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 DESCRIPTION
This activity also relates to activities in human capacity development and health system strengthening.
AIDSTAR commences activities in COP09 by building staff capacity in three teaching hospitals to
implement PMTCT services. The AIDSTAR project will work with three hospitals in the south-south zone of
Nigeria (Abia, Akwa Ibom and Rivers states) to design interventions aimed at preventing HIV transmission
of mother to child, including targeting STI and HIV infections in women of reproductive age. This is in
accordance with the 2005 Abuja Call for Action in order to ensure universal access to PMTCT Plus
interventions by 2010 and increase uptake of services.
AIDSTAR will build capacity of these hospitals to provide comprehensive HIV and AIDS prevention, care
and treatment to women of reproductive age and their families, and will work to integrate HIV intervention
activities into existing maternal child health (MCH) and reproductive health (RH) services being provided in
the facilities to provide the minimum service requirements. AIDSTAR will provide counseling and testing
services to 1,600 pregnant women with same day results. Based on the 2005 ANC prevalence of 4.4% it is
expected that 70 women who are counseled, tested, and receive their results will be found to be HIV-
positive and will be placed on ARV prophylaxis. All HIV-positive women identified will be linked to further
care and support services regardless of their eligibility for treatment for their own disease.
For the HIV-positive women not requiring HAART, the current WHO recommended short course two drug
ARV option will be provided. This includes zidovudine (ZDV) from 28 weeks with intrapartum single does
nevirapine (sdNVP) and a 7-day ZDV/3TC postpartum tail or ZDV/3TC from 34-36 weeks with intrapartum
sdNVP and a 7-day ZDV/3TC postpartum tail. Infant prophylaxis will consist of sdNVP and ZDV for 6
weeks.
Routine provider initiated testing and counseling (PITC) will be implemented as part of the standard of care
in health facilities with opt-out decision at ANC and labor and delivery wards. HIV positive pregnant women
will be provided with Mama Packs at the point of registration. CD4 testing will be prioritized for all HIV-
positive pregnant women and regimens as outlined in the national PMTCT guidelines will be implemented.
AIDSTAR will build the capacity of the sites to encourage linkages for PMTCT and child health services by
having HIV exposure status on child health card registered on the mothers' card. In continuance of the plan
to integrate MCH and PMTCT services, AIDSTAR will work with the sites to provide family planning services
at ANC and HCT with HIV-positive women linked to family planning services six (6) weeks postpartum.
Couple counseling and testing will also be addressed as part of the PMTCT services and will focus on
disclosure as well as to address issues of violence to women at disclosure. Couple counseling will also
afford opportunities for providers to address exclusive breast feeding and breast milk substitute if AFASS,
and to provide necessary support for HIV-positive mothers and exposed infants.
AIDSTAR will build the capacity of 24 healthcare workers (HCWs) to provide standard package for PMTCT
including referral and supportive supervisory skills. This will be integrated through the training of a core
group of senior HCWs in quality improvement and in mentoring lower level facilities which will be linked to
the sites as part of a referral system. An additional four nursing staff from each of the sites, making a total
of 12 nurses, will especially be trained on counseling issues which will include couples counseling, infant
feeding counseling and referral systems in order to focus on all issues regarding counseling and referrals.
AIDSTAR will assist the sites to upgrade their facilities to provide the necessary clinical regimens to prevent
mother to child transmission based on outcomes of HIV test, CD4 cell count and other clinical staging. HCT
services will be provided at point of contact of ANC. The sites will have the capacity to offer appropriate
treatment for things such as management of opportunistic infections (OI), nutritional support, antiretroviral
therapy and psychosocial support for HIV-positive pregnant women. AIDSTAR will ensure that the facilities
will also provide objective and individualized systematic follow-up care for HIV-positive mothers and their
infants from initial contact to referral to other follow-up care and treatment.
For HIV exposed infants, AIDSTAR will work with sites to expand diagnostic capacity through collection of
dried blood spots (DBS) and linkages to sites with early infant diagnosis (EID) PCR, to strengthen infant
follow-up, to introduce earlier antibody testing (9-12 months), and to institutionalize cotrimoxazole
prophylaxis.
In order to reinforce family-based HIV care, AIDSTAR will assist the sites to initiate PMTCT services that
will be linked to existing community services to support HIV-positive mothers, their infants and family
members with the use of a standard care package for the community-based service providers. Community
services and support will enhance community awareness of HIV prevention, treatment adherence and
counseling on individualized choice regarding infant feeding, as well as other psychosocial support needed.
ARV and tuberculosis clinic linkages will also be established and strengthened.
Necessary follow-up of HIV-positive clients from the clinic setting will further be strengthened and loss due
to follow-up will be greatly reduced. Linkages to networks of people living with HIV and other community-
based and faith-based organizations will be strengthened for service delivery in PMTCT and care for
children. HIV-positive women and mothers will be included in service delivery, especially in increasing
awareness and advocacy at the community level. HIV-positive women who have accessed PMTCT
services will provide periodic awareness programs during ANC to educate clients on the advantages of
services being provided. This will increase uptake of PMTCT services and reduce loss to follow-up as well
as encourage more women to utilize delivery services in the health care setting.
AIDSTAR will be required to submit monthly data of clients accessing PMTCT and other treatment services
to USAID as well as quarterly, semi-annual and annual progress reports of implementation and
management. Supportive supervisory services will be provided to staff monthly in collaboration with state
government HIV/AIDS programs (SACAs and SASCPs).
Contributions to overall program area:
Activity Narrative: AIDSTAR will support the national scale up plan to improve access to PMTCT services in Nigeria,
especially in hard to reach sites in the south-south geo-political zone. Activities in the program area are
focused on ensuring that HIV-positive pregnant women get quality healthcare and support and that referral
systems are in place to address their health needs. It also mobilizes the focal communities to provide further
needed care and support for mothers and children. These activities will contribute to global PEPFAR goals
and are consistent with the Nigerian National Plan of Action on PMTCT.
Links to other activities
The PMTCT services will be linked to HCT, adult and pediatric care and treatment, OVC, TB/HIV, laboratory
services, and SI.
Population being targeted:
This activity intervention targets women of reproductive age and their partners, infants and PLWHAs. This
activity also targets training of health care providers and mothers who will work as peer educators and
referral persons.
Emphasis areas:
This activity has a major focus on capacity building and supportive supervision aimed at basic capacity
building for sites to implement PMTCT services and other referral services in the health system for the
target population. Community mobilization and participation, development of network/linkages/referral
systems, and information and communication issues will also be addressed.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Gender
* Increasing gender equity in HIV/AIDS programs
* Reducing violence and coercion
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* Safe Motherhood
* TB
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY DESCRIPTION:
AIDSTAR will be required to identify and build planning and managerial capacity of local partners as well as
strengthen local technical capacity to deliver high-quality comprehensive AB prevention programs and
services aimed at promoting partner reduction and preventing transactional sex.
Specific activities will entail the identification and building the capacity of indigenous faith-based and
community-based organizations (FBOs and CBOs) to provide high quality prevention programming that will
bring about effective behavior change as it relates to reduction of multiple sexual partners and transactional
sex. In addition, AIDSTAR will undertake community based activities to facilitate normative changes that
enhance the practice of abstinence and mutual fidelity. These activities will address adults, and men in
particular, with messages that promote fidelity, discourage male norms that encourage risky behaviors,
encourage partner reduction through risk reduction messages and personal risk perceptions skills. Activities
will also focus on unmarried young men and women across the board who are at high risk owing to
contextual factors (domestic workers, street vendors, etc.). Messages will be tailored to each target group.
Activities to prevent transactional sex and or protect youth involved in transactional sexual relationships will
focus on skills based HIV education for vulnerable young women and young men with broad based
community activities that create supportive normative environment for the practice of abstinence and fidelity.
Influencers of young people, including parents, teachers, religious leaders and community leaders will also
be reached. These interventions will be reinforced with mass media activities that highlight the importance
of mutual fidelity, risk behavior reduction and avoidance of transactional sex. AIDSTAR will concentrate
activities in areas that will be identified through secondary analysis of national behavioral data generated
through the Project SEARCH data triangulation exercise and the NARHS+ survey.
AIDSTAR will utilize a minimum package of interventions identified from a pool of best practices in the
national prevention plan to provide high quality prevention interventions for the population group identified.
These interventions include: peer education interventions, peer education plus models, workplace
programs, community awareness campaigns, school based program approaches, intervention programs to
address issues of vulnerability, provision of STI management, and infection control measures in clinical
settings. The national prevention plan 2007-2009 recommends that a minimum of three of these
interventions be used to reach each target while mass media activities will serve as reinforcement. The
AIDSTAR prevention program will build capacity of community-based, faith-based, and other non-
governmental organizations (CBOs, FBOs and NGOs) to provide this minimum package intervention for the
specific population groups. Technically this will entail familiarizing the organizations with the minimum
package modules and adopting a program approach that ensures delivery of the package.
AIDSTAR will reach 97,500 individuals utilizing minimum package interventions that promote abstinence
and/or being faithful (AB) with 32,500 individuals reached through interventions that promotes abstinence
only (a subset of total reached with AB).
500 individuals will be trained to promote HIV/AIDS prevention programs and 25 organizations will receive
capacity building toward high quality prevention programs for identified high risk population.
AIDSTAR will document and disseminate best practices; successful and innovative approaches with
lessons learned and share these with their implementing agencies as well as other partners within the
PEPFAR program in Nigeria. In COP 09, a particular focus will be on lessons learned on effective
approaches for improving linkages between clinical services and community based services to provide
basis for strengthening the prevention with positives programs and other specific interest high risk groups
programs.
Implementation will be through NGOs, CBOs and FBOs whose capacity has been built by AIDSTAR and
who have the capacity for rapid scale up. Within the initial 6 months of implementation, capacity-building for
provision of prevention (AB) services for identified FBOs and CBOs will be carried out, followed by
development of materials on prevention of cross generational and transactional sex. AIDSTAR interventions
will be in line with national priority plan and national prevention plan.
Geographic location will be negotiated with the GON with South-South, South-East and North-Central states
considered as prime regions for selection, considering gaps in the PEPFAR response and based on the
location of identified high risk groups from review of behavioral surveillance data of prevalence among these
groups.
CONTRIBUTIONS TO OVERALL PROGRAM AREA
The programs and activities implemented will increase the reach of AB interventions into epidemiologically
important populations to better address gaps in coverage and to better address specific behaviors within
underserved populations. This AIDSTAR prevention program, delivered through implementing agencies, will
contribute to strengthening and expanding the capacity of the Nigerian response to the HIV/AIDS epidemic
and increasing the prospects of meeting the Emergency Plan's goal of preventing 1,145,545 new infections.
LINKS TO OTHER ACTIVITIES
This activity also links with OVC and SI activities (i.e., the Project SEARCH activity for data informed
program design).
POPULATIONS BEING TARGETED:
Populations targeted in these AB activities will include younger unmarried men and women and their
corresponding figures-of-influence (parents, teachers and religious leaders) and adult males to better
address issues around cross-generational and transactional sex.
KEY LEGISLATIVE ISSUES ADDRESSED:
Key legislative issues will address male norms and behaviors, and increased equity and access to
information and services for women.
EMPHASIS AREAS:
Activity Narrative: The service delivery component will focus on information, education, and communication in the community
and will build linkages with other sectors and initiatives.
New/Continuing Activity: Continuing Activity
Continuing Activity: 16991
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
16991 16991.08 U.S. Agency for John Snow, Inc. 7405 7405.08 USAID Track $3,000,000
International 2.0 FS
Development AIDSTAR
* Addressing male norms and behaviors
Table 3.3.02:
In COP09 AIDSTAR will provide adult treatment, care and support services to secondary Treatment
Facilities and PHC centers. These services will take place in 3 states. Through primary and secondary
facilities in COP09, AIDSTAR will provide ART services to underserved rural communities to reach adult
patients. The number of patients to be reached will be determined as contract negotiations are finalized
and will be reported to OGAC. A comprehensive package of care and support services will be provided to
PLWHA and PABAs in the same period.
The package of care services provided to each PLWHA will include one clinical service with the basic care
kit and two supportive services including psychological, spiritual, and PwP delivered at the facility,
community, and household (home based care) levels in accordance with the PEPFAR and National care
and support policies and guidelines. The basic care kit for PLWHAs in AIDSTAR sites include Basic Care
Kit (ORS & SSS, LLITN, water treatment solution, water vessel, gloves, soap, condoms and IEC materials,);
Home-Based Care (client and Caregiver training and education in self-care and other HBC services);
Clinical Care (basic nursing care, pain management, OI and STIs prophylaxis and treatment, nutritional
assessment- weight, height, BMI, micronutrient counseling and supplementation and referrals) Laboratory
Services (which will include baseline tests - CD4 counts, hematology, chemistry, malarial parasite, OI and
STI diagnostics when indicated); Psychological Care (adherence counseling, bereavement counseling,
depression assessment and counseling with referral to appropriate services); Spiritual Care (access to
spiritual care); Social Care (support groups' facilitation, referrals, and transportation) and Prevention Care
(Prevention with Positives). All PLWHAs' nutritional status will be assessed at contact and on follow-up
visits .By doing BMI and plotting on infant growth charts Micronutrients will be provided as necessary, and
those diagnosed as severely malnourished will be placed on a therapeutic feeding program through
wraparound services as well as direct funding. AIDSTAR will procure basic care kits through the SCMS
central mechanism and OI drugs will be procured through mechanisms that ensure only NAFDAC approved
drugs are utilized.
ART services at sites that are co-located in facilities with TB DOTS centers will have the services integrated
to facilitate TB/HIV service linkages. All PLWHA will have CD4 counts and other necessary lab analyses
performed at least every 6 months to determine the optimal time and eligibility status to initiate ART and
monitor effectiveness/side effects for those on ART. AIDSTAR 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; IEC
materials and provider delivered messages on disclosure. Cotrimoxazole prophylaxis will be provided for
PLWHAs when CD4 <200 or prior TB or other AIDS defining illnesses. AIDSTAR will support a pilot
program for cervical cancer screening in HIV positive women.
AIDSTAR will collaborate with faith-based organizations (FBOs) to achieve these targets by recruiting
volunteers and community-based organizations (CBOs). Through these partnerships clients in care will
receive a comprehensive package of community and home based care services. AIDSTAR HBC teams
comprising nurses, community health workers and trained volunteers are supported by AIDSTAR to provide
HBC services as well as facilitate support group activities. HBC providers will use HBC kits. AIDSTAR
partners will focus on improving pre-ART retention in support groups. Strategies to retain clients in care
include intensive home visits by HBC team during the first 6 months of enrolment.
All sites will consolidate on their capacity to provide comprehensive quality ART services through
management of OIs and ART, a safe, reliable and secure pharmaceutical supply chain, technologically
appropriate lab diagnostics, treatment preparation for patients, their families and supporters and community
based support for adherence. This technical and programmatic assistance utilizes on-site mentoring and
preceptorship. It also supports the development of site specific work plans and ensures that systems are in
place for financial accountability. AIDSTAR partners will adhere to the Nigerian National ART service
delivery guidelines including recommended first and second line ART regimens. In addition, AIDSTAR will
partner with Clinton Foundation and Global Fund as appropriate to leverage resources for providing
antiretroviral drugs to patients
Monitoring and evaluation will be carried out by a team of trained volunteers working in the communities
who work with AIDSTAR data officers and M and E unit officers. In addition, data generated will be shared
with local government areas to allow for them to track their clients and provide ongoing support for
sustainability. Registers, forms, and other data tools will be provided and replenished as necessary and
staff trained in their use AIDSTAR will report on sex distribution of PLWHAs receiving care and support
services and the numbers of PLWHAs reached with community home based care. Personnel will be trained
in the use of registers for documentation and data reporting.
In COP09 AIDSTAR partners will continue to strengthen institutional and health worker capacity through the
training, retraining and mentoring of health service providers to provide care and treatment services at the
facility and community levels. Doctors, pharmacists, nurses, counselors, and community health extension
workers will receive training and onsite mentoring that will allow them to provide comprehensive care.
Training will maximize use of all available human resources including a focus on community nursing and
community adherence. Care and Treatment trainings will be based on the national curricula. AIDSTAR will
collaborate with the GoN and other stakeholders to develop task shifting strategies to enable nurses and
community health officers to provide ART. Training targets will be set as contract negotiations are finalized.
In COP09 AIDSTAR will conduct 2-week intensive didactic and practical trainings preceding site activation
followed by regular onsite mentoring. APS 2 will also train community volunteers including PLWHA and
religious leaders to provide peer education counseling, psychosocial and spiritual counseling, respectively.
AIDSTAR will use GON/USG recommended standardized training curriculums, manuals and training aides
for all trainings. Information, education and communication materials will be provided to enhance these
trainings. AIDSTAR partners will work closely with the USG and GoN team to monitor quality improvement
at all sites and across the program. Health care workers will benefit from these trainings referred to above in
HIV Care, Treatment and Support.
Activity Narrative: A key component for successful ART is adherence to therapy at the household and community levels.
PLWHA on treatment are encouraged to have a treatment support person such as a family member to
whom he/she had disclosed HIV status to improve support in the home and increase adherence. AIDSTAR
will continue to build and strengthen the community components by using nurses and counselors to link
health institutions to communities. Each site will appoint a staff member to coordinate the linkages of
patients to all services. This will also build the capacity of sites for better patient tracking, referral
coordination, and linkages to appropriate services. These activities will be monitored by the AIDSTAR
technical and program management regional teams.
In COP09, AIDSTAR will continue to strengthen its expanded Quality Improvement Program (QIP)
consisting of the annual cross sectional Outcomes & Evaluation (O&E) exercise, the GON/USG supported
HIVQual monitoring and the quarterly Continuous Quality Improvement (CQI) activities in order to improve
and institutionalize quality interventions. AIDSTAR partners will standardize patient medical records to
ensure proper record keeping and continuity of care at all sites. Monitoring and evaluation of the AIDSTAR
ART program will be consistent with the national plan for patient monitoring. The specialists will conduct
team site visits at least quarterly during which there will be evaluations of infection control, the utilization of
National PMM tools and guidelines, proper medical record keeping, efficiency of clinic services, referral
coordination, and use of standard operating procedures across all disciplines. On-site technical assistance
(TA) with more frequent follow-up monitoring visits will be provided to address weaknesses when identified
during routine monitoring visits. Some of the data will be used to generate biannual life table analyses that
identify factors associated with early discontinuation of treatment. In addition, at each site an annual cross
sectional evaluation of program quality shall consist of a 10% random sample of linked medical records,
adherence questionnaires and viral loads to examine treatment compliance and viral load suppression for
adult patients who have been on treatment for at least 9 months. A similar process will be undertaken for all
children who have been on ART for at least 9 months. Each of these activities will highlight opportunities for
improvement of clinical practices.
Sustainability lies at the heart of the AIDSTAR program, and is based on durable therapeutic programs and
health systems strengthening. AIDSTAR will focus on the transition of the management of care and
treatment activities to indigenous organizations by actively using its extensive linkages with faith based
groups and other key stakeholders to develop a transition plan that is appropriate to the Nigerian context.
The plan will be designed to ensure the continuous delivery of quality HIV care and treatment, and all
activities will continue to be implemented in close collaboration with the Government of Nigeria to ensure
coordination, information sharing and long term sustainability. For the transition to be successful,
sustainable institutional capacity must be present within the indigenous organizations and sites they
support; therefore, AIDSTAR will strengthen the selected indigenous organizations according to their
assessed needs, while continuing to strengthen the health systems of the sites. This capacity strengthening
will include human resource support and management, financial management, infrastructure improvement,
and strengthening of health management information systems.
AIDSTAR will continue to participate in Government of Nigeria (GON) harmonization activities and to
participate in the USG coordinated clinical working group to address ongoing topics in ARV service delivery.
CONTRIBUTIONS TO OVERALL PROGRAM AREA:
AIDSTAR's expansion of adult care and treatment activities, including effective linkages with HBC
providers, will contribute to increased access of such services to underserved rural communities. By
providing services to XXX Adult PLWHA, AIDSTAR will contribute to the overall PEPFAR care and support
target of providing these services to 10 million people globally by 2009 and will help accomplish the
PEPFAR Nigeria target of placing XXX clients on ART by 2009 and will also support the Nigerian
government's universal access to ART by 2010 initiative. This activity contributes to the overall AIDSTAR
comprehensive HIV and AIDS services by providing the supportive services for all adult PLWHA including
those on ART.
LINKS TO OTHER ACTIVITIES:
AIDSTAR activities in adult care and treatment are linked to HCT), PMTCT, ARV drugs, laboratory, OVC,
Sexual Prevention, Medical Prevention,TB/HIVand SI to ensure that PLWHA and their family members have
access to a continuum of care. AIDSTAR will continue to collaborate with theprogram of the AIDSTAR to
establish networks of community volunteers to support livelihood development program for PLWHA and
caregivers requiring such services and support identified child or adolescent headed households to be
linked with other OVC programs which will meet the needs of the household. Networks will be created to
ensure cross-referrals and sharing of best practices among AIDSTAR and other implementing partner sites
for the provision of psychosocial support and community and home based services to PLWHA. Effective
synergies will be established with the Global Fund to Fight AIDS, Tuberculosis and Malaria through
harmonization of activities with GON and other stakeholders for harmonization of basic care and support
services and the standardization of training manuals for community volunteers and providers
This activity targets PLWHA, particularly those who qualify for the provision of ART, including PMTCT
clients from rural and underserved communities. This activity also targets CBOs and FBOs for capacity
building and targets care providers (healthcare professionals and community volunteers) for training.
This activity will include emphasis on human capacity development specifically through in-service training
and task-shifting, local organization capacity building for community mobilization and participation,
development of networks/linkages/referral systems, and quality assurance/ quality improvement This activity
will also ensure gender equity, ensuring access to ART through linkages with PMTCT services, addressing
male norms & behaviors, increasing women's legal rights and access to income & productive resources,
and reducing violence & coercion against women. AIDSTAR will work with CBOs, networks of PLWHA and
FBOs and other USG/GON programs to promote economic strengthening activities; education and safe
Activity Narrative: water initiatives, and create access to food and nutritional services. The extension of this activity into rural
and previously underserved communities will contribute to the equitable availability of ART services in
Nigeria and towards the goal of universal access to ARV services in the country. This activity will improve
the quality of life of PLWHA and thus reduce the stigma and discrimination against them.
Construction/Renovation
* Malaria (PMI)
Estimated amount of funding that is planned for Human Capacity Development $30,600
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $8,500
and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Commodities $8,500
Estimated amount of funding that is planned for Water $8,500
Table 3.3.08:
Estimated amount of funding that is planned for Human Capacity Development $149,400
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $41,500
Estimated amount of funding that is planned for Food and Nutrition: Commodities $41,500
Estimated amount of funding that is planned for Water $41,500
Table 3.3.09:
In COP09 AIDSTAR will provide care and treatment services to treatment facilities in Rivers, Akwa Ibom
and Abia states. The number of sites to be supported is to be determined. As a new partner, AIDSTAR will
be working directly with the state governments to determine the exact number of facilities to be included.
Through primary and secondary facilities AIDSTAR will extend care and treatment services to selected
communities in the target states to reach 130 children in care and on ART by the end of the COP year.
Entry points where children will be identified for pediatric basic care and support will include the ANC and
labor and delivery (PMTCT clinics) where mothers who are identified as HIV positive will be encouraged to
return to deliver their babies and ensure they receive PMTCT services. Other entry points include the
TB/DOTS centers from family contact tracing, mothers support groups, outpatient clinics, inpatient wards,
and immunization centers. Mothers will be further encouraged to return for "well child" visits with their
babies, at which time they will be weighed, receive immunizations and nutritional counseling and education
on safe infant feeding. At the age of six weeks, according to the Nigerian national algorithm, these babies
will all have dried blood spot (DBS) collection for DNA PCR diagnosis and, based on their results, will be
referred for treatment if positive or will continue to receive follow up care at the facility if negative. A second
test will be performed at the age of 18 months or six weeks after the cessation of breastfeeding whichever
comes later to ascertain the child's final HIV status.
Implementation of the early infant diagnosis (EID) scale-up will be done under the guidance of the GON and
in conjunction with other IPs who will be conducting the laboratory testing. AIDSTAR will engage PMTCT
support groups and the larger support group(s) in tracking unbooked pregnant women and infants in the
community, linking them to sites where they can access HCT. AIDSTAR will establish linkages with other
health care providers; public and private, proximal to AIDSTAR sites, with full fledged ANC activities. This
will encourage two-way referrals of HIV-positive mothers and their infants from these providers to AIDSTAR
-supported sites and thus benefit from EID/ART activities at the sites. Site EID focal persons will ensure
prompt dissemination of results to providers and mothers as soon as they are available.
Key to increasing pediatric enrollment into care and treatment will be to strengthen linkages at all service
levels within the sites that AIDSTAR will be working, as well as reinforced and expanded community
outreach. This will require staff training and strengthened referral linkages. In order to increase the number
of children brought into care and treatment, AIDSTAR will support a multi pronged approach: organization of
services to provide family centered care and treatment, provider initiated testing and counseling for all
children (PITC) and community mobilization. Organization of ART clinics to include family days will also
provide opportunities to increase testing for children and provide comprehensive care. All exposed infants
delivered in the ART sites or identified through the family centered approach will be linked to the HIV
comprehensive care clinic for enrollment for care and support, and to community based OVC programs.
The package of care services provided to each HIV-positive child/care givers includes a minimum of clinical
service with basic care kit and two supportive services in the domain of psychological, spiritual, and PwP
delivered at the facility, community, and household (home-based care) levels in accordance with the
PEPFAR and Government of Nigeria (GON) national care and support policies and guidelines. The basic
care package for HIV positive child/care givers in AIDSTAR sites includes: basic care kit (ORS & SSS,
LLITN, water treatment solution, water vessel, soap, IEC materials, and gloves); home-based care (client
and caregiver training and education in self-care and other HBC services); clinical care (basic nursing care,
pain management, OI and STIs prophylaxis and treatment, nutritional assessment- weight, height, BMI,
micronutrient counseling and supplementation and referrals); laboratory services (which will include
baseline tests - CD4 counts, hematology, chemistry, malarial parasite, OI and STI diagnostics when
indicated); psychological care (adherence counseling, bereavement counseling, depression assessment
and counseling with referral to appropriate services); spiritual care (access to spiritual care); social care
(support groups' facilitation, referrals, and transportation) and prevention care (Prevention with Positives).
All HIV-positive children's nutritional status will be assessed at contact and on follow-up visits,
micronutrients will be provided as necessary, and those diagnosed as severely malnourished will be placed
on a therapeutic feeding program. This will be done through wraparound services as well as direct funding.
AIDSTAR will procure basic care kits through a central mechanism and OI drugs will be procured
mechanisms that ensure only NAFDAC approved drugs are utilized.
Also discussed under PMTCT and linked to pediatric care and treatment is safe infant feeding. This will be
supported from the antenatal period through pregnancy, delivery and infancy. Mothers will receive individual
and group counseling using the Nigerian National HIV and infant feeding protocol, and they will be further
supported psychosocially after they have made informed decisions about infant feeding choices to ensure
they avoid mixed feeding which will be emphasized continually. Mothers will continue to receive infant
feeding support through the support groups, which will address the social issues around breastfeeding or
choosing not to breastfeed, as well as how to reduce stigmatization through education of peers and family
members. A nutritional assessment, through the use of growth monitoring and recording on growth charts,
will be accompanied by nutritional education around supplementary and complementary feeding and safe
early weaning. Mothers will be encouraged to exclusively breastfeed except if AFASS. PEPFAR funds will
not be used to procure BMS except clinically indicated.
All sites will be strengthened in their capacity to provide comprehensive quality care and treatment services
through a variety of models of care delivery. This includes quality management of OIs and ART, a safe,
reliable and secure pharmaceutical supply chain, technologically appropriate lab diagnostics, treatment
preparation for patients, their families and supporters and community based support for adherence. This
technical and programmatic assistance utilizes on-site mentoring and preceptorship. It also supports the
development of site specific work plans and ensures that systems are in place for financial accountability.
AIDSTAR will provide access to viral loads for children with suspected treatment failure by intake to other
facilities with viral load. All infected children will be evaluated for ART using CD4 count or CD4%. All
AIDSTAR sites will be equipped with capacity to determine CD4% for evaluation of immunological status of
children less than six years.
Activity Narrative: Based on available evidence on child survival and morbidities in relation to immunological staging,
AIDSTAR will provide ARVs for all infected infants (less than one year) in accordance with revised WHO
recommendations so as to prevent mortality and brain damage in rapid progressors. Appropriate first and
second line regimens that preserve future options with minimal toxicity profiles will be adopted for all sites.
AIDSTAR will partner with the Clinton Foundation and Global Fund as appropriate to leverage resources for
providing antiretroviral drugs and nutritional supplements to infected children.
ART sites are co-located in facilities with TB DOTS centers to facilitate TB/HIV service linkages. AIDSTAR
will intensify collaboration with GON and other stakeholders to ensure prompt diagnosis of TB in children
and facilitate provision of pediatric TB formulations. A key component for successful ART is adherence to
therapy at the household and community levels. AIDSTAR will ensure intensive treatment preparation
directed at an identified caregiver to ensure strict adherence. AIDSTAR will continue to build and strengthen
the community components by using nurses and counselors to link health institutions to communities. Each
site will appoint a specific staff member to coordinate the linkages of patients to all services. This will also
build the capacity of sites for better patient tracking, referral coordination, and linkages to appropriate
services. These activities will be monitored by the AIDSTAR technical and program management regional
teams. All children on ARV will have at least monthly home visits to ensure adherence and assess the need
for intervention. Specific efforts and training will be made to develop adolescent friendly services for infected
and affected children including linkages to reproductive health.
Non ART eligible children will be enrolled into care for periodic follow-up, including laboratory analysis at
least every six months, to identify changes in ART eligibility status. All enrolled children will be linked to an
OVC program to access an array of services including nutritional support, preventive care package (water
sanitation/treatment education, ITN) and psychosocial support. All sites will be empowered with training and
tools to ensure nutritional assessment. Educational support and food supplements will be leveraged from
other partners.
In COP09 AIDSTAR will train 10 health service providers in pediatric care and treatment according to the
National Pediatric HIV Training curriculum. Training will maximize use of all available human resources
including a focus on community nursing and community adherence to ensure care is decentralized to the
home level. AIDSTAR will collaborate with the GoN and other stakeholders to develop task shifting
strategies to enable nurses and community health officers to provide Pediatric ART. AIDSTAR will work
closely with the USG team to monitor quality improvement at all sites and across the program. AIDSTAR
will actively participate in and facilitate activities to review practices in pediatric HIV care and treatment
particularly GON technical working group meetings. AIDSTAR will share with the GON a new pediatric
counseling curriculum developed with the African Network for Caring for Children with HIV and roll this
training out to all AIDSTAR sites. AIDSTAR will support the development of a national pediatric HIV care
and support guideline and training curriculum.
In COP09, AIDSTAR will build a team of specialists to ensure Continuous Quality Improvement (CQI) to
improve and institutionalize quality interventions. The team will sustain the efforts with a modification of
evaluation tools to assess and report on both qualitative and quantitative indicators of care delivery.
Monitoring and evaluation of the AIDSTAR ART program will be consistent with the national plan for patient
monitoring. The CQI specialists will conduct team site visits at least quarterly during which there will be
evaluations of infection control, the utilization of National PMM tools and guidelines, proper medical record
keeping, efficiency of clinic services, referral coordination, and use of standard operating procedures across
all disciplines. On-site TA with more frequent follow-up monitoring visits will be provided to address
weaknesses when identified during routine monitoring visits. Some of the data will be used to generate
biannual life table analyses that identify factors associated with early discontinuation of treatment. In
addition, at each site an annual evaluation of program quality shall consist of a 10% random sample of
linked medical records, adherence questionnaires and viral loads to examine treatment compliance and
viral load suppression for adult patients who have been on treatment for at least nine months. A similar
process will be undertaken for all children who have been on ART for at least nine months. Each of these
activities will highlight opportunities for improvement of clinical practices.
sustainable institutional capacity must be present within the indigenous organizations and the sites they
support. AIDSTAR will strengthen the selected indigenous organizations according to their assessed needs,
while continuing to strengthen the health systems of the sites. This capacity strengthening will include
human resource support and management, financial management, infrastructure improvement, and
strengthening of health management information systems.
CONTRIBUTION TO THE OVERALL PROGRAM AREA:
This activity will contribute to achieving the overall PEPFAR Nigeria target of reaching more children with
care and treatment services and will also support the Nigerian government's universal access to ART by
2010 initiative.
This activity is linked to HCT services. It also relates to activities in ARV drugs, laboratory services, and
care and support activities including sexual prevention, PMTCT, OVC, AB, TB/HIV, and SI.
Networks will be created to ensure cross-referrals and sharing of best practices among AIDSTAR and other
implementing partner sites. Effective synergies will be established with the Global Fund to Fight AIDS,
Tuberculosis and Malaria through harmonization of activities with GON and other stakeholders.
Activity Narrative: POPULATIONS BEING TARGETED:
This activity targets children infected with HIV and their caregivers/HCWs from rural and underserved
communities.
This activity will include emphasis on human capacity development specifically through in-service training.
These ART services will also ensure gender and age equity in access to ART through linkages with OVC
and PMTCT services in AIDSTAR sites and neighboring sites. The extension of ARV services into rural and
previously underserved communities will contribute to the equitable availability of ART services in Nigeria
and towards the goal of universal access to ARV services in the country.
Table 3.3.10:
This is a new program area for Africare in COP 09. In this program area, Africare will be supporting facility
based activities for HIV exposed and infected children aged 0-17 years and their families, aimed at
extending and optimizing quality of life from diagnosis through the continuum of illness by providing clinical,
psychosocial and prevention services. These services will be provided as an extension of PMTCT
programs, and they will be provided in facilities where PMTCT is also supported.
Clinical services will include early infant diagnosis which will be linked to the existing PMTCT program,
appropriate HCT services for at risk children and adolescents, prevention and treatment of OIs, malaria and
diarrhea, provision of access to commodities such as LLITNs, safe water interventions, pain and symptoms
relief, and nutritional assessment and support. The preventive care package would be provided for children.
Psychosocial, and prevention services would be provided as part of Africare's OVC care services, and
these services would be linked as appropriate.
This program component specifically will be addressing the issues around ensuring HIV exposed infants get
enrolled into care by providing early infant diagnosis and critical linkages between PMTCT and pediatric and
maternal care and support within communities to ensure adequate and dedicated follow up of these infants
and identification of the HIV infected among them. These children when identified by DBS testing at the
designated centers would be referred into a referral pediatric treatment center for treatment, and would
continue to receive their supportive care at the referring
facility.
Psychosocial support would be provided at on site facility based pediatric support groups ( kids clubs) which
would be co-located and co-scheduled with maternal support groups, immunization clinics and nutritional
demonstration activities for mothers. Children would receive age appropriate psycho social support around
disclosure and feelings, and participate in games and activities appropriate for their ages
Age appropriate prevention activities would be provided- for the younger children, information and education
would mostly be provided to mothers and caregivers, and the older children and adolescents would be
counseled directly by peer educators from the OVC program which would be linked with this program.
Altogether 450 children will receive pediatric basic care and support during COP 09, in addition to the 1896
children who would receive OVC services during the same reporting period.
Entry points where children would be identified for pediatric basic care and support would include the ANC,
Labor and delivery (PMTCT clinics) where mothers who are identified as HIV positive would be encouraged
to return to deliver their babies and ensure they receive PMTCT services. Other entry points include the
TB/DOTS centers from family contact tracing, mothers support groups, immunization centers and The
mothers would be further encouraged to return for well child visits with their babies, at which time they
would be weighed, receive immunizations and nutritional counseling and education on safe infant feeding.
At the age of 6 weeks, according to the Nigerian National algorithm, these babies would all have dried blood
spot collection for DNA PCR diagnosis, and based on their results would be referred for treatment if positive
or will continue to received follow up care at the facility if not. A second test would be performed at the age
of 18 months or twelve weeks after the cessation of breastfeeding whichever comes later to ascertain the
child's final HIV status.
In the interim, the infant would be followed up according to National guidelines for follow up of HIV exposed
infants and would as part of this receive the basic care package which consists of Co-trimoxazole
prophylaxis, malaria prevention through the provision of LLITNs, safe water interventions through the
provision of waterguard ® and continuing education for the family with the performance of home visits by
members of the mothers support group and with enrollment of the child into OVC services to ensure he/she
continues to receive follow up. Services will be actively linked to PMTCT, OVC and mothers support groups
meetings which will coincide with immunization and well visits in individual facilities. Standing orders for
commencement of Co-Trimoxazole until infant's HIV status is known would be in place for the facilities
where physicians are not always present.
Safe infant feeding would be supported from the antenatal period through pregnancy, delivery and infancy.
Mothers would be receive individual and group counseling using the Nigerian National HIV and infant
feeding protocol, and they would be further supported psychosocially after they have made informed
decisions about infant feeding choices to ensure they avoid mixed feeding which would be emphasized
continually. Mothers would continue to receive infant feeding support through the support groups, which
would address the social issues around breastfeeding or choosing not to breastfeed, as well as how to
reduce stigmatization through education of peers and family members. Nutritional assessment through the
use of growth monitoring and recording on growth charts would be accompanied by nutritional education
around supplementary and complementary feeding and safe early weaning
Africare will ensure at least 80% of all HIV exposed infants receive a basic package of post natal
interventions, ensuring that mothers receive both facility and home and community based care
interventions, as well as link these children all into OVC services, with the intention that all of them receive
other core services.
PMTCT services would be strongly linked with OVC and pediatric care and support services, with co-
location and co-scheduling of appointments and support group meetings, immunization and well child days.
Champion mothers who recently have gone through pregnancy and delivery would ensure active referrals
and linkages are maintained. Age appropriate prevention counseling would be offered. A buddy system will
be set up to pair mothers who live close by or who have certain interests in common to ensure they benefit
from one another. Children who need to be referred for treatment would be actively transported in small
groups to ensure group cohesion and support on specific enrollment days at treatment centers, and
opportunities for provision of outreach treatment services would be explored with the Massey Street
children's Hospital to further reduce the burden on caregivers.
Twenty (20) additional health care workers would be trained to provide early infant diagnosis care, DBS
Activity Narrative: collection and provision of pediatric basic care and support in 3 facilities, all of which would be existing or
new PMTCT sites, which would subsequently be designated PMTCT-plus sites. At the level of the local and
state governments, four supervisors would also be trained to ensure sustainability and further monitoring of
the program which would be integrated into PMTCT, OVC and child survival programs offered and
supported at the level of facilities and communities. TB/HIV infected patients at the TB/DOTS sites would
also be actively followed up and their children brought into facility based care, as well as referred into
community based care as appropriate.
Monitoring and Evaluation of the program would be supported by Africare's M and E team which would work
to provide National registers, forms and tools for data capture, ensure that all staff are trained to recognize
and use these tools appropriately, and provide supportive supervision around data capture after service
provision to ensure pediatric clinical care services are appropriately documented as such, and OVC
services are documented separately. Supervisory support from the state M and E program would also be
obtained and supported to ensure sustainability; these officers would also be trained to use the National
data capture tools.
Personnel shortages in state primary and secondary health facilities will be addressed through limited task
shifting and task sharing, in keeping with National guidelines around these, ensuring that community health
extension workers and community health officers also play a role in counseling, immunization support and
growth monitoring and developmental evaluation of infants, especially as the clinic sizes increase.
This program will be targeting HIV exposed and infected infants and children from 0 to 17 years, and will be
linked with the OVC program as well as the adult basic care and support, prevention, PMTCT and support
groups. Health care workers would be trained to provide basic clinical care and recognize the need for,
initiate and follow up with referrals into other appropriate program areas to ensure holistic family centered
care is provided for all the beneficiaries of the program
Emphasis areas include provision of health related wrap around programs including child survival activities,
malaria prevention, safe water provision, food and nutrition- providing support and supplementation
addressing tools and service delivery as well as human capacity development.
Table 3.3.11:
In COP09 AIDSTAR will maintain services to the 14,400 OVC reached in COP 08 and train an additional
2,000 Caregivers in Enugu, Imo, Delta, Akwa Ibom, Rivers, Bayelsa, Gombe and Taraba States.
COP 08 Narrative
This is a new activity and it links to AIDSTAR activities in AB prevention to ensure that all OVC get age-
appropriate prevention messaging integrated into their general health care. An analysis of the current USG
Nigeria OVC portfolio, conducted by the USG Nigeria's Orphans and Vulnerable Children (OVC) TWG and
reinforced by recommendations from previous technical assistance (TA) assessments, identified a number
of key programmatic gaps: current paucity of indigenous partners to take programs to scale; poor
understanding of OVC definitions by implementing partners; inadequate monitoring and supervision; weak
referral networks between facility-based and community-based partners; lack of coverage in high
prevalence states; few programs addressing the needs of adolescent OVC, particularly females; and little
programming for young married girls in Northern Nigeria who have increased vulnerability. In addition to
these programmatic gaps, the analysis identified a number of contracting constraints, as the current in-
country capacity for making awards to new partners is limited by the current capacity of indigenous, civil
society organizations (CSOs) to respond to the USG solicitation and award standards. The analysis also
showed that to achieve community-level service provision and comprehensive services, a partner is needed
with the technical expertise and implementation capacity to not only envision, but also have the ability to
rapidly develop a large-scale effort in a country as large, complex and challenging as Nigeria. Finally, the
analysis noted that implementing partners should have the mandate and capacity to engage local partners
to ensure that the program is implemented comprehensively at the grassroots level.
Based on these recommendations, the AIDS Support and Technical Resources (AIDSTAR) Indefinite
Quantity Contract (IQC) mechanism has been selected as a new partner under COP08, due to the fact that
AIDSTAR contractors have demonstrated technical capacity in a range of technical areas related to care
and support addressing multifaceted needs of OVC and palliative care. These include pediatric home-based
care, gender, stigma and discrimination, and program-related data collection and analysis. This partner will
work closely with the inter-agency OVC TWG and will be overseen by the PEPFAR Nigeria Senior
Management team to ensure that it is integrated within the broader USG OVC portfolio. The scope of work
will be developed in conjunction with the OVC TWG, and targets and specific activities will be shared with
O/GAC prior to award, as is USG/Nigeria's practice for TBD activities.
The Nigeria OVC task order will use AIDSTAR to provide:
1. Long-term in-country support for coordination and scale-up of HIV/AIDS activities in support of
USG/Nigeria OVC strategies.
2. Service delivery focusing on the multifaceted needs of OVC, including home-based care for infected
children, gender issues related to the vulnerability of female OVC and heads of household, stigma and
discrimination. Specifically AIDSTAR contractors will:
a) Identify OVC: Activities will be designed to build provider understanding of who is eligible for OVC
services, and work with communities and clinical service providers to identify all children that are eligible for
services. The geographic area of focus for AIDSTAR activities will be in areas of Nigeria with HIV
prevalence at or above the national average that are underserved, particularly in the Southeast, South-
South, North East and North West regions. Community-based and faith-based organizations in particular
will be targeted as sub-partners.
b) Develop a holistic OVC service model: AIDSTAR contractors will understand and establish the standard
level of care for each of the 6+1 services using standards and practices that have been developed with
USG support and GON collaboration. All OVC will receive at least 3 of these services, one of which must be
psychosocial support. These services will be delivered through a family-centered and community-based
model that reaches out to all children in a family infected/affected by HIV/AIDS.
c) Ensure a multi-program and multi-sectoral referral system: AIDSTAR contractors will collaborate and
form linkages/referrals between existing clinical and community-based partners within the geographical area
of focus. In some states, AIDSTAR contractors will serve as case managers that coordinate referrals for
OVC to ensure comprehensiveness of services. Wherever possible, community partners will engage with
and link to clinical service providers; refer clients for HCT, care, and treatment; accept client referrals; and
use this as a starting point to engage families in order to assist all children infected with or affected by
HIV/AIDS.
d) Address girls vulnerability issues: AIDSTAR contractors will focus activities in key Northern and Southern
states where increased vulnerabilities of female girls are common, and provide support for girls'
continuation in, or return to, school as well as improve outreach and linkages with HIV-related health
services, particularly outreach efforts by USG projects (ACQUIRE, ACCESS, and Pop Council).
3. Increase the technical capacity of Nigerian decision-makers and personnel to design and implement
effective, evidence-based HIV/AIDS interventions. Specifically, AIDSTAR contractors will: a) link with State
Ministries of Women's Affairs (SMOWA) in focus states to build technical capacity so that they can roll out
national-level policies, strategies, guidelines, quality assurance, and data collection systems; b) provide
technical support to FMOWAs to plan, manage, monitor and evaluate OVC service provision; and c)
contribute to OVC program M&E in collaboration with the USG SI team and PEPFAR IPs tasked with overall
M&E and SI capacity building.
4. Document and disseminate successful innovative approaches and sustainable models, evidence-based
best practices and lessons learned, and new approaches, tools and methodologies in HIV/AIDS OVC
programming.
Activity Narrative: This activity substantively contributes to the overall USG Nigeria's Five-Year Strategy and to the
implementation of Nigeria's National Plan of Action on OVC by developing and strengthening the
community based service delivery for affected children. The suggested targets are determined based on the
current estimated cost per targets for a minimum package of OVC interventions. As this is an IQC
mechanism, the prime partner and final targets will be vetted with O/GAC and uploaded into COPRS after
final award negotiations. The programs and activities implemented will increase the reach of OVC
underserved populations and geographic areas with fairly high HIV/AIDS prevalence in comparison with the
national average.
The activities implemented under the AIDSTAR IQC will achieve set targets for OVC served and caregivers
trained while also providing clear linkages between their own activities and the wider OVC portfolio as
implemented by other IPs. Strong linkages with the LMS project will be developed as LMS focuses on
institutional capacity building in the FMOWA, while AIDSTAR focuses on increasing technical capacity. The
emphasis on dissemination of best practices will also help develop the sustainability and efficacy of the
program.
Populations targeted in these activities will include all OVC, with particular focus on the female adolescent
OVC in the Northern and Southern parts of Nigeria. Also targeted are community members, traditional
leaders, religious leaders, men and women who act as caregivers for OVC.
Emphasis areas will include human capacity development. The service delivery component of this award
will have a key focus on community mobilization/participation and local organization capacity development.
Other emphasis areas are development of network/linkages/referral system; information, education and
communication and linkages with other sectors and initiatives.
Continuing Activity: 16302
16302 16302.08 U.S. Agency for John Snow, Inc. 7405 7405.08 USAID Track $3,000,000
* Increasing women's access to income and productive resources
* Increasing women's legal rights
Estimated amount of funding that is planned for Human Capacity Development $300,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $100,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $300,000
Estimated amount of funding that is planned for Economic Strengthening $500,000
Estimated amount of funding that is planned for Education $900,000
Estimated amount of funding that is planned for Water $50,000
Table 3.3.13:
These funds will be used to award grants to implementing partners to provide adult and pediatric
antiretroviral (ARV) drugs in underserved areas in Nigeria. The recipient will support the treatment
components of the PEPFAR Nigeria program by ensuring an uninterrupted availability of high quality first
and second-line ARV drugs to clinic sites.
Choice of ARVs to be used on the program will be based on the guidance provided in the National
Treatment Guideline disseminated by the Government of Nigeria. Zidovudine and Tenofovir-based
regimens will dominate the first line regimen for adult patients to be placed on treatment, and second line
regimen will be a combination of nucleoside reverse transcriptase inhibitors (NRTI) and protease inhibitors
(PI). The ARV regimen to be used with children include Zidovudine and Stavudine-based combination for
first line, and a combination of NRTI and PI for those requiring second line regimen. Procurement will be
based on the COP year ARV morbidity-based forecast by team of supply chain experts on the program,
taking into consideration the patient targets and enrollment rates. Provision for a 6-month buffer will be
made in the forecast to ensure an uninterrupted supply of ARVs in the COP year.
High quality ARVs (predominately generic formulation) will be procured in line with US FDA, PEPFAR and
NAFDAC (Nigeria Drug regulatory agency) guidance. Bulk of the ARVs will be procured through the SCMS
mechanism and other suitable procurement agencies to achieve cost effectiveness resulting from
economies of scale. All purchases of Truvada (TDF/FTC) and ZDV-3TC-NVP Fixed Dose Combination will
be procured via SCMS pooled procurement mechanism in line with OGAC's guidelines. SCMS and
procurement agencies used by USG agencies certify packaging and storage conditions during shipping and
provide insurance to the point of delivery at the frontier. Potential collaboration with other agencies will
facilitate leveraging of resources (ARVs supplies and technical assistance) for this program area and
theClinton Foundation will be approached for donation of second line adult ARVs, first and second line
children ARVs .
The storage and distribution of ARVs to service delivery points will be coordinated from the program's
central warehouse and the program will exploit opportunities of integrating this activity with the Nigerian
Government Logistics system at the federal and state levels where possible. To ensure proper management
and utilization, storage facilities at service delivery points will be assessed and supported to meet standard
requirements that will ensure optimum storage; support will include renovations of storage infrastructures,
training of Pharmacists and support staff on logistics management with emphasis on ordering, storage,
inventory management and Logistics Management Information System (LMIS). Periodic LMIS reports from
various sites will be collated and used for program management and improvement. The program will work
closely with the Federal Ministry Of Health in achieving Nigeria's long-term goal of supporting a sustainable
supply chain management system for ART that incorporates and bolsters existing Nigerian institutional
structures and is harmonized with Government of Nigeria (GON) activities.
Quality control measures involve routine monitoring visits by program staff from the central level to sites at
least on a quarterly basis during with implementation of SOPs related to commodity management with be
reviewed and improvement measures discussed with the site staff. This program area may likely result in
the generation of hazardous waste products through expiries of ARVs; affected items will be inventoried and
destroyed in line with relevant national policies at recommended sites using the appropriate mode of
destruction.
CONTRIBUTION TO OVERALL PROGRAM AREA: This activity supports the scale up of ARV treatment in
Nigeria, a major priority for the FMOH. Through these activities, AIDSTAR will continue to strengthen the
structure of its ARV drug procurement system in accordance with PEPFAR goals in order to ensure cost
effective and accountable mechanisms for drug procurement and distribution. Furthermore, efforts to build
local capacity through infrastructure building and training mechanisms are consistent with PEPFAR 5-year
goals to enhance the capacity of supply chain management systems to respond to rapid treatment scale-up.
Additionally, through procurement via SCMS, AIDSTAR seeks to build capacity related to drug procurement
and distribution. This activity also supports the ARV program for adults and children as well as the PMTCT
program for provision of ARVs to pregnant women and infants
LINKS TO OTHER ACTIVITIES: This activity relates to activities in TB/HIV, ART services, and strategic
information. This activity will maintain significant linkages with PMTCT 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.
POPULATION BEING TARGETED: ARV drugs will be offered to HIV positive infant, children and adults.
EMPHASIS AREAS: Emphasis include strengthening of health facility logistics systems to manage ARV
drugs in a sustainable manner, drugs for OI, RTKs and lab reagents and quality assurance, quality
improvement and supportive supervision. areas will
Program Budget Code: 16 - HLAB Laboratory Infrastructure
Total Planned Funding for Program Budget Code: $41,706,290
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
USG Nigeria's COP09 Laboratory strategy builds on the laboratory network created in previous years and works with the
Government of Nigeria (GON) on coordinated high-quality expansion that improves the lab services offered in Nigeria. The
PEPFAR program in Nigeria currently works with eight implementing partners (IPs) that support 261 labs. In COP09 the number
of implementing partners within the lab program area will expand to 17. These partners will be supporting activities in 316 tertiary,
secondary, and primary labs (including 5 mobile labs) in all 36 states of the federation and the Federal Capital Territory (FCT).
Current and new sites will be supported by an additional 2,784 trained laboratorians to increase capacity to conduct an estimated
3,666,953 tests.
Emphasis areas for COP09 include: (1) actualizing the tiered lab system in support of the network of care model; (2) implementing
expanded and harmonized lab quality assurance/quality control (QA/QC) activities, (3) undertaking limited expansion of lab
services to new sites in current and new PEPFAR supported states, (4) continuing the support for the implementation of a
national network for early infant diagnosis (EID), (5) implementing a standard, tiered lab equipment platform for HIV clinical
monitoring, (6) strengthening lab management capacity, (7) supporting improved TB and Malaria diagnostic capability, (8)
implementing selected site biotech engineers training in equipment maintenance, (9) supporting training in shipping and transport
of diagnostic and infectious specimens, (10) working with Strategic Information (SI) team and IPs to standardize and harmonize
the already developed or conceptualized Laboratory Information Management Systems(LIMS) in line with the national guidelines,
and (11) supporting the development of a National Laboratory Strategic Plan.
The USG currently has 11 laboratory staff, most are CDC employees: Associate Director for Laboratory; Senior Laboratory
Specialist; 5 lab specialists (focused in HIV molecular, QA, surveillance/blood safety, TB and procurement/inventory control), 2
Lab staff each for USAID and DOD . USG lab staff and senior IP laboratorians are active participants in the USG supported
Laboratory Technical Working Group (LTWG) which meets monthly to discuss current lab issues, define lab strategies and to
improve harmonization on lab issues. DOD laboratory staff members function additionally as implementing partners for the DOD
Due to funding constraints, expansion of lab infrastructure will occur through maximizing the use of the current lab system with
limited growth to new sites. Development of a true tiered lab system will require continuing coordination with governing bodies at
various levels (tertiary healthcare facilities which are federal institutions, secondary sites are state institutions and primary sites
are supported by Local Government Areas). Down referral of stable ART patients from tertiary level facilities and up referral of
specimens requiring complex testing will become more widespread. The LTWG with the PEPFAR IPs will work with FMOH to
strengthen linkages between labs at various levels to create national lab networks.
In COP09 training for laboratory staff continues to be a priority in order to keep pace with PEPFAR plans. All laboratorians will
continue to receive training on Good Laboratory Practices (GLP), lab safety, and Quality Assurance (QA), presented as a
combination of didactic lectures and lab practical. In COP09, facility based Biotech engineers and equipment maintenance
technicians will be trained on equipment maintenance and repairs as part of sustainability and strategic plan for the Lab system
strengthening. Training will be provided by partners in collaboration with the equipment manufacturers/vendors.
The LTWG in collaboration with American Society for Clinical Pathology (ASCP) standardized, harmonized and adapted
Hematology, Chemistry and CD4 training curriculum in COP08. The LTWG also in collaboration with Association of Public Health
Laboratories (APHL) developed and delivered Laboratory Management training modules to all PEPFAR IPs and Government of
Nigeria staff as a Training of Trainers (TOT) in COP08. Partners will continue to use these training packages for lab trainings in
COP09. Training packages will be stepped down and appropriately customized to match the education and work experience of
the lab staff functioning at the lower levels. Refresher training will be offered to all laboratorians on a yearly basis.
Nine PEPFAR training labs currently provide high quality lab training to large numbers of laboratorians from sites supported by IPs
and GON. In FY09, an additional 2 training labs will be created to further expand trainings provided through these training sites to
larger number of staff from non-EP supported labs. PEPFAR will also support improved TB/OI training and in-service curriculum
for practicing laboratorians.
A systems approach to QA will be continued in 2009; this includes adequate training for all laboratorians using standardized
SOPs / job aids. All labs IPs are responsible for conducting quarterly site monitoring visits using a standardized tool developed by
the IPs, supporting Proficiency Testing (PT) and reporting results to the USG LTWG. In COP09 the LTWG will provide all IPs with
a standardized site monitoring tool developed and piloted in COP08 by the LTWG. The Medical Laboratory Science Council of
Nigeria (MLSCN) is the federal body responsible for licensing laboratory scientists, technicians and assistants and accrediting
medical labs. In COP08, IPs were required to seek accreditation for a limited number of their supported labs with the MLSCN.
This phased lab accreditation process will continue in COP09. PEPFAR will support the MLSCN in the development of a national
PT program and will lend technical support to improve the accreditation tool and provide training in its use.
All IPs developed Standard Operating Procedures (SOP) for their HIV post exposure prophylaxis (PEP) programs in line with the
national guidelines. IPs provide appropriate sharps and bio-medical waste disposal containers to supported sites and ensure
appropriate waste disposal using standard tools developed in collaboration with Making Medical Injection Safe(MMIS/JSI).
In COP08, 21 PCR sites (made up of 19 PCR labs for non- routine viral load and DNA testing of dried blood spots (DBS) for early
infant diagnosis (EID), 1 PCR dedicated to TB testing (HAIN assay), and 1 dedicated to HIV sequencing), were supported by 3
PEPFAR partners. Two additional PCR sites will be established in COP09 to support the growing demand on PCR services for
the expanding EID program. Three of these PCR sites are GON supported labs with technical support from a PEPFAR IP and
equipment procured through Global Fund (GF). In COP07 an EID pilot led to the development of a phased implementation plan
with all participating PCR labs enrolled into the HIV DNA Dried Blood Spots (DBS) PT of CDC Atlanta. Other phases of
implementation of this program will continue in COP09 and PEPFAR Nigeria will continue to work closely with the Clinton
Foundation for procurement of test kits, collection supplies (bundle kits), transport of specimen and results.
The GON has approved the report of the phase one HIV rapid test kit evaluation and the country has adopted serial testing
algorithm that is based completely on non-cold chain-dependent test kits. In COP09 USG will provide technical support to the
GON in the second and third phase evaluation of these HIV diagnostic rapid tests through a multi-GON Agency working group.
All IP supported labs will have appropriate supplies, equipment and trained staff to perform TB diagnosis. In COP09, IPs
supporting sites with high volume TB samples will be providing fluorescence microscopy to improve diagnostic sensitivity and
efficiency. The USG has worked closely with the National TB and Leprosy Control Program (NTBLCP) to adapt and disseminate
the new AFB smear microscopy training package. PEPFAR has supported the National TB Training Center for improved
diagnostic capacity. Appropriate technical guidance on TB culture and sensitivity testing will be provided to the IPs and the GON
by the LTWG to ensure sustainability and efficiency in TB lab diagnosis.
Data management within clinical labs is currently paper-based; which can be time consuming and highly prone to transcriptional
errors. In 2007 and 2008, some IPs have developed and piloted lab information management tools .The LTWG will work with SI
team and IPs in COP09 to standardize and harmonize these Lab information systems across partners in line with the National
Guidelines on SI.
In COP09 USG LTWG will continue to provide technical support in the following areas: lab management training, support for
national QA program, standardized training for CD4/chemistry/hematology, improvements to in-service curriculum, international
accreditation of two tertiary labs, improved TB/OI diagnosis (comprehensive QA system) and improved TB/OI training curriculum,
enhanced smear microscopy TB diagnosis, training of facility based biotech engineers and lab equipment maintenance
technicians.
The approach outlined in this document supports ongoing IP activities as contained in the USG Five-Year Plan for AIDS Relief in
Nigeria and is consistent with the goals of the Technical Advisory Committee for Laboratory of the HIV/AIDS Division (HAD) of
Federal Ministry of Health (FMOH). Over the past years the USG has provided support to the FMOH in the development of the
first National Medical Laboratory Policy. The development of increased laboratory capacity requires policy adoption, strategic
planning, and implementation of activities as defined by the Maputo Declaration on Strengthening of Laboratory Systems in 2008.
In COP09, the LTWG will support the FMOH in developing a National Laboratory Strategic Plan. This will be a 5 year plan that
provides charted course or roadmap for improvement and strengthening the provision and delivery of laboratory services to
ensure equitable access to quality services based on the adequacy and availability of skilled human and other resources inputs
(financial and material). The objective is to improve, strengthen and promote the institutional and operational capacities of
laboratories that will improve their diagnostic and monitoring capabilities.
PEPFAR will continue to support the GON in COP09, in developing the capacity of the Central Public Health Lab. HIV epidemic
has emphasized the Public Health Laboratory's critical role in assessing, leading, and developing health policies. The public
laboratory system has recognized the need for established laboratory priorities for bio-terrorism, emerging and re-emerging
pathogens (e.g., anthrax, SARS, avian influenza. This facility will provide reference support to the GON's HIV program and will be
a lab base for the Field Epidemiology and Laboratory Training Program (FELTP).
Table 3.3.16:
This activity will provide robust comprehensive quality laboratory support for HIV/AIDS treatment programs
and general health services system strengthening in partnership with three state governments to be
identified in consultation with the Government of Nigeria (GoN). The activity will identify, upgrade, and
equip selected secondary level hospital laboratories (1 in each state) to provide comprehensive laboratory
services for the diagnosis, treatment and drug toxicity monitoring for HIV/AIDS and related opportunistic
infections. The laboratories will also be equipped to provide standard laboratory services for HIV diagnosis,
ARV treatment monitoring, and infection control to service the needs of the population within the
catchments areas of the target facilities.
In this model partnership between AIDSTAR and the states governments, Laboratory Infrastructural needs
that will be identified in an initial Lab service readiness assessment, including water and electricity, provided
by the partnering governments, while the partner will provide the needed basic and state-of the-art lab
equipment, and build the capacity of laboratory scientists and other lab staff to use these equipment and
provide lab services following good laboratory practice and standard best practices. The lab equipment that
will be provided in these sites will be in conformity with the guidelines from the Lab Technical Working
Group (TWG) and WHO recommendations on the appropriate use of lab technology and equipment that is
most suitable for the different levels of care . The partner and the partnering governments will jointly recruit
appropriately qualified staff to fill identified positions.
The activity will support 3 laboratories to develop capacities for the following laboratory assays: Complete
Blood Count, Chemistry panel including electrolytes, CD4 counts, serology assays for HIV, syphilis,
Hepatitis including but not limited to HBV and HCV, malaria, pregnancy test, TB microscopy and referral for
TB cultures, and general medical microbiology and blood group serology assays. Capacities for limited
fungal studies will also be developed. Referral linkages will be established with other PEPFAR-supported
facilities with PCR capacities, such as IHVN, APIN and FHI/GHAIN, for RNA based viral load assays for
patients when clinically indicated. Similar referral arrangements shall be used for the provision of Early
Infant Diagnosis (EID) for all identified HIV-exposed infants within the activity's PMTCT and Pediatrics
treatment programs (this activity is also detailed in the Pediatrics program area). Support for EID specimen
collection and shipment will be provided by Clinton Foundation through a collaborative arrangement with the
USG. It is estimated that a total of 15,000 Lab tests will be conducted in COP09 in all the supported sites.
Counting of the number of Lab tests performed will be based on the guidelines from the Lab Technical
working Group (LTWG).
In COP09, AIDSTAR will also be piloting routine cervical cancer screening for HIV-positive females in its
supported site in a selected state. This will be done by establishing referral linkages between 2 activity-
supported comprehensive ART facilities in the state a tertiary level Laboratory where PAP smear services
are offered.
In AIDSTAR's arrangement with collaborating state governments, the activity's Laboratory program will be
staffed with seasoned Medical Lab specialists with cognizant experience in the following disciplines;
Medical Microbiology, Clinical Chemistry, Hematology, Flow Cytometry and Laboratory Management/Lab
Information Management System. This Lab team will be headed by a Laboratory Program Director. To
ensure effective mentoring of site lab staff, after the initial trainings and site preparations, the lab team will
work with site lab staff, on a daily basis for a minimum of one month, providing continuous on the job
training and mentoring,. When AIDSTAR site Lab staff have demonstrated the required proficiency in Lab
services provision, the Lab team will then fall back to providing service quality oversight, supervision and
mentoring on a monthly basis, following the period of mentorship, then quarterly. The outcome of these
quarterly Lab assessments will be shared with the sites, and be fed into a central Lab assessment data
system that will be supported by the LTWG.
AIDSTAR will collaborate with USG IPs with well-established training structures and programs, such as
FHI/GHAIN, IHVN and APIN to provide Laboratory trainings for all Lab staff of the supported facilities. In
COP09, the activity will train a total of 20 Lab staff from the 3 facilities). The trainings will include HIV
Testing based on the WHO/CDC training package; Flow-Cytometry techniques for CD4 enumeration,
Clinical Chemistry, and Hematology, using the training packages developed and adapted for use in Nigeria
by ASCP; and TB AFB microscopy training using the WHO/CDC training package that has been adapted for
use in Nigeria. These will be in addition to the Basic Laboratory procedures, Good Laboratory Practice,
Laboratory Reagents and Equipment Logistics Management, to be provided in collaboration with SCMS,
and Laboratory Information Management System. The Lab managers for each of the supported Labs will
further be trained on Laboratory Management based on the training package developed by APHL, and
Laboratory Quality Assessment and Audit using standard training package that will be identified. The
partner shall further collaborate with Lab equipment manufacturers/vendors to provide specific equipment
trainings that will cover equipment principles and techniques, routine maintenance, calibration, and trouble
shooting. The activity will not have a dedicated Bioengineer in its employment; instead, Lab equipment
maintenance engineers within the supported sites will be supported to obtain the required equipment
maintenance and repairs training from the specific equipment manufacturers/vendors. In COP09, 3 site
equipment bioengineers (1 from each site) will be supported to obtain these specialized training.
The major Lab equipment procurement, warehousing and distribution will be through the Axios mechanism,
while HIV test kits procurement will be through the SCMS mechanism. Other Lab consumables will however
be procured locally using the established facility procurement system. The partner will collaborate with
SCMS to train staff logistics managers on supplies forecasting and general logistics management in order to
build site staff capacity and ensure program sustainability.
In COP09 AIDSTAR will seek accreditation for all of its supported Labs from the Medical Laboratory
Science Council of Nigeria - the government Lab accrediting agency.
During the mentoring period, AIDSTAR's Lab specialists will work with the site staff to develop site specific
standard operating procedures for all Lab processes and procedures including Quality Control and Quality
Assurance processes. In conjunction with USAID, AIDSTAR will provide training and support the
Activity Narrative: implementation of the use of quality control charts to monitor all the internal quality control processes.
Supported facilities will have their capacities built in the local brewing and characterization of heat
inactivated serum and use this for HIV testing proficiency testing program that will be administered to all the
HCT, TB, STI and PMTCT sites that will be supported by the Lab for HIV testing quality assurance. The
Labs will be linked to the PEPFAR supported National Lab QA for Proficiency Testing program.
As part of its Lab safety procedures, AIDSTAR will collaborate with JSI/MMIS to provide medical waste
management and injection safety training to all Lab staff, in addition to procuring standard laboratory
autoclave to ensure potential infectious materials from the Lab are sterilized before being disposed,
following standard procedures. The partnering state governments will be responsible for the procurement of
appropriate hospital incinerators for efficient waste management. Post exposure prophylaxis (PEP)
treatment training shall also be provided and guidelines/protocol for seeking PEP will be developed and
appropriate clinical staff designated for this purpose in all the supported sites.
CONTRIBUTIONS TO OVERALL PROGRAM AREA: The provision of Laboratory services through
AIDSTAR will contribute to strengthening and expanding the capacity of the GON response to the HIV/AIDS
epidemic, build the capacity of laboratory staff at the project sites and contribute to infrastructural upgrade
of the health facilities and provision of necessary equipment. Considering the complexity of antiretroviral
therapy (ART) and the strict requirements for standards and procedures, the laboratory component will aim
to establish a well coordinated and efficient quality assurance, supervision and monitoring system at all
supported sites.
LINKS TO OTHER ACTIVITIES: This program element relates to activities in PMTCT, BC&S, TB/HIV and
HCT. A referral linkage system will be strengthened to ensure that clients are referred from sites with limited
or no laboratory infrastructure to properly equipped laboratory sites using an integrated tiered national
laboratory network.
POPULATIONS BEING TARGETED: This activity will provide laboratory services to PLWHAs (including
pregnant women), HIV positive children, tuberculosis (TB) patients including those that are HIV positive and
are eligible for ART, HIV positive infants and other most at risk populations (MARPS). These clients will be
generated from PMTCT, Care and Treatment, facility based counseling and testing and TB-HIV programs.
EMPHASIS AREAS: Major emphasis area for the partner's Lab program is human capacity building. This
will be done through training and mentoring of Lab staff in all of its supported sites. A second emphasis area
is sustainable health infrastructural development which the partner hopes to achieve through its model
partnership with state governments in the provision of basic infrastructures in all the hospitals that will be
supported, while the human capacity building and all lab equipment needs will be provided by the activity.
Estimated amount of funding that is planned for Human Capacity Development $175,000
