care and services including health assessments, treatment of
common childhood diseases like malaria, diarrhea, respiratory track infections, etc; provision of LLITNs,
water guard, water cans, laboratory supports and multivitamin supplementation. The Coordinator will link
medically vulnerable children to community OVC providers and ensure that at least two additional needed
core services are provided. The Coordinator will also identify HIV affected children who are vulnerable due
to inadequate adult support, family care, or are marginalized/stigmatized, and link these children to
community OVC providers which will be supported in each of the 30 care networks by ACTION and ensure
that needed services in at least 3 core areas are provided.
OVC providers will ensure that food and nutrition services are available to all OVC regardless of HIV status.
Leveraging support from the Clinton Foundation, ACTION will provide comprehensive nutritional support for
OVC through the provision of fortified cereals, Kwashi-pap and PlumpyNut, targeting any child meeting the
definition of acute malnutrition. All children will receive nutritional assessment and counseling at intake and
periodically. Those meeting the definition of acute malnutrition will receive food by prescription (either
Plumpy Nut or the ACTION meal soy based Kwashi-pap formulations, both vitamin fortified ready to mix
nutritional supplements approved by NAFDAC) provided by ACTION under an existing clinical care protocol
for short term nutritional support. In the provision of nutritional supplements, ACTION will build the capacity
of caregivers by providing raw materials and instructions so that affordable food supplements can be
prepared by them at home. This caregiver instruction will be provided by medical points of service and
community OVC providers using a training manual and demonstration materials provided by ACTION. For
OVC with ongoing food insecurity, ACTION will prioritize partnering with USG-supported wraparound
services in states where it is co-located with these activities to meet these needs through referral.
Community OVC providers supported by ACTION in each of the 30 care networks are expected to provide
educational assistance through support of school fees, uniforms and educational supplies for OVC. In
addition ACTION will provide educational grants to three identified educational institutions. They will provide
residential shelter and care as a last resort for OVC who cannot be placed in family care. They will provide
protection for those children at risk of physical or psychological abuse. Community OVC providers will be
trained in psychosocial support through training focused on developmentally appropriate adherence
counseling and support of children. The curriculum includes formal child development, socialization, limit
setting, pediatric counseling, diagnosis disclosure, grief and loss, and adherence to medications.
Community home-based care (HBC) for children is described under Pediatric Care and Support and
available in each of the 30 networks. In a number of networks, the HBC provider for children is also the
Community OVC Provider. This is implemented by a supervising community HBC nurse, health extension
workers and volunteers. This activity will be linked to primary prevention and HCT programs emphasizing
the home-based approach to ensure that family members at risk including other children in the household
are tested and counseled. This strategy supports family engagement in HBC and identifies family members
in need of HIV care. In addition to HBC for those children requiring care and support services interventions,
home based care staffs support parents with ART adherence for children in the home setting through
education and addressing adherence barriers. Home based care staff focus on linkages to services,
ensuring that clients in need of hospital care are able to access this care and linking family members to
PMTCT, community immunization, family planning, and TB DOTS services. ACTION will continue to utilize
different models depending upon the site preference including supplementing site staffing with dedicated
home based care staff or developing agreements with local NGOs/CBOs/FBOs to provide this service.
Extension workers will be preferentially recruited from the PLWHA support group membership. HBC will be
linked to the child's medical care source, as the supervising community home based care nurse/PHC
extension worker will work under the medical direction of the site physician.
Training of Community OVC providers will be conducted primarily at the site level to ensure maximum
coverage in the most cost effective manner. 30 site-based trainings of 20 staff each will be conducted for a
total training target of 600. Training in the issues of HIV for NGOs engaged in OVC services and for social
workers will target improved understanding of the issues including stigma surrounding HIV positive children
Activity Narrative: and the need to integrate healthy HIV positive children into mainstream social and school settings without
fear due to lack of understanding of risks surrounding HIV transmission in school-aged children.
This activity provides services which are a high priority for the 2-7-10 Emergency Program strategy by
providing core OVC services to all HIV+ children. The services are consistent with the National OVC
Standard of Practice and OVC National Plan of Action. Capacity development at the site level and
consistency with national guidelines will ensure sustainability. Capacity development will be achieved
through regional training and skills development.
This activity is linked to HCT (5426.09), ARV services (3255.09), TB/HIV (3254.09), AB (15651.09), lab
(3256.09), and SI (3253.09). HCT services will be available to HIV affected family members (PABAs) in
need of HIV testing including in-home HCT through HBC services. Home based care programs will be
implemented by a number of indigenous NGOs, CBOs and FBOs. Sub-agreements will be coordinated with
other PEPFAR IPs to ensure non-overlap of funding and services. Some services are co-located with TB
DOTS centers and ACTION staff work with sites to ensure coordination systems are in place. High quality
laboratory services supported by an ACTION facilitated laboratory QA program are available at sites. This
will include EID available in all catchment areas (see lab narrative).
OVC services are offered to infants and children in HIV/AIDS infected and or affected families, children
orphaned by HIV, and caregivers of OVC. Doctors, nurses, social workers, care givers, teachers, family
members and other health workers in the public and private sector are targeted for training. Community
groups including CBOs, NGOs and FBOs will be targeted for training and system strengthening, linkages
and identifying OVC.
Emphasis is placed on training and human resources as capacity development for sustainability is a key
focus and much of the community linkages are through partners. In addition, community mobilization and
infrastructure development of CBOs/FBOs is critical for the identification and care of OVC.
This activity addresses the area of wraparounds as activities that will strengthen/develop linkages between
HIV/AIDS services and other sectors for food resources. The activity also addresses the key area of stigma
and discrimination as training of health care workers and community volunteers will reduce stigma.
Estimated amount of funding that is planned for Human Capacity Development $115,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $150,000
Table 3.3.13:
The narrative has been updated to reflect COP09 goals and targets. As a result of the necessary shift in
resources to maintain care and treatment activities across the PEPFAR-Nigeria program, there is a
reduction in funding and targets for HCT services from COP08 to COP09. The ACTION narrative reflects
the consolidation of activities in this program area for COP09; HCT Points of Service (POS) will be co-
located with Condoms and Other Prevention sites to focus on most at risk populations, and hospital and
community based HCT will be phased out of direct commodity support. In anticipation of this and in order to
minimize the potential impact on the availability of services, ACTION will also work with these sites during
COP08 to evaluate the opportunity to seek out other sources of funding for these activities. In COP09 the
ACTION 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.
In COP08, ACTION provided support to 121 Points of Service (POS). In COP09 ACTION will provide
Counseling & Testing (HCT) services complementing Condoms and Other Prevention services targeting
13,500 persons at 12 points of services in 9 states (Anambra, Benue, Delta, Edo, Imo, Kwara, Lagos, Ogun,
and Osun). With a mobile HCT van in 2 regions, ACTION will collaborate with indigenous NGOs to offer
testing focusing on most at risk persons (MARPs) using a mobile strategy linking HCT to Condoms and
Other Prevention (C&OP) activities. HCT carried out at an additional 110 TB DOTS POS will reach 25,000
persons under the TB/HIV program area will provide HCT services to an additional 5,500.
HCT services will be provided by trained counselors using the national testing algorithm and opt-out
approach in accordance with the national HCT guidelines. The national "Heart to Heart" branding logo will
be utilized at all POS. Counseling and information, education and communication (IEC) materials will focus
on abstinence, be faithful, and consistent and correct condom use (ABC). In addition, IEC materials will
include information promoting couple counseling and counselors will be trained on Couple HIV counseling
and testing (CHCT). Discordant couples will receive a package of services including safer sex behavior
messages, condoms and information targeting both positive and negative partners. This activity will be
linked to PwP (prevention with positives) as detailed in the Care and Treatment narrative. Client witnessed
testing will be carried out to encourage client confidence in the result. Intensive advocacy for
implementation of HIV testing by non-laboratorians has taken place, thus counselors will carry out rapid
tests in most settings. To ensure the quality of test results, laboratory program officers will provide training
and QA program focused on rapid testing. Prevalence will be monitored regularly to optimize targeted
screening of populations with high rates of infection.
Post-test counseling for negative clients will focus on prevention using a balanced ABC approach, and
partner testing will be encouraged. Based on risk assessment, a follow-up testing interval will be
recommended. Post-test counseling for positive clients will include PwP counseling which also includes
balanced ABC messaging as appropriate. Counselors are trained in CHCT to address disclosure to spouse
and sexual partners while addressing potential negative consequences of such disclosure. PLWHA
treatment support specialists are employed at ART treatment sites to ease the referral and linkages for
newly diagnosed clients. Newly identified HIV+ clients will be linked to HIV care centers in the network.
Community based mobile HCT services will be supported with one van based at two of the ACTION
regional offices in Edo and Lagos States, to assist hospital based HCT teams that frequently provide HCT in
the community setting and to link HIV+ clients into care and support services. The monitoring and
evaluation (M&E) staff will compile data on rates by target population and venue; this will facilitate their use
of data to guide systematic screening strategies. HIV sero-prevalence among MARPs tested in mobile
settings has been consistently above the national average, 19.1% in COP06, 27.5% in COP07 and 15.4%
in the first quarter of COP08 demonstrating the ability to identify communities at high risk of HIV acquisition
and transmission. Another strategy to increase access to HCT outside of facilities is to train and equip home
based care (HBC) teams to provide home-based HCT to family members of HIV+ clients. In COP09, 12
community based testing sites will be developed through collaborations with indigenous NGOs and local
public health clinics as mentioned above. These are co-located with C&OP sites so that activities will be
properly linked. The NGOs will establish stationary HCT sites and utilize the mobile HCT van at truck stops
and other venues appropriate to access hard to reach MARPs as detailed in the C&OP narrative. MARPs
testing HIV- will be linked to C&OP services offering education, counseling, social support, and syndromic
STI management.
The M&E system will be primarily ledger based to maximize time devoted to service provision and facilitate
services in the primary health center and community mobile settings. Aggregate data will be reported to the
ACTION regional M&E program officer monthly. A referral tracking system for HIV+ clients has been
developed and will be utilized. The quality assurance (QA) strategy for counseling will include post-test
client surveys, quarterly site monitoring visits using an existing quality assessment tool, and routine
reviewing of M&E data. A major metric of the QA process will be the percentage of positives entering care.
Feedback to sites will occur quarterly with targeted refresher courses and regional TA for those needing
capacity building. An extensive laboratory QA program (described under lab program area) is in place to
ensure the accuracy of HIV rapid testing. Test kits and consumables will be warehoused by ACTION and
provided to sites based on a pull system using site level inventory control systems linked to ACTION's
logistics management information system. The current system can be easily harmonized with the national
test kit logistics management information system and inventory control system once implemented.
Five HCT counselors each will be trained at the 12 HCT sites co-located with C&OP sites for a direct
training target of 60 individuals. The 10 day National HIV training curriculum will be utilized. The National
"Heart to Heart" logo will be used at HCT sites for integration with National Branding of HIV testing services.
This activity supports the national HCT scale up plan by promoting the accessibility of HCT services using
Activity Narrative: the FMOH approved training curriculum and procedures. HCT services are essential to identifying HIV-
positive people to meet national prevention goals and the national ARV/HIV care scale-up goals. HCT
services will target most at risk persons to maximize this impact. The activity will support the FMOH and EP
goal of having high quality HIV testing available at all sites.
This activity is linked to care and support, OVC, ARV services, condoms & other prevention, AB, lab and SI.
PwP counseling and a prevention care package will be integrated with post-test counseling for HIV+
persons. Access to care services and ARV services will be provided. Other at risk family members including
vulnerable children will be identified through community based HCT approaches and referred to services. In
appropriate settings, testing will be carried out by counselors with training and oversight by ACTION
laboratory staff. HCT sites are incorporated into the laboratory QA program to ensure that HIV testing is of
high quality.
This activity serves youth and adults with special focus on MARPs, including commercial sex workers,
discordant couples, mobile populations, partners/clients of commercial sex workers and those who abuse
alcohol and other substances. Training will be targeted to health care workers, counselors and community
volunteers.
An emphasis for this activity is human capacity development as nearly all supported personnel are technical
experts who focus on this at the central and site level. Other areas of emphasis include local organization
capacity building and SI. This activity addresses the issue of stigma and discrimination since HIV
counseling reduces stigma associated with HIV status through education.
Continuing Activity: 13113
13113 5426.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $1,705,000
6772 5426.07 HHS/Centers for University of 4184 632.07 Cooperative $2,495,383
5426 5426.06 HHS/Centers for University of 2778 632.06 UTAP $682,150
Estimated amount of funding that is planned for Human Capacity Development $30,000
Program Budget Code: 15 - HTXD ARV Drugs
Total Planned Funding for Program Budget Code: $104,371,905
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
In COP 09, $103,802,106 will be allocated for antiretroviral (ARV) drugs and disbursed among 14 implementing partners (IPs)
providing ARV treatment to 300,000 patients in Nigeria. These partners are: Catholic Relief Services (CRS)/AIDS Relief;
Columbia University (CU)/ICAP; Harvard School of Public Health; APIN Ltd.; Family Health International (FHI)/GHAIN;
Management Sciences for Health (MSH/LMS); University of Maryland, Institute of Human Virology (IHV)/ACTION; Department of
Defense (DOD); University Research Company (URC); Vanderbilt University; Partners for Development; CHAN; AIDSTAR;
NEPWHAN
The extended USG lead Logistics Technical Working Group (Log TWG) will continue coordinating the activities of these partners.
USG Nigeria's long-term goal is to support a sustainable supply chain management system for antiretroviral treatment (ART) that
incorporates and bolsters existing Nigerian institutional structures and is harmonized with Government of Nigeria (GON) activities.
In keeping with the PEPFAR Nigeria strategy, COP 09 will focus on the following tasks: 1) providing an uninterrupted supply of
ARVs to patients; 2) consolidate acquisition and leverage volume purchasing through SCMS; 3)participate in product selection,
forecasting, procurement, warehousing and distribution, and vital data collection from the field; 4) move toward generic
formulations; 5) leveraging resources from other stakeholders; 6) creating a single harmonized nation-wide logistics system; and
7) developing viable solutions for expired ARV waste disposal.
In COP09, PEPFAR Nigeria will continue its efforts to provide an uninterrupted supply of quality ARVs to patients across the
country. Partners' clinical teams, together with other stakeholders from the HIV/AIDS clinical community participated in a country-
wide development of Standard Treatment Guidelines (STG). The 2007 STG was recently printed and widely distributed among
existing and new partners. The new STG plays a crucial role in product selection for new and existing partners. Partners also
select only Federal Drug Administration (FDA) approved or FDA tentatively approved drugs.
In August 2008, PEPFAR Nigeria conducted a forecasting exercise with all IPs. The exercise was facilitated by the Supply Chain
Management Systems (SCMS)/Nigeria office. The purpose of the exercise was to establish requirements for ARV drugs for
COP09. Most partners were able to come up with their own projections, which were cross-checked with forecasts from SCMS.
The result of the forecast was captured in budget distributions among partners during COP planning.
All partners must procure drugs in line with STG, FDA and National Agency for Food and Drug Administration and Control
(NAFDAC) regulations. If an FDA approved drug is required by a partner and not yet approved by NAFDAC, the USG Logistics
Team will request a NAFDAC waiver for the product. A waiver is compiled yearly and on behalf of all the treatment partners.
In COP09, partners will continue utilizing their existing procurement mechanisms. Partner procurements of ARV drugs are
managed by SCMS, AXIOS, IDA Foundation, UNICEF, AIDS Relief, as well as corresponding university mechanisms, such as
University of Maryland or Harvard. SCMS Nigeria has taken on an increasing role in partner procurements. In line with OGAC
guidelines, SCMS will be pooling procurement for two ARV commodity lines on behalf of all the partners; Truvada and ZDV-3TC-
NVP Fixed Dose Combination. The "high cost, high volume" criterion was used in selecting the commodities. Funding for the
activity was taken off the top of all partners' budgets, based on their established needs during the forecasting exercise.
All ARV drugs and other HIV/AIDS related commodities are imported under diplomatic status. Port clearance administrative
requirements and duty waiver requests are managed by the US Embassy on behalf of PEPFAR Nigeria. A fast track mechanism
for perishables has been put in place to ensure timely clearance of corresponding commodities. Several registered customs
agents clear products on behalf of IPs. However, as more partners come on board, a need for an alternative mechanism will be
inevitable. The USG Logistics TWG is working on the request for a PEPFAR managed duty waiver, which will lessen the work
load for the US embassy, save costs, and speed up the pre-clearance approval process.
To date, warehousing and distribution are specific to each IP. As part of the harmonization efforts, shared facilities and channels
have been explored within PEPFAR and with the GON. Many partners maintain their regional warehouses in addition to state and
zonal stores. This practice has ensured continuous knowledge sharing between pharmacists and logistics managers. Every
partner has a mechanism in place to support optimal stock management; however, there is a limit to the logistics information that
travels back to the donor level.
Limited access to logistics information will be addressed in the upcoming year by increased emphasis on central level reporting of
logistics data. The Logistics TWG is creating a per-IP ARV report, which will allow the USG team to assess stock balance of IPs
and provide an early warning for signs of inappropriate logistics management. This will prevent unnecessary expiries by trading
stock among the various IPs and facilitate cross collaboration among IPs in terms of commodity utilization (e.g., loans, exchange,
etc). Monitoring indicators of the supply chain systems will also be rolled out in the next year. These indicators will assess the
viability and sustainability of various logistics networks and will give USG management in country a tool to access partners'
performance in the supply chain process.
In 2007, 63% of drugs purchased were generics while the rest were branded (this is an increase since 2005). Lower cost generic
ARV drugs are and will continue to be procured in place of their equivalent branded versions as soon as they have received FDA
approval or tentative approval and a waiver has been granted for importation and use from NAFDAC.
USG Nigeria leverages resources from the Global Fund for AID, Tuberculosis, and Malaria (GFATM) and GON to supply some
first line ARVs to hybrid sites in several states. This collaboration has an ad hoc nature and is not orchestrated from higher levels.
Frequent personnel changes within the Federal Ministry of Health (FMoH) make harmonization efforts more difficult. However
PEPFAR/Nigeria is resolved to staying the course towards a single centralized drug logistics system for ARVs. The Clinton
Foundation is also partnering with the USG and the GON National Program to provide second line adult regimens and pediatric
formulations, including fixed dose combinations for IPs. USG and partners still budget for first line, second line and pediatrics
formulations for both new and maintenance patients. Should some of the drugs come from GON, GFATM or the Clinton
foundation, additional targets will be reached or more funds will be available for system strengthening activities.
The USG will increase its coordination and collaboration with the GON to develop shared logistics management tools, processes,
structures, guidelines, standard operating procedures (SOPs), training curricula, and assessment tools. In that regard, all
treatment IPs will coordinate with policy and system strengthening as well as strategic information (SI) activities under PEPFAR
and with the GON to ensure the development of a sustainable national logistics system. USG and IPs will continue to participate
in and support the harmonization process for procurements led by the GON. In COP08, members of the extended Logistics TWG
as well as colleagues from the IP community sat in on various harmonization committees chaired by the GON. Several systems
strengthening exercises conducted by SCMS have helped create a more sustainable GON distribution network operating from the
Central Medical Store in Lagos. SCMS / JSI logistics training helped bring the concept of logistics management to key
government colleagues in various divisions of the Federal Ministry of Health.
As the program matures, more effort needs to be placed on developing viable solutions for ARV waste disposal. As per guidance
from OGAC, partners are encouraged to think of expenses associated with proper waste management of expired ARVs. In
COP09, the USG Logistics TWG and the Prevention TWG will continue advocating for approval of the National Health Care
Management Plan developed by several key stakeholders in 2007. In the mean time we will map out a network of existing
incinerators in Nigeria and create partnerships with these waste management facilities for PEPFAR partners to use.
In COP09, the Logistics TWG will continue managing in-country distribution by coordinating forecasting exercises, monitoring
partners' pipelines on ARV spending, receiving logistics management information system (LMIS) reports from the partners on
ARV consumption and stock balance, and receiving information on logistics indicators, as well as continue facilitating cross-
partner collaboration. We will continue working closely with the Government of Nigeria on harmonization efforts. We will also
spend considerable effort on centralizing forecasting, procurement and overseeing functions in the hands of USG management
team. Strong oversight on ARV spending and compliance with various guidelines are top priorities for the group. The team will
also continue disseminating news and ensuring proper adherence to various guidelines. We will visit partners' warehouses,
depots and sites to better understand issues and challenges they face every day. As a cross agency group we will continue
working with each and every partner on issues and challenges they may have.
Table 3.3.15:
If continuing, paste your COP08 narrative here and put one of the following at the beginning of your
narrative:
ACTIVITY UNCHANGED FROM FY2008
No change except for targets.
In COP09 ARV drugs will be procured so that ARV treatment can be provided to 70,953 adults (7,953 new)
and 8,000 children (2,450 new) at 110 clinical sites in 23 states in Nigeria. Sites are located in states
chosen consistent with the National ARV Scale-Up Plan with the goal of universal access and include: Akwa
Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano,
Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, and Sokoto. This support is an
increase from the 78 ARV treatment sites supported under COP08.
The first component of this activity includes forecasting and procurement of ARV drugs. As part of the
COP09 budgeting process, a forecast was jointly carried out by ACTION and SCMS and utilized to project
COP09 ARV requirements. It is estimated that 90% of patients begun on EP-provided ARVs will be adults
and the remaining 10% will be children. Patients on ARVs include those started on ARVs in prior years,
patients in care who roll over into treatment, and newly diagnosed patients needing ART. Overall, it is
assumed that 5% of both adults and children begun on ARVs during prior years will ultimately require
second line treatment under COP09. Forecasting and pipeline is reviewed and adjusted if necessary
monthly based upon site level consumption data provided by Axios.
ACTION will follow the National Treatment Guidelines in the provision of ARV regimens for adults and
children. The regimen mix has been forecasted based on current utilization and balancing best clinical
evidence with scalability. The present preferred first line adult regimen is zidovudine/lamivudine/NNRTI with
the alternative regimen tenofovir/emtricitabine/NNRTI with stavudine rarely employed. PEPFAR and FDA-
approved generic formulations will be utilized whenever available ,and we anticipate 70% of the budget will
be utilized to purchase generics . For all regimens, a four-month buffer stock is maintained to minimize the
likelihood of problems with drug supplies. ACTION staff develop ARV projections, and plan procurements
accordingly. In COP09 all purchases of Truvada (TDF/FTC) and ZDV-3TC-NVP Fixed Dose will be
purchased via SCMS pooled procurement mechanism, in line with OGAC's recommendation.. A standing
open purchase order for up to 50% has also been established with IDA Foundation as a backup. Based on
current drug unit costs, an additional 14% for procurement and Insurance/ shipping has been added to the
budget for IDA Foundation. Both SCMS and IDA inspect drugs for authenticity and test selected batches
prior to accepting for shipping. SCMS and IDA certify packaging and storage conditions during shipping and
provide insurance to the point of delivery at the frontier. Drug procurement will follow USG regulations, FDA
and National Treatment Guidelines, as well as comply with requirements for NAFDAC registration or waiver.
Although collaboration with the FMOH may facilitate some sites being provided with first line ARV
formulations through Global Fund or GON support, the full cost of ARV drugs required to care for new and
maintenance ARV patients has been budgeted in the COP at this time. Should FMOH be able to provide
first line ARV formulations, targets will be adjusted accordingly, and ACTION will ensure access to
alternative first line and second line ARVs, pediatric formulations, and wrap around services including lab
monitoring. Similarly, IHVN will continue leveraging resources with other stakeholders such as the Clinton
Foundation. In that case, a similar procedure will be followed. Coordination with the FMOH to plan site
targets will ensure a single comprehensive HIV care program although there may be multiple ARV sources.
The key principle adopted by ACTION is that all patients receive equal high quality clinical, laboratory, and
community services regardless of the drug source.
The second component of this activity includes expediting commodities through the port of entry, followed
by storage, distribution, and management of the commodities. This includes site assessment of pharmacies
and storage facilities with corrective recommendations and actions. Needed site renovations for proper
security and storage conditions in pharmacy stores will be undertaken by ACTION. Training of site
pharmacists for drug commodity management using a computer or card-based inventory control system at
the site level and training in proper drug storage will be carried out. Storage and distribution of ARVs,
maintenance of a site level commodities management system, and instruction to site staff regarding the
system, has been subcontracted to the Axios Foundation. Axios documents proper storage conditions at the
central warehouse, regional warehouse, and site levels. With an expansion of ARV access to community
venues including mobile clinics, local health centers, DOTS centers, and community pharmacies, logistical
management of ART drugs will require increasingly resource intensive logistical and technical support due
to geographic spread. The success of such approaches is vital to increasing adherence and avoiding
patient default which program evaluations have shown is often linked to distance traveled from home to the
ARV center.
Quality control involves routine monitoring visits by ACTION staff from the central Abuja office or from
regional offices to all sites every six months to review the implementation of SOPs and to compare reported
usage based on monitoring and evaluation data with local manifests and pharmacy logs. The ACTION
training department analyzes data for patterns of deficiencies as well as individual site deficiencies in order
to improve training and target weaknesses to address through retraining.
This activity supports the scale up of ARV treatment in Nigeria, a major priority for the FMOH. Through
these activities, ACTION will continue to strengthen the structure of its ART drug procurement system, in
accordance with PEPFAR goals in order to ensure cost effective and accountable mechanisms for drug
procurement and distribution. Furthermore, efforts to build local capacity through infrastructure
improvements such as pharmacy and drug storage facility renovations and training mechanisms are
consistent with PEPFAR 5-year goals to enhance the capacity of supply chain management systems to
respond to rapid treatment scale-up. Additionally, through procurement via SCMS, ACTION seeks to
provide support to USG efforts to build capacity related to drug procurement and distribution in Nigeria. This
Activity Narrative: activity also supports the ARV program for adults and children as well as the PMTCT program for provision
of ARVs to pregnant women and infants..
This activity relates to activities in TB/HIV (3254.08), ART services (3255.08), and strategic information
(3253.08). This activity will maintain significant linkages with PMTCT (3257.08) and ART services through
the procurement of ARV drugs for individuals served by these programs. Additionally, linkages to TB/HIV
activities will be developed and maintained. The supply chain management system will serve to provide
drugs to ART sites that are providing TB services in conjunction with ART services. SI activities will provide
crucial information for M&E as well as efficacy of the drug regimens, which may impact drug procurement
decision-making.
The primary targets of these activities are health care workers, including program managers doctors,
nurses, and pharmacists who are involved in the drug procurement and distribution process. Furthermore,
by building mechanisms for drug procurement, these activities seek to target PLWHA, both adults and
children, who are in need of or already receiving ART care.
Human capacity development is an emphasis area. Training initiatives have been incorporated into these
activities in order to build the local human resource capacity to manage a sustainable drug procurement and
distribution system. Other areas of emphasis include the development of SI management, through M&E
activities, to provide feedback on the cost effectiveness of these drug procurement activities. SI
management also ensures accurate drug projections in order to prevent stock-outs.
Continuing Activity: 13114
13114 5429.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $11,406,128
6773 5429.07 HHS/Centers for University of 4184 632.07 Cooperative $19,850,000
5429 5429.06 HHS/Centers for University of 2778 632.06 UTAP $12,928,058
- Our ‘national' target of 98 labs with T-lymphocyte counting or CD4 capacity is presented. This target
includes Primary Health Care (PHC) level labs that have the capacity to carry out simple T-lymphocyte
counts, as is described in the narrative.
- TB diagnostics section updated to develop PCR technology to support HAINS assay as per USG request.
- One additional PCR lab proposed at Ile Ife, at the request of the Government Of Nigeria (GON).
- Accreditation of 9 IHVN labs by the local accreditation body.
- Biotech engineering step down training for site biotech engineers at selected sites, added as per USG
LTWG request.
ACTION will support ARV Services, Basic Care and Support (BC&S), OVC, TB/HIV, PMTCT, and HCT
programs by building lab infrastructure and training staff to accurately diagnose, stage and monitor patients.
ACTION will monitor laboratories through its QA/QC activities to ensure high quality results while upgrading
the infrastructure at new sites. A minimum of 792,690 lab tests will be performed in COP09. ACTION will
continue to be at the forefront of Early Infant Diagnosis (EID) by scaling up and expanding viral load testing
for adults and children based on an algorithm that is being evaluated with the Federal Ministry of Health
(FMOH).
ACTION will support lab services at 136 individual points of service using a network model to provide
appropriate lab capacity and patient support at comprehensive sites as well as HCT stand alone and DOTS
sites. An integrated, tiered referral lab network, with mentoring by trained lab personnel, has been
established at existing hub sites. This includes the use of appropriate technology at all service levels, using
the USG-PEPFAR Lab Technical Working Group equipment platform as a guide. At the tertiary, or large
secondary hospital level, 32 network reference (or hub) labs, provide high throughput hemogram, clinical
chemistry, and CD4 assessment services. Ten of these provide virology services and 1 of these provides
TB culture. At the secondary and comprehensive primary health center level, an additional 32 labs provide
patient monitoring and diagnostic capability including HIV rapid testing, hemogram, and CD4 count. At 34
other primary level sites, where ARV services will be provided, labs are equipped to provide HIV rapid
testing, hemogram (including lymphocyte count), and to collect/package samples for transport to a more
advanced lab in their network. Thus, a minimum of 84 labs with the capacity to perform HIV testing and T
lymphocyte counting or CD4 measurement will be supported with PEPFAR funds. IHVN's lab target to
reach for COP08 was 78 sites, and in COP09, it will be 84 lab sites. Thus, with the 98 labs IHVN has
established (32 tertiary, 32 secondary or primary, and 34 primary health clinics), IHVN has already achieved
its lab site targets for both COP08 and COP09.
A Bar-coding system will be used to improve tracking, reduce transcriptional errors and reduce turn around
time. This is in addition to scaling up the interface of Cyflow and Sysmex machines used for CD4 and
Haematology measurements, respectively with the Careware system, so that transcriptional errors are
further minimized. Novel approaches for access to lab services, such as five mobile laboratories on HCT
vans, will be piloted to provide high quality on-site lab services to small PHC sites. Services at HCT stand
alone, and TB DOTS points of service, are limited to HIV rapid testing. This approach facilitates the rapid
scale up of ART services at all tiers of health care facilities.
ACTION has 1 Senior Technical Advisor, 2 U.S based QA consultants and 35 local lab program staff
assigned to six units (Field Operations and Commodities, Special labs, QA/QC, TB, Training and
Maintenance) and five regional offices. ACTION has an aggressive QA/QC program with specially trained
lab staff dedicated to carrying out on-site quarterly monitoring, retraining, and overseeing a proficiency
panel testing program. QA monitoring is carried out jointly with the FMOH, or SMOH responsible for the
point of service, using the newly developed lab QA monitoring tools for PMTCT and HCT, communication
log and incident report forms for Regional, Central and Baltimore offices. Tools and expertise will continue
to be shared with other IPs, and with the GON, and technical support will be provided to the Medical Lab
Science Council of Nigeria (MLSCN). ACTION has expanded site lab capability to screen for Hepatitis B, to
diagnose additional OIs such as Cryptococcus, and screen for common STIs including syphilis.
TB BL3 culture capacity has been developed at ACTION's supported NTBLTC in Zaria using the Bactec
system. Due to the safety concerns for the microscopic observation drug susceptibility (MODS) assay by
CDC and WHO, ACTION will develop PCR capability at the NTBLTC and work with CDC Nigeria to pilot the
PCR based HAINS Assay, a molecular method for rapid diagnose of TB and INH/Rifampicin drug resistance
at Zaria and some selected PCR facilities. ACTION has already established the superiority of the LED
based microscopes on auramin stained direct sputum smears. For COP09, ACTION will roll out this
technology at its sites, DOTS centers within its sites, and mobile labs following adequate training in the
technology at the NTBLTC Zaria. ACTION will also coordinate with Global Fund supported initiatives in the
roll out of TB culture capacity in Nigeria to maximize regional availability.
Nine regional virology laboratories in seven states (Sokoto, Kano, Plateau, FCT (two), Edo, Anambra,
Gombe, and Akwa Ibom) have been established by ACTION. Under COP09, two additional virology lab (at
the NTBLTC and at Osun state) will be developed for a total of eleven. Ten of these laboratories will focus
on EID regionally using the DBS collection method described under PMTCT while the eleventh at the
NTBLTC will focus on the development of the HAINS molecular technology for the detection of TB.
ACTION has played a key role in the EID roll out in COP07 and 08, utilizing the ACTION training and
reference lab at PLASVIREC to provide QA for the national EID pilot and providing training in proper DBS
collection and transport. All functional PCR labs supported by ACTION are participating in the CDC DBS
DNA PCR proficiency program. ACTION is actively collaborating with the Clinton Foundation (CF) and the
FMOH to develop EID SOPs and is carrying out testing of samples from sites that are geographically
proximate including those supported by other IPs, GON, and the Global Fund. The CF also supports
procurement of DNA test kits and DBS collection supplies and transport of specimens/results. In addition to
EID, virology labs carry out viral load for selected patients identified through a standard clinical algorithm.
Leveraging expertise in viral sequencing, ACTION will develop a HIV genotyping and drug resistance
testing facility in COP08 which will be readily accessible to the USG and other IPs and serve as a regional
Activity Narrative: resource for West Africa.
Four training laboratories have been developed as national resources by ACTION and placed zonally (FCT,
Kano, Edo, and Plateau States). These laboratories are each configured with a didactic and a lab bench
training venue with standard equipment utilized at EP sites for CD4 measurement, hemogram, and
chemistry as well as teaching microscopes. The training laboratories are staffed with a master lab trainer
and assistant, but utilize local site lab experts to serve as resource persons for specific trainings to promote
sustainability. The regional lab training centers will be used to train personnel from new sites and offer
refresher training guided by QA results to staff from existing sites. Centralized trainings will include: Good
Lab Practices (GLP), HIV diagnosis, pediatric diagnosis, viral load estimation, CD4 staging, hematology,
blood chemistry, record keeping and storage. This is followed up by refresher trainings carried out at sites.
566 lab staff will be trained. Training laboratories established by ACTION have been and will continue to be
utilized by the FMOH, public private partnerships, and other IPs for capacity development for national ARV
scale up, PMTCT, and TB priorities. These facilities will be used to train 536 scientists for ARV monitoring
and an additional 400 lab scientist from other organizations (not counted under IHVN training targets). The
National TB and Leprosy Training Centre in Zaria (Kaduna State) is supported by ACTION, and serves as a
fifth training lab supporting the National TB and Leprosy Control Programme. This facility and the regional
training laboratories will provide training for 500 TB DOTS staff (not counted under IHVN training targets).
ACTION will work with the USG and Medical Lab Scientist Council of Nigeria (MLSCN) as well as hospital
management and the FMOH/SMOH for the local accreditation of 9 laboratories by the MLSCN. Regional
labs and those critical to PHEs will be the first to be accredited. Through the PEPFAR lab working group
(LTWG) ACTION will work with the MLSCN, the Lab-CoAg, and the USG and FMOH to integrate its QA/QC
activity into a sustainable national QA program including a national EQA program. For procurement of lab
reagents ACTION will utilize SCMS and local vendors. ACTION maintains a warehouse and distribution
system in-country. To maintain lab equipment, ACTION has two biotech engineers on staff who provide
training, installation, routine preventive maintenance, trouble shooting and regular calibration. The
availability of spare parts and back up equipment at ACTION's warehouse in Abuja allows for prompt
response to site needs. Focusing on sustainability, ACTION will train 30 laboratory scientists from high
performing sites, and hospital biotech engineers at selected sites, in equipment maintenance and basic
trouble shooting. (This combined with training in ARV lab monitoring for 536 is a total direct training target of
566.) PEP is available at all ACTION supported labs. Waste management and disposal, including TA to
sites on procurement of a proper incinerator, is a key component of training and site activation.
Sites are located in states consistent with the National ARV Scale-Up Plan with the goal of universal access
to HIV services. They include: Akwa Ibom, Anambra, Bauchi, Benue, Cross River, Delta, Edo, FCT, Gombe,
Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto.
EID regional availability will strengthen PMTCT, OVC and ARV Services. Testing for OIs will strengthen
BC&S. Regional training and Virology laboratories established by ACTION will support other IPs,
particularly for PMTCT and ARV. ACTION will train lab personnel and healthcare providers from TB labs of
other IPs and FMOH DOT centers, strengthening both HCT and TB. Through Public Private Partnership,
private industry supported labs benefit from ACTION's training and QA/QC program. These activities will
provide essential lab services to people living with HIV/AIDS, HIV positive pregnant women, HIV positive
infants, and HIV positive children. The QA/QC program of ACTION will strengthen the overall quality
initiatives of the GON.
These activities will be linked to activities in PMTCT, OVC, ARV Services, Blood safety and SI. Tests for
opportunistic infections and training in theses techniques will strengthen BC&S, HCT, and HIV/TB. ACTION
will collaborate with the Clinton Foundation in EID and pediatric ARV scale up.
These activities will provide essential lab services to people living with HIV/AIDS with or without co-infection
with TB, HIV pregnant women, HIV- infants, and HIV children. Lab workers will benefit from the Lab Training
centers and developed SOPs and training curriculum. As part of a Public Private Partnership, industrial
health care providers will benefit from ACTION's training and QA/QC program.
An emphasis for this activity is human capacity development for sustainability through in-service training,
supportive supervision and quality assurance/improvement for laboratorians. Also emphasized is
infrastructure development through lab renovations for new sites, local organizational capacity building, and
strategic information.
Continuing Activity: 13116
13116 3256.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $10,375,092
6767 3256.07 HHS/Centers for University of 4184 632.07 Cooperative $4,565,000
3256 3256.06 HHS/Centers for University of 2778 632.06 UTAP $2,480,250
Estimated amount of funding that is planned for Human Capacity Development $506,600
Program Budget Code: 17 - HVSI Strategic Information
Total Planned Funding for Program Budget Code: $16,969,902
The top priority of Strategic Information (SI) remains the establishment of a unified national monitoring and evaluation (M&E)
framework with harmonized measurement and reporting activities across partners for timely strategic data for evidence-based
policy and program decisions. The USG SI unit works closely with PEPFAR implementing partners (IPs), the National Agency for
the Control of AIDS (NACA), the HIV/AIDS division of the Federal Ministry of Health (FMoH), and other stakeholders to: 1) build
M&E capacity at national and state levels; 2) institute measures for quality assurance and improvement; 3) promote data
utilization toward evidence-based decision making; 4) evaluate intervention efforts; 5) respond to donor and country reporting
requirements; and 6) better understand the epidemic in Nigeria through surveys and surveillance.
In COP09, SI will play a critical role in leading the shift in monitoring and reporting to reflect PEPFAR II emphasis areas, new 5-
year targets, and the new indicators. Nigeria's SI team is actively participating in the review of PEPFAR next generation indicators
and will oversee a smooth transition into PEPFAR II data collection and reporting among IPs in coordination with Government of
Nigeria (GoN) and other donors.
A National M&E Technical Working Group (NTWG) facilitated by NACA provides national coordination for SI in Nigeria. USG SI
provides sustained engagement in support of country surveillance, health management information system (HMIS), and M&E
systems through active participation and co-leadership on NTWG sub-committees. In COP09, ongoing support in the further
development and utilization of the National M&E Plan and the Nigeria National Response Information Management System
(NNRIMS) will include assistance and harmonization of the new PEPFAR II indicators with GoN reporting requirements. A new
initiative in FY09 will assist NACA in establishing a committee to coordinate public health evaluations.
Functioning of SI Team within the Country Team
The PEPFAR/Nigeria SI team has grown to meet the SI needs of PEPFAR/Nigeria and the USG agencies involved in the
response. Staffing expertise includes program M&E, HMIS, research (including public health evaluations [PHEs]), survey and
surveillance, and specialized skills in mapping, modeling, and strategic planning. The SI Team is organized around specific task
groups: HMIS; M&E; data and service quality assessment; research & evaluation; and surveys/surveillance. Beginning in COP09,
SI will focus on key questions in the SI paradigm, specifically:
1.What is the nature of the epidemic; prevalence, incidence, ART eligibility, number of OVC, and mortality rates and trends?
2.What specific risk behaviors are correlated with transmission among specific populations?
3.What HIV services are currently available to provide prevention, care and treatment services in an integrated, decentralized
manner?
4.Is the range of services, their geographic distribution and access reaching potential HIV+ clients within reasonable costs per
target?
5.Are priority groups (pregnant women, infants and children, MARPS) receiving the services they need?
6.Are networks of services effective in providing a continuum of comprehensive care?
7.Are data collection tools and HMIS providing sufficient, quality information required by program managers for reporting and
decision-making?
In addition to providing timely and accurate information from routine reporting, SI also provides technical support to program
evaluations, PHEs, surveillance, and population- or community-based surveys, such as the Nigeria Demographic and Health
Survey (NDHS), Integrated Bio-Behavioral Surveillance Survey (IBBSS), and National AIDS and Reproductive Health Survey
(NARHS) as evidence for effective program and policy decision making by the USG PEPFAR team, and by extension, the GoN
and HIV stakeholders. In COP09, this will include geographic mapping and disease modeling. With COP08 funding, SI is leading
a data triangulation exercise toward improved programming and targeting in the sexual transmission prevention portfolio.
SI contributes technical guidance to COP target setting and monitoring of progress toward annual and 5-year targets, and leads
the development of tasks and timelines for the COP submission and review process. Currently a database in ACCESS and its
mirror in Excel are utilized to track PEPFAR-supported IP targets. Data are utilized for a variety of reporting, planning, targeting,
and quality improvement, in coordination with program area technical working groups. The data base plays a crucial role in
country operational plan (COP) target setting as well as SAPR and APR reporting. In addition, an M&E report on key indicators
will soon be provided to USG Senior Management on a monthly basis.
USG also supports the GoN in the development of guidelines, protocols, and standards of practice in service delivery and quality.
In COP09, HIVQual will continue to expand with a long term goal of implementation in the more than 250 treatment sites. USG SI
will develop measurement tools for compliance with standards and provide quality assessments in all program areas to ensure
adherence to standards of quality
Overarching SI System
SI works closely with GoN to build capacity for a trained workforce in all areas of strategic information. Federal and state-level
M&E officer training is supported through the MEASURE Evaluation mechanism, and PEPFAR support to IPs provides training in
M&E and HMIS. Both the ANC surveillance and Project SEARCH data triangulation (to take place in calendar year 2009) activities
include an explicit component for capacity building of GoN. In COP09, 895 local organizations will receive TA and 2,544
individuals will be trained in SI.
The coordination of SI functions and activities between various stakeholders is achieved through a variety of mechanisms,
including the NTWG as mentioned above, and USG SI participation and engagement with GoN, IPs, and other donors (such as
UNAIDS, World Bank, DFID, Global Fund and others) in policy and standards development, survey and surveillance activities,
and strategy development workshops.
Surveillance and Surveys
Several major survey results will be used to update the EPP (Estimates and Projections Package) Spectrum Ten Year
Prevalence/ Incidence Estimates document; a cornerstone of "Knowing Your Epidemic." Results of the 2007 NARHS, which
included sero-prevalence data, are expected in the last quarter of 2008. The NDHS is currently in the field and official results are
anticipated in 2010. ANC survey 2008 data collection has just been completed, with data analysis and report writing underway.
Results are anticipated by the end of 2008 or in the first quarter of 2009. Incidence testing will be conducted for the first time on
ANC 2008 specimens. Trends in new cases will be available from the ANC 2010 survey. The results of these survey activities will
be utilized along with the results of the 2007 IBBSS, which focused on most at risk populations and included linked sero-
prevalence data, to inform a GoN-led socio-economic impact study to be carried out in 2009 (with technical input provided by USG
SI Team members). The second round of IBBSS will be conducted in 2009. A recent service provision assessment (SPA) of
public health delivery sites was completed with PEPFAR support (a final report is anticipated before the end of 2008) and a SPA
of private facilities will be carried out in 2009 with COP08 funds.
HIV drug resistance threshold survey activities will commence in the final quarter of 2008, with finalization of the protocol. The first
phase of a pilot study on HIVdrug resistance prevention monitoring among patients on first line ARV drug has been completed.
This surveillance activity will be scaling up in 2009 with COP09 funding. In addition, a TB multiple drug resistance survey,
designed to detect levels of resistance to anti-TB drugs and funded under TB/HIV will be completed in 2009. This study will
complement the TB prevalence survey anticipated in 2009.
Understanding the HIV Epidemic and the Health Care System in Nigeria
The USG intends to support the mapping of service delivery points (SDPs) and begin the development of a fully populated
geographical information system (GIS) relational database for in-depth analysis of the nature and trends of the epidemic in
Nigeria. A necessary first step is to identify tasks and associated costs for the geo-coding of available data and migration to a
robust GIS software. In COP09, USG SI will engage Health Systems 20/20 to identify available GIS data (including data from their
human resources for health [HRH] assessments at private and public facilities, as well as available shape files), compatibility, and
information gaps. Health Systems 20/20 plans to work in collaboration with one or two research institutes—African Health Project,
Zaria Training Institute, or the Nigeria Institute for Social and Economic Research (NISER), or possibly Harvard's APIN project—to
build local capacities in the use of GIS software. Existing data will be used to generate maps coupled with HIV/AIDS
epidemiological data and HRH data to show the distribution of human resources available to deliver HIV services in each area.
HS20/20 activities do not overlap with the GIS development support provided by Voxiva, but rather complement Voxiva Task 4
activities. A desktop survey of current literature will be conducted to gather information on male circumcision practice in Nigeria
including geographic distribution, prevalence, characteristics of circumcised males and trends. An evaluation of the Adult ART
Services program will be conducted in 2009 to determine the quality and outcomes of HIV care and treatment. With the
information gained through such survey activities, SI will be able to better address the key questions in the SI paradigm.
Several multi-country PHEs planned for COP08 and COP09 are pending. Public health evaluation questions Nigeria plans to
address include: effectiveness of interventions to reduce early mortality among adults initiating ART; optimizing PMTCT and early
infant diagnosis effectiveness; the impact of task shifting for ART delivery; and the impact of PEPFAR programming on the
broader health system.
Health Management Information Systems
With USG support, the GoN has developed consensus around core indicators and common tools for patient monitoring and
management (PMM). USG SI continues to work closely with IPs, NACA and FMoH to ensure availability of standard registers and
NNRIMS forms at PEPFAR-supported sites and promote their availability and correct use at all SDPs. USG SI supports the
harmonization of the HIV/AIDS HMIS that currently utilizes the PEPFAR-supported Voxiva logistics and health program
management information platform (LHPMIP) and the National district health information system (NDHIS) platform. A strategy to
incorporate the HIV/AIDS HMIS into the broader national health information is under discussion. To this end, an assessment of
current PMM tools and HMIS utilized by PEPFAR IPs was conducted. An initial roll-out of Voxiva/LHPMIP has been completed in
6 states (including the FCT). With its web portal, pc offline, and phone-based user access for data input and reporting, retrieval,
and mapping functionalities, this system has the capacity to handle real-time HMIS data reporting. In the next two years, full
utilization of LHPMIP and harmonization with NDHIS is anticipated at state and Local Government Area (LGA) levels to improve
national, state, and local capacity to utilize data reported through this system.
The incorporation of community services, such as home-based care and support to OVC into the HMIS platform is lagging. USG
SI is working with PEPFAR OVC and Adult/Pediatric Care and Support TWGs and engaging corresponding National technical
working groups to identify specific information needs while targeting the improvement of field-based monitoring tools for OVC and
home-based care. A data flow plan and timeline (to include reporting and feedback), from community to LGA and/or state and
federal level will be developed in collaboration with IPs. Data quality improvement efforts are ongoing with IPs involved in
community-based interventions. Specific guidance and mentoring efforts will be directed at improving quality and integrity of data
through improved data collection tools and harmonization of the process. Recent data quality assessment (DQA) visits have
highlight the need to develop appropriate, standardized tools across IPs engaged in community-level programs, especially in OVC
and palliative care. In COP09, SI will prioritize community-based M&E systems development and linkages with facility-based
reporting; again, an emphasis area will be in palliative care, an area of need highlighted in recent DQA visits.
Monitoring and Evaluation
Three major SI challenges addressed in COP08 and in COP09 are: inconsistent data quality resulting from low M&E capacity at
the state level and SDPs; limited utilization of data; and lack of an M&E culture at all levels. In addition to the DQA/I plan
described, COP09 will continue training and mentoring in data demand and information use (DDIU) undertaken with COP08
funds.
SI evaluates IP performance according to achievements versus targets, given the budget and historical costs-per-achievement
recorded, and other factors, such as local prevalence rates. With COP09 support, IPs are expected to strengthen M&E systems
toward improved tracking across the prevention-care-treatment continuum. As part of USG SI's SI systems strengthening and
human capacity development, new SI indicators are currently under development and will be raised in Global SI discussions.
Additionally, CDC SI is piloting a monthly bulletin with selected IPs who currently report on a monthly basis. A revised monthly
data collection tool has been under development by USG SI and with the engagement of program area TWGs toward developing
a more robust reporting tool that goes beyond standard annual and semi-annual PEPFAR reporting. This information will meet the
expectations set out in the key questions of the SI paradigm.
Table 3.3.17:
Number of organizations assisted updated.
References to PHEs removed.
Technical assistance to states on Monitoring and Evaluation
ACTION will strengthen Strategic Information (SI) under the "One M&E Framework" by supporting the
implementation of standardized HIV program reporting within the National Health Management Information
System. In COP08, ACTION supported SI activities in 151 sites in 23 states (Akwa Ibom, Anambra, Bauchi,
Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos,
Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto). In COP09, it is expected that ACTION will support SI
activities in 168 sites in 23 states, including 110 comprehensive sites, 26 PMTCT sites, , and 32 Community
NGO providers of OVC or C&S services. 369 individuals to be trained in Strategic Information.
Action will support effective use of paper-based and electronic-based data collection and management
systems in clinical, laboratory, and pharmacy settings to enhance the assessment, enrollment, follow-up,
and referral/linkages to other services (e.g. TB, STI, home-based care, etc.) for all clients in HIV care.
National registers and data collection tools will be used at all service delivery points. Funds will be used to
provide information technology (IT) infrastructure and CAREWare at ART sites with capacity for automation.
For ART sites where there is other donor support, data collection and indicator reporting will be harmonized
and one reporting system will be used in accordance with the national guidelines and indicators. Data
collected through facility-based and community-based services will be used to make evidence-based
decisions for program quality, impact, and effectiveness. A goal of this activity is to better integrate the
outputs of SI data into clinically relevant reports that will facilitate patient management and encourage
improved data recording by clinical staff. A comprehensive quality management system will be implemented
in addition to HIVQUAL to enable continuous quality improvement across all program areas. This will
provide readily available quality metrics and individual patient data to site staff which will enhance site staff
investment in the M&E process.
To this end, the ACTION SI team has worked with HRSA to facilitate direct download of laboratory data
electronically from laboratory equipment rather than depending on manual data entry of electronic
information. This was implemented in COP08 at selected sites. Reports that record serial laboratory data in
tabular or graphic form will strengthen patient care practice by streamlining data reporting in a user friendly
fashion. Additional means of developing site-based tools to promote accurate laboratory data reporting to
support patient care and treatment is vital to Quality Improvement (QI) and where possible clinical data to
support patient care at the site such as direct download from lab equipment to CAREWare and other
measures to eliminate transcription errors will be emphasized. This data will also be employed to monitor
loss to follow-up, treatment adherence and other key metrics of clinical quality that will guide improved
assessment, training, retraining and help define best practices and strategies.
ACTION conducts quarterly data analysis meetings at each supported site to ensure data quality and
provide recommendations for improvements. On-site TA with more frequent follow-up monitoring visits will
be provided to address weaknesses when identified during routine visits. Randomly selected individual
patient records will be reviewed across tools as one method of assessing accuracy. Data quality
improvements at the local level supported by ACTION will ensure accurate data provision to the Nigerian
National AIDS surveillance and information system as well as state and local governments.
Since 2000, with support from CDC, ACTION assisted the Federal Ministry of Health (FMOH) in developing
and implementing the National PMTCT Monitoring Information System (PMTCT MIS) in Nigeria. ACTION
will continue to technically support the GON as needed in software maintenance of the national system and
will continue to work with GON on a mechanism to align the PMTCT MIS and Patient Monitoring and
Management (PMM) systems effectively to improve follow-up and continued care for HIV-infected women
and their exposed infants. ACTION is also supporting implementation of the National EID data base in
support of the national scale up of EID.
In addition, ACTION facilitates the provision of site level data to State Action Committees on AIDS (SACA)
and State Ministries of Health (SMOH) for state level surveillance activities. ACTION is engaged in
providing TA to the SACAs and SMOHs in the implementation of the Nigerian National M&E System
(NNRIMS). SACA and SMOH staff are invited to every SI training activity supported by ACTION that takes
place within their states. TA through joint field monitoring visits will also be explored. Each ACTION state
level point of service has a representative to the SACA. State level data for the NNRIMS is reported by the
SACA to the National Agency for the Control of AIDS on AIDS (NACA). In addition to state level support,
ACTION SI staff collaborate on a regular basis with NACA and National AIDS/STD Control Program
(NASCP) on development and review of National data collection tools and guidelines. It is anticipated that
the USG-supported VOXIVA system will complement the NNRIMS when the VOXIVA web-portal becomes
operational. ACTION is working in collaboration with the USG and GON in the implementation and piloting
of the Logistics and Health Program Management Information Portal (LHPMIP) using this Voxiva
technology. ACTION will support the implementation of this system at appropriate points of service.
Additionally, ACTION will ensure the reproduction and distribution of NNRIMS and patient registries at
supported sites. The SI team will continue to be active participants on the SI working group established and
coordinated by USG-Nigeria. Action will also provide technical assistance to state governments to enhance
SI activities at the state levels.
ACTION program staff will provide training to 369 individuals in monitoring and evaluation (M&E),
surveillance, and HMIS. A special focus will be placed on building the capacity of state level SI staff
(SACAs/SMOH) and Medical Records staff at the site level to support sustainability. Trainees will include
record clerks, M&E officers, clinicians, pharmacists, nurses, laboratorians, NGO staff/counselors.
Emergency Plan (EP) funding will be used to train health care providers and medical data personnel on
data collection, data use and reporting. Site level M&E staffs are hired through the hospital or health center
personnel system. While sites are asked to provide for M&E staffing, temporary staffing support is available
Activity Narrative: to new sites that must agree at program initiation to list these staff in the budget request for the institution
for the next fiscal year. Dedicated M&E program staff are posted at ACTION regional offices to implement
site data quality control/quality assurance activities. In addition, program staff are based at larger treatment
sites to ensure accuracy and completeness of PMM data. In COP08, ACTION hired additional SI program
assistants to facilitate development and refinement of M&E materials and provide support in the
development and establishment of a systematic procedure for patient monitoring and evaluation including
collecting, collating and reporting data tracked by the ACTION Nigeria program.
CONTRIBUTIONS TO OVERALL PROGRAM AREA
Strengthening SI will enable timely, transparent, and quality data reporting of substantial portions of 2009
EP targets for Nigeria and will, through collaboration with the GON, establish one standardized system to
monitor the National HIV program.
Of interest is evaluating barriers to care and access to care for HIV positives identified and referred through
HCT. ACTION will work to promote effective use of patient data by care providers to ensure best practices
of HIV care. These activities will contribute a more strategic use of information at all levels. This activity also
contributes to Nigeria's 5-Year National Strategic Framework's (2005-2009) emphases on documenting
best practices on ART, HCT, PMTCT, OVC, etc., on information linkages between sites and services, on
one standardized reporting framework, and on program evaluations through increased involvement of local
evaluation officers.
SI activities are cross-cutting and relate PMTCT, blood safety, AB, condoms and other prevention, basic
care and support, TB/HIV, OVC ARV services, and lab. Linkages between these program activities will be
strengthened to improve efficiency and effectiveness of services in order to catalyze the formation of
networks of care.
This activity targets health care providers in best practices of information use and reporting. Provision of TA
targets host country government workers. HMIS and program evaluations target the general population and
people affected by HIV/AIDS receiving services supported by the ACTION Project.
This activity includes an emphasis on human capacity development and SI.
Continuing Activity: 13117
13117 3253.08 HHS/Centers for University of 6394 632.08 HHS/CDC Track $2,760,000
6764 3253.07 HHS/Centers for University of 4184 632.07 Cooperative $1,450,000
3253 3253.06 HHS/Centers for University of 2778 632.06 UTAP $1,015,000
Estimated amount of funding that is planned for Human Capacity Development $32,000
FY08 CollaborativeNigeriaNG.08.0205Multi-countryHRHImpact of Task Shifting Type II for ART Delivery on
Patient and Process Outcomes in Emergency Plan Countries
Estimated amount of funding that is planned for Public Health Evaluation $469,931
Table 3.3.18:
ACTION will continue to support the efforts of the Nigerian FMOH and nursing and midwifery educational
sectors in strengthening the skills of nurses and midwives for the national response to the HIV/AIDS
epidemic in the country in line with the Health Sector National Strategic Framework for HIV/AIDS. Nurses
and midwives constitute the highest number of health care workers in Nigeria and spend the highest
number of hours with patients. However, there has not been a specific program to address the weak
nursing knowledge in HIV care that exists country wide. If adequately trained and empowered to utilize
learned skills, nurses could render more appropriate care for PLWHAs and contribute meaningfully to
mitigating the impact of HIV/AIDS as well as to sustaining the efforts supported by the Emergency Plan. As
the number of patients accessing ART services continues to increase without an exponential increase in the
number of doctors, especially in primary and secondary sites, doctors are overworked and patient access to
care is sub-optimal. With proper training, nurses can be utilized through task shifting to address the
personnel challenges faced by ART sites.
This activity is aimed at continuing to support a HIV care nurse training program at the practice and nursing
education levels to address the weaknesses that exist in the skill levels of nursing professionals in Nigeria in
a sustainable manner. This training will be tied in with an integrated care strategy being implemented at the
model HIV Clinical Training Clinic at University of Abuja Teaching Hospital at Gwagwalada. The care model
employs a care team strategy that upgrades the role of the nurse in care provision and case management
and frees the physician to address patient management challenges rather than focusing on onerous paper
work. A care team consisting of a physician, several nurses, adherence counselors, PLWHA treatment
support specialists and pharmacy staff work together to facilitate efficiency and quality of patient care. A
community liaison links the team and the patient to community-based services targeting improved treatment
access, adherence, nutrition, safe water, linkage to other services and home-base care. Evaluation of this
model and expanded training of other sites in an evidence-defined care model will help shape policy for
operationalizing the IMAI/IMC approach.
The standardized curriculum developed and piloted in COP07 & COP08 was crafted to focus on specific
skills sets and knowledge needs identified by the Nursing and Midwifery Council of Nigeria and Nigerian
nursing educators. The curriculum incorporates the FMOH/NACA adopted IMAI/IMCI approach to HIV/AIDS
care with emphasis on such nursing skills as: aseptic technique, injection safety, universal precautions,
nursing triage, nursing assessment, follow up of stable ARV patients with prescription re-authorization,
monitoring for ARV adverse effects and treatment efficacy, adherence/general counseling, and linkages
with community care and other services. In addition, HIV palliative care at facility and community levels are
emphasized including treatment of minor ailments (such as thrush, malaria, and diarrhea) using standing
orders developed and approved by supervising physicians based on IMAI/IMCI guidelines. Through the
training, nursing skills are enhanced to provide counseling for prevention, HCT, disclosure/partner
notification and other support services. As many of these skills are transferable, the ability of nurses to
manage and care for patients with other chronic disease conditions is enhanced.
In COP07/COP08, ACTION collaborated with FMOH, Nursing & Midwifery Council of Nigeria and other
USG partners, MSH/LMS in particular, to develop a standard HIV/AIDS curriculum for nurses in practice. A
pilot TOT was conducted for 45 trainers drawn from different facilities at all tiers of the healthcare system
through the PEPFAR Healthcare Professional Fellowship program. This Fellowship program was jointly
implemented by ACTION and MSH/LMS. Participants of this fellowship program have received support from
their facility and stated administrators to step down training in their various facilities and communities. Also
in COP08, ACTION rolled out this training to its 5 regions as TOTs for a total number of 150 nurse master
trainers, mostly continuing education nurses from tertiary and secondary facilities, and others from PHCs to
enhance facility based and sponsored HIV training and retraining. Through advocacy by ACTION, the USG,
and others, the Nursing and Midwifery Council of Nigeria has mandated nursing schools to include
HIV/AIDS nursing in their training curricula and has identified the need to standardize the content of these
curricula. The HIV/AIDS nursing training curriculum developed under COP07 & COP08 was adapted by the
Council as the model curriculum for HIV/AIDS nursing education for incorporation into standard education of
nursing & midwifery students country-wide. ACTION supported meetings with key stakeholders to carry out
the adaptation for nursing students; supported an initial pilot TOT for 25 nursing and midwifery school
faculty and produced copies of the curriculum for dissemination. In addition, nursing school administrators
were encouraged to incorporate clinical rotations at ACTION and other IP supported hospital and
community based sites into their curriculum to enhance hands on experience for students.
Under COP09, ACTION will focus on continuing to strengthen the capacity of nursing and midwifery schools
countrywide to improve the knowledge base of future graduating nurses and midwives in the area of HIV
prevention and comprehensive care of PLWHAs and PABAs. ACTION will support 2 regional step down
trainings for a total of 60 nurse educators from a least 5 schools of nursing who will be identified by the
Nursing and Midwifery Council of Nigeria. These trainings will be held at 2 nursing schools in ACTION
regions utilizing the master trainers from COP08. IHV Nigeria Training Department will continue to oversee
assessments and monitor for quality as well as coordinate and improve training materials and follow up of
trainees.
ACTION currently supports ARV services at 78 sites and will develop 32 additional primary care sites under
COP09 for a total of 110 sites structured under a hub and spoke network model. 32 hub sites are affiliated
with 32 smaller secondary hospital sites and 32 additional primary health center ARV sites so that routine
care of stable patients can be available at the community level. These primary health center sites already
have established referral relationships with existing ARV sites at the secondary or tertiary level and will be
strengthened under COP09 to provide ARV in a more accessible location. Most of these sites are staffed
by nurses. ACTION anticipates that at least 16 of the primary health centers will be developed as "nurse
managed" ART sites with oversight from the affiliated hubs. These are ideal settings for student rotations.
ACTION support for nurse HIV and AIDS training will not be limited to ACTION supported sites or states, as
the program is designed to provide supports across PEPFAR and beyond.
Sites were selected in line with the National ARV Scale-Up Plan with the goal of universal access. They
Activity Narrative: include: Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa,
Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto.
Curriculum development and implementation will lead to capacity development at the site level and nursing
schools. This is consistent with national guidelines to ensure sustainability. ACTION staff will ensure that
there is a step down training with trainees from various hospitals using the Training Centers in Benin, Kano,
Jos and Abuja. The GON and other IPs will also utilize the curriculum and other trainers developed to
further step down the trainings with development of a cohort of trainers across the country.
This activity focuses on training, as capacity development for sustainability is a key focus. This activity also
focuses on training curriculum and module development, provision of additional training resources for
trainers and trainees for step down training in hospitals, and human resources, as manpower shortfalls to
address HIV care needs will be addressed.
Program Budget Code: 19 - HVMS Management and Staffing
Total Planned Funding for Program Budget Code: $19,729,238
The M&S budget for COP09 reflects the shift from scale-up to sustainability while still enabling the team to provide technical
support and monitoring of PEPFAR activities across a significant number of implementing partners. As such, the only new
positions requested in COP09 are a Human Resources Specialist and a Program Assistant to the PEPFAR Coordinator, both
funded through the Dept. of State and to be located at the Embassy.
Thirty positions for the Centers for Disease Control (CDC) and the Department of Defense (DOD) remain vacant due to lack of
Human Resources infrastructure at the Embassy to support the classification and recruitment of these previously approved
positions. Thus, the Department of State seeks to fund a full time, contracted, Foreign Service National (FSN) Human Resources
Specialist at the US Embassy - Abuja. PEPFAR will fund this position as it is integral to ensuring that CDC and DOD attain the
determined staffing pattern in support of PEPFAR Nigeria programs.
The second position requested is a full time Eligible Family Member (EFM) or FSN Program Assistant in the PEPFAR
Coordinator's office. Given the size of the PEPFAR Nigeria program and the responsibilities placed on the Coordinator, the team
has agreed that administrative, planning, and organizational support is necessary in order for the Coordinator to be successful in
coordinating as well as in representing the PEPFAR team. The incumbent will be funded by PEPFAR through the Department of
State and will be located at the U.S. Embassy. Other support to the Coordinator and the PEPFAR team in general is the Public
Affairs Specialist who is dedicated to PEPFAR.
USAID is well on the way to filling COP08 vacancies, with all hires expected on board prior to the start of COP09. It should also
be noted that USAID will be looking at using a greater number of local hire staff when expatriate technical advisors conclude their
terms of service during COP09. This is an indication of the greater availability of technical specialists within the Nigerian
populace, as well as move to increase cost efficiencies.
Challenges still exist for the continued scale up of human resources, including an extraordinarily long lag time between position
approval to actual employment due to the many and time consuming bureaucratic processes. Additionally, Nigeria is a "hard to
recruit" post for USDH or qualified expatriates, suffering from high rates of crime and environmental factors such as malaria and
other infectious diseases, and lacking amenities such as recreational opportunities and quality health care.
The following section is the beginning of a response to the cable request on best practices in interagency coordination (STATE
112759). We understand that the deadline for this response has been shifted to December 1st, but we offer the following
information towards that deadline. The Interagency management process developed by the PEPFAR Nigeria team is one that
aims to strategically direct activities and align communications to Washington, the Government of Nigeria and other donor groups.
PEPFAR Nigeria has created administrative structures, governance mechanisms, and decision-making procedures to ensure
effective communication, coordination and decision-making.
The PEPFAR team is managed by senior leadership from the U.S. Embassy, CDC, USAID, and DOD. Weekly meetings are held
with the HIV/AIDS leadership from these Departments/Agencies and are chaired by the PEPFAR Coordinator, in order to discuss
planning or reporting issues, Global Fund and other donor coordination, guidance from Washington, planning for Technical
Assistance (TA) visits, and any upcoming events or meetings that require the attendance of one or more of the team members.
Also held weekly is a meeting with the Investing in People team, which is chaired by the DCM. This meeting provides a linkage
between senior management of the PEPFAR team and other health and education programs operating with support from the USG
in Nigeria.
The PEPFAR team is subdivided into 14 Technical Working Groups (TWGs) as represented in our functional staffing chart.
TWGs cover the following topics: (1) procurement and; (2) ABC and Other sexual prevention; (3) medical transmission; (4)
PMTCT; (5) pediatric and adult ART; (6) basic care and support and OVC; (7) TB/HIV; (8) counseling and testing; (9) the SI and
HMIS working group; (10) laboratory; (11) networks of care; (12) gender; (13) human resources for health; (14) health systems. In
addition there are three cluster groups that meet less frequently to discuss linkages between programs in terms of planning,
implementation and policy developments. The cluster groups are the care and treatment cluster, the prevention cluster, and the
SI/lab (cross-cutting) cluster. Each working group is composed of chairperson(s), a network coordinator, liaisons from other
working groups and general members. Each working group has a chair or two co-chairs. There is a specific network coordinator
assigned as a member of all technical working groups. These network coordinators liaise with implementing partners to clearly
map out physical locations and the types of services offered for network referral purposes. Extended versions of these working
groups include implementing partner and GON representatives. All working groups report back to the senior management and
policy group. This regular reporting is done through various mechanisms from as needed verbal and/or written communication to
scheduled presentations to the USG management team
The Team utilizes knowledge management tools in order to ensure effective communication and information sharing across the
interagency team. PEPFARNigeria.org is a password protected internet site that allows the team to share document drafts, notes
from meetings, TA briefings, and other information of use. A central budget and strategic information database has also been
developed so that reliance on excel spreadsheets will soon be a thing of the past for PEPFAR Nigeria. This database will allow
the team to readily access data and tailor reports on PEPFAR implementing partners for use with donor groups, the GON and
media outlets.
One current obstacle faced by the PEPFAR team is HR support from the Embassy in support of CDC and DOD hiring and
benefits/compensation functions. This is remedied in COP09, as is support for the PEPFAR Coordinator's Office.
Where have we eliminated redundancy and applied department/agency strengths to achieve efficiencies? USAID, under COP08,
is hiring a position to focus on Nutrition to cover all agencies.
How have we eliminated "turf" to forge an implementation action team that speaks as one USG? The Nigeria team is very much
integrated. All agencies are represented on TWGs, and joint site visits are often conducted with representatives from CDC, DOD
and USAID to mutually learn from and provide TA to USG partners. Instead of representing one agency when giving a speech or
talk, the individuals speak on behalf of USG PEPFAR.
Table 3.3.19:
