ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

In COPs 08 and 09, the Christian Health Association of Nigeria (CHAN) Nigeria Indigenous Capacity Building (NICaB) project used drugs donated by the Clinton Foundation and leveraged training resources from other USG-funded IPs to provide PMTCT services at 12 facilities in 6 states of Abia, Benue, Delta, Oyo, Sokoto and Taraba. Services provided included HIV counseling and testing at the maternity, EID and infant feeding counseling. Prophylaxis was given to pregnant mothers, while those who needed HAART for their own health were referred to the ART clinic. Community health workers promoted PMTCT, and followed up Mother/infant pairs within the community to provide support for infant feeding choices and provide referrals in case of complications. In COP 2010 this activity will continue as before, conducting EID and infant feeding counseling components under the pediatrics care and support program area. Additionally, NICaB will continue to facilitate the formation of PMTCT committees where this committee does not already exist and facilitate their monthly meetings with the aim of supporting the states to develop a scale up and implementation plan.

The Christian Health Association of Nigeria (CHAN) Nigeria Indigenous Capacity Building (NICaB)

project utilizes a network model with PMTCT care centers linked to secondary level CHAN member institution health facilities "hub sites" that provide more complex PMTCT care and lab testing, to reach HIV+ women with HIV related services. In COP2010, 6819 women will receive PMTCT counseling & testing and receive their results through networks that include 12 hub and 12 spoke sites, giving a total of 24 PMTCT sites supported in 6 states of Abia, Benue, Delta, Oyo, Sokoto and Taraba. This activity will take advantage of all women being tested and counseled including negative women - so they stay negative and positive women to avoid cross infection due to increased vulnerability during pregnancy.

As part of the USG local government area (LGA) coverage strategy in PMTCT, CHAN NICaB will support PMTCT services at sentinel survey sites in Abia state slowly expanding to primary health center level as resources become available. PMTCT stand alone points of service in the network are linked to adult and pediatric ARV care through utilization of a PMTCT consultant coordinator and the health facility coordinator in each network based at the hub site, network referral SOPs, monthly PMTCT network meetings, and incorporation of team approaches to care in all training and site monitoring. Meetings with the State Action Committees will be facilitated that will lead to the formation of a state PMTCT committee in order to strengthen the scale up and implementation plans in 3 NICaB states of Abia, Sokoto, and Delta. In line with the National PMTCT guideline, HIV+ pregnant women with CD4 cell count of 350 or less require HAART for their own health and they will be linked to an ARV point of service at CHAN member institutions (MIs), and facilitate linkages between HIV exposure status on mother's and child's health card for mother/infant pairs. Particular emphasis will be placed on the involvement of community health workers who are the primary source of care for women in the pre and post-partum period and are integral to a program that seeks to engage women where they seek care. This program will work closely with the care and support team to maximally engage community based PMTCT and ARV linkages. In addition to receiving PMTCT services, each HIV+ pregnant woman will be referred to OVC services in order to facilitate care for all of her affected children.

Provider initiated testing and counseling with opt-out option and with same day test results will be provided to all women presenting for ANC and untested women presenting for labor and delivery. All women would be provided pre-test group health information services on prevention of HIV infection including the risks of MTCT using members of mother to mother support as lay counselors. Male involvement in PMTCT will be strengthened by promoting couple counseling and partner testing will be offered as part of counseling through referral to on-site HCT centers. A step down training of couple counseling and prevention for positives package will be utilized in all sites. This will provide an opportunity to prevent heterosexual transmission, and reduce incidence of violence against positive partners, especially in discordant couples. Master trainers for HCT already trained in COPs 08 and 09 at CHAN comprehensive sites will in turn train labor and delivery staff in the use of HIV rapid tests for women who present at delivery without antenatal care.

An anticipated 259 HIV+ pregnant women will be identified and provided with a complete course of ARV prophylaxis (based on CHAN NICaB's current program 5%). HIV+ women will have access to lab services including CD4 counts without charge. This will be available on-site or within the network through specimen transport. Women requiring HAART for their own health care will be linked to a network ARV center. For the anticipated 2/3 of women not requiring HAART, the current WHO recommended short course ARV option will be provided which includes ZDV from 28 weeks or ZDV/3TC from 34/36 weeks, intra-partum NVP, and a 7 day ZDV/3TC post-partum tail. Women presenting in labor will receive single dose Nevirapine (sdNVP) and a 7 day ZDV/3TC post-partum tail. All HIV+ women will be linked post- partum to an HIV/ARV point of service, which will utilize a family centered care delivery model whenever feasible, co-locating adult and pediatric care and providing linkage to family planning services. Positive pregnant women with CD4 <350 will be placed on co-trimoxazole preventive therapy in the 2nd and 3rd trimesters. Women frequently face barriers to facility-based treatment access as a result of demands on them for child care and to contribute to the family economic capacity. To address this, mobile clinic outreach as described in the ARV service provision and care and support narratives will be integrated at the community level to bring services to women who otherwise will opt-out of care and treatment.

Health workers at facilities and community levels will be trained to counsel HIV+ women pre- and post- natally regarding exclusive breast feeding during the first six months of life or exclusive breast milk supplements (BMS) if Acceptable, Feasible, Affordable Sustainable and Safe (AFASS) using the WHO UNICEF curriculum adapted for Nigeria. Couples counseling or family member disclosure will be utilized to facilitate support for infant feeding choices. Consistent with national policies on importation of infant formula and recent concerns regarding appropriate use of BMS, CHAN NICaB will not utilize emergency program funds to purchase BMS. As part of OVC programming CHAN NICaB will provide safe nutritional supplements as well as water guard, bed nets and other home based care items. HIV+ women will be linked to support groups in their communities which will provide both education and ongoing support around infant feeding choices and prevention for positives. PLHA are currently engaged at CHAN NICaB ARV points of service as treatment support specialists. The use of dedicated treatment support specialists for PMTCT in the clinic and community will be expanded based upon the successful "Mothers to Mothers" model in Southern and East Africa. This will ensure that HIV+ women remain in care throughout pregnancy and receive appropriate services for herself and her infant during follow up.

Infant prophylaxis will consist of single dose NVP with ZDV for 6 weeks in accordance with Nigerian National PMTCT Guidelines. Cotrimoxazole suspension is provided to all exposed infants pending a negative virologic diagnosis. CHAN NICaB will collaborate with USG supported laboratories for DNA PCR. Testing of infants will be carried out using dried blood spot (DBS) specimen collection. DBS specimens from PMTCT sites in the network will be pooled at the hub sites from where they will be taken

to nearby USG supported labs by trained lab personnel for DNA PCR. A systematic coordinated approach to program linkage will be operationalized at the site level and program level including linkages to adult and pediatric ART services, OVC services and basic care and support. Quality monitoring will be undertaken through site visits using an existing assessment tool and routine monitoring and evaluation indicators. Hospital coordinators will supervise activities on a daily basis while the NICaB clinical coordinator will collaborate with the USG TWG and GON to conduct quarterly site visits. Reports of activities will be sent to the USG and copies to NACA. The NICaB project will work with community based workers including traditional birth attendants to support the already wide spread practice of male child circumcision

The CHAN NICaB project will train and provide refresher training to an average of 4 health care workers (HCWs) from each of the 24 sites including 48 nurse/midwife, 12 community-based health workers and 12 trained traditional birth attendants (TBAs) in the provision of PMTCT services and infant feeding counseling. The national PMTCT training curriculum, national infant feeding curriculum and new national training tools currently under development will be utilized. TBAs will be trained using a version of the PMTCT National Curriculum that has been adapted and modified for TBAs which focuses on HCT and referral of HIV+ women. Thus the total direct training target is 72.

CONTRIBUTIONS TO OVERALL PROGRAM AREA: This activity will provide counseling & testing services to 6819 pregnant women, and provide ARV prophylaxis to 259 mother and infants pairs. With 72 operational sites, the PMTCT activity is in line with the desire of the GON to have 1,200 PMTCT sites operational by 2009 and the USG's target of having 80% PMTCT coverage.

LINKS TO OTHER ACTIVITIES: This activity is linked to care and support BC&S, OVC , ARV services, laboratory infrastructure, condoms & other prevention, AB , and SI. Prevention for positives counseling will be integrated within PMTCT care for HIV+ women. The basic package of care provided to all HIV+ patients will be available to HIV+ pregnant women. Positive pregnant women will be linked with nutritional support for women where they exist. CHAN NICaB lab staff will ensure that HIV testing provided within the PMTCT context is of high quality by incorporating PMTCT sites into the laboratory QA program. CHAN NICaB will collaborate with UNICEF in the support of PMTCT services at some sites, leveraging their training expertise and other resources without duplication and creating a more sustainable service support structure. POPULATIONS BEING TARGETED: This activity targets pregnant women who will be offered HCT, HIV+ pregnant women for ARV prophylaxis and infant feeding counseling, and exposed infants for prophylaxis and EID. Couple counseling will be used to reach partners of pregnant women so as to reduce instances of violence

following disclosure and family members will be counseled to provide support of pregnant and breast feeding mother.

EMPHASIS AREAS The key emphasis area is training as most supported personnel are technical experts. A secondary emphasis area is network/ referral systems as networks of care will be supported which are critical to ensuring quality of care at the PHC level, identifying women in need of HAART, and ensuring access to HAART within the network. In addition, partners and PABAs will be identified for linkage to care and support services. In addition, this activity addresses gender since treatment will be provided to women and will focus on family centric issues including male involvement in PMTCT programming.

In COP10, under 'PEPFAR Nigeria's accelerated PMTCT plan', CHAN, 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.

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