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MTCT: PMTCT: In COP010, the 7D-PMTCT project will continue to increase access to PMTCT services for pregnant women by building community support for PMTCT and increasing the capacity of health facilities to provide PMTCT services. 7D will use existing diocesan AIDS structures and Parish AIDS Volunteers (PAVs) to create demand for PMTCT services through social mobilization campaigns in two ways. Firstly, PMTCT Point of Services (POS) will establish a network of Primary Health Care Centers that will provide basic ANC and Counseling and Testing Services for everyone including pregnant women. Secondly, educational sessions on PMTCT followed with Counseling and Testing (CT) will be done during outreach activities.

The PMTCT package will include Group CT using opt-out strategy with same day results in ANC, Labor and delivery. Other include partner counseling and testing, OI treatment and prophylaxis, like malaria and Pneumocystis Jiroveci Pneumonia prophylaxis using cotrimoxazole and management of diarrhea. The project will also provide infant feeding counseling during first and subsequent ANC visits with key messages like exclusive breast feeding for the first 6 months or avoiding all breastfeeding if replacement feeding is acceptable, feasible, affordable, sustainable and safe. ART prophylaxis for pregnant women using Zidovudine at 28 weeks with single dose Nevirapine at onset of labour for mother and single dose Nevirapine and one week of Zidovudine for the infant or a combination of Zidovudine and Lamivudine at 34 weeks for mother with the same regimen one week post partum for mother and single dose

Nevirapine and one week Zidovudine for the infant will be provided.

Free baseline hematinics, STD screening, CD4 Count to assist with determining need for immediate therapy and viral loads where possible for monitoring HIV progression, will be conducted to all pregnant women accessing PMTCT in 7D supported sites. ARV treatment when indicated during pregnancy improves the health of the woman and decreases the risk of HIV transmission to the infant; where these services are not available, they will be referred to facilities including AIDS Relief (AR) ART sites and other IPs. A significant numbers of 7D PMTCT Sites are positioned within AIDS Relief (AR), FGON and IPs' ART networks to which women who need ART will be referred. Since 7D and AR PMTCT Team functions as a unit and are co-located in 90% of sites, seamless transition of patients between the two will be initiated. This will happen in two ways. The first way is through the existing co-location in facility. Since 7D PMTCT and AR ART are already located in the same facilities in current 7D PMTCT sites, women determined by a lower CD4 Count (<350) to be eligible for ART in accordance with the national PMTCT guidelines, will be taken up by AR for full ART. Secondly, for co-location in geographic area, 7D PMTCT attendants who qualify for ART will be referred to an AR sites where they will receive ART. This referral mechanism will function since 7D and AR PMTCT Teams currently function as an integrated team that plans and executes tasks as one unit. To prevent double counting or loss of clients to AR, all clients from 7D that access services from AR sites are required to provide proper documentation (like a referral note) before the client is taken up by AR; the same will apply for AR clients seeking treatment at 7D sites.

For clients with CD4 count >350 and not requiring ART, the nationally recommended short course will continue to be available. This includes Zidovudine from 28 weeks, and single does NVP at onset of labor for mother and single dose Nevirapine and one week Zidovudine for infants; All HIV-exposed infants will be provided with cotrimoxazole from 6 weeks for at least 6 months, preferably until HIV infection has been ruled out. 7D PMTCT sites will abide by existing national guidelines on PMTCT. It will also ensure that all 7D PMTCT sites have the approved PMTCT registers and other required M&E tools.

7D will refer clients for HIV infant diagnosis testing in line with the nationally recommended Early Infant Diagnosis Initiative from 6 weeks of age using Dry Blood Spots. Infants will also be linked to immunization services to access the WHO/UNICEF and FGON recommended set of vaccines. This will be done in health facilities that provide immunization services in areas where 7D operates.

7D will continue to collaborate with Traditional Birth Attendants (TBAs) through trainings using nationally recommended curricula and provision of PMTCT HBC kits and information packs for effective support of pregnant women who choose to give birth outside health facilities. Trained TBAs are expected to work in partnership with the health center with back and forth linkages. Two TBAs from each of the 13 PMTCT

sites will receive refresher trained and one TBA from 12 partner arch/dioceses will also be trained resulting in 38 re-trained TBAs. The expected outcome of the TBA training will be improved obstetric practices and awareness on key PMTCT issues.

To ensure quality, supervisory visits will be made by diocesan and CRS staff monthly to each site. These will continue through COP010. M&E tools will be standardized with national tools and disseminated to all arch/dioceses in COP09 and maintained through COP010. Volunteers will continue to be sensitized on PMTCT, maternal nutrition and safe infant feeding practices for correct PMTCT service provision. Volunteers will support mothers' infant feeding choices through on-going counseling. CRS will also ensure all PMTCT sites benefit from the ongoing collaboration between SUN and MARKET on nutritional support to four OVC's project partners. These are Makurdi, Otukpo, Jos and Shendam.

Support and capacity building given to Abuja, Ibadan and Makurdi provincial structures in COP09 will continue in COP010. This support has encompassed engagement of key points of staff including PMTCT and financial management specialists.

Targets for COP010 include 11,455 pregnant women counseled, tested and receiving results, 650 pregnant women placed on ARV and retraining of 30 health care workers using national PMTCT curriculum in 13 sites. Test kits will be procured centrally through the USG supply chain management system.

All collaborative initiatives put in place with AR from the era of COPO7 Plus Up funds through COP09 will be improved upon in COP010. These initiatives enabled 7D collaboration with AR in leveraging resources and expertise through forming a PMTCT Team that plans and responds to 7D, AR and partner PMTCT needs coherently. Partner PMTCT capacities have been enhanced through training of POS staff and archdiocesan PMTCT Co-ordinators. Site antenatal clinic refurbishment and laboratory support have also been done. These activities will continue throughout COP010

CONTRIBUTIONS TO OVERALL PROGRAM AREA Activities that were conducted in year 2009 that will continue in 2010 include CT, HBC, and Support Groups for HIV positive pregnant women. Infant feeding counseling in all sites will be undertaken; this will be done right from the time pregnant women start their antenatal visits. These PMTCT services will continue to contribute to several of the PEPFAR goals. The goal of preventing new infections by offering CT services to pregnant women, as well as providing PMTCT prophylaxis to prevent infecting the newborn child is already contributing to prevention of new infections.

Issues of violence against women after disclosure of HIV status are a grim reality which will be tackled

during Couple Counseling sessions as a pre emptive measure. PMTCT-specific HBC, are being provided to pregnant women by PAVs. Support groups provide participants with coping mechanisms for addressing stigma and discrimination towards PLHWA. These activities will continue in COP10.

LINKS TO OTHER ACTIVITIES PMTCT activities will be linked to CT (3.3.09), ART (3.3.10 and 3.3.11) services, care and support (3.3.06), TB/HIV (3.3.07), and OVC (3.3.08) services. 7D has established referral linkages with TB DOTs centers and other health care facilities to ensure that PMTCT clients are treated for TB, STIs and other opportunistic infections. However there will be STI and opportunistic infection treatment in 7D supported health facilities. 7D will work closely with AR for ART services where project activity areas overlap. Referral coordinators have been employed to ensure timely referrals to services offered by other implementing partners. This area has been identified as a "best practice" that needs support both at state and national levels. 7D will continue linking with the GON by sending copies of her reports to them and attending PMTCT Task team meetings on a regular basis. Also there are plans to link the sites to GON drug program for sustainability even when the present source ceases.

POPULATIONS BEING TARGETED Pregnant women and HIV + pregnant women, HIV-exposed infants, care givers, partners, religious leaders and affected children are the populations being targeted.

KEY LEGISLATIVE ISSUES ADDRESSED Gender-activities have been organized with the aim of addressing inequalities between men and women and subsequent behaviors that increase the vulnerability to and impact of HIV/AIDS. Women's legal rights and access to income and productive resources will be carried out through linking care and support programs to income generation activities within 7D SUN programs.

Work has been done to reduce the stigma associated with HIV status and discrimination faced by PMTCT mothers and their families through support group membership. This aspect is will be enhanced in the COP010.

EMPHASIS AREAS The major emphasis area is developing the capacity of Partners to effectively manage the PMTCT program with a focus on sustainability. The minor emphasis areas are: improving linkages /networks/referral systems between the communities and the 7D PMTCT sites

In COP10, under 'PEPFAR Nigeria's accelerated PMTCT plan', CRS 7D, will strengthen its support to PMTCT service delivery by implementing activities that further improve the coverage and quality of

PMTCT services. These activities will be directed towards increasing utilization of PMTCT services at existing service outlets through demand creation in collaboration with community resources and ensuring the upgrade of existing supported PHCs offering stand alone HIV counseling and testing to render at least minimal package of PMTCT services. In order to leverage resources, priority will be given to PHCs located in the selected focal states with presence of other donor agencies and in local government areas already earmarked for HSS support through GFATM. Where new sites are envisioned, those that are used for national ANC sero-sentinel surveys but yet to commence PMTCT services as well as PHCs located in communities with high HIV prevalence rates above the National average will be given priority.