During COP10, Harvard will provide PMTCT services to 65,500 pregnant women at 64 sites, ART services to 57,200 patients at 24 sites, HIV-related basic care and support services to 79,675 patients, and additional care services to 2,500 orphans and vulnerable children. We aim to enroll 7,900 new patients on ART. In addition, we will provide HIV counseling and testing services to 8,500 individuals, and prevention services focused on abstinence and/or be faithful (AB) messaging for 4,355 individuals and on messaging focused on behavior change beyond AB for an additional 35,000. Program activities will take place in 10 target states of Nigeria.

Health system strengthening is a crucial element of our program. REDACTED. Furthermore, we have implemented a network of care model, which links primary healthcare centers (PHCs) and secondary level hospitals to tertiary care institutions, facilitates long-term sustainability of services, multi-level capacity development, and strong community linkages to ensure access to care at the community level.

The foundation for our efforts in the area of health system strengthening are comprehensive training programs for physicians, nurses, lab personnel, pharmacists, counselors, community health workers, data management personnel and others who work with HIV patients. During COP10, nearly 1,200 personnel will be trained in the provision of ART services, 363 personnel on the National PMTCT Training curriculum, 985 in the provision of clinical prophylaxis and treatment of HIV/TB co-infected individuals, 384 in SI in order to build capacity and the sustainability of both site-based and national M&E systems, 324 personnel in prevention activities, 280 in safe injection practices, 140 in blood safety and 650 in laboratory services. To build the capacity of our sites in pharmacy and logistics management and pharmaceutical expertise, we will conduct a variety of on-site training workshops as well as centralized workshops in Abuja throughout COP10.

To further strengthen the overall health system, Harvard has worked with in-country staff to develop standardized protocols for clinical management, laboratory testing and pharmacy handling which conform to an optimized standard of care. We have established an ART supply chain and logistics management system and a central warehouse and distribution system. During COP08, we established a local NGO,

APIN Ltd./Gte. (APIN), which subsequently received direct funding for the management of two former Harvard sites (PHC Iru and Sacred Heart Lantoro) and support for 40 TB-DOT centers in Oyo State. At the beginning of COP09, 4 additional Harvard sites (NIMR, LUTH, Onikan, and Mushin) were also transferred to APIN.

Through each one of our program areas, we target a number of cross-cutting issues. REDACTED. We address the area of food and nutrition through HBHC, PDCS, OVC and PMTCT. More specifically, in our pediatric and adult programs, we monitor anthropometric measurements and dietary issues to support our clinical management of HIV disease. All patients are provided with nutritional counseling and supplements, including multivitamins. In the PMTCT program, all mothers are counseled on safe feeding practices and provided follow-up care to ensure safe motherhood. For patients that are unable to come to the clinics, HBC teams assist them on a variety of issues, including nutritional support. Through our HBHC, PDCS and OVC activities, we also address the area of economic strengthening through facilitating access to economic empowerment and education. In addition, through our care and support activities, we also address the area of safe water by providing water vessels and Water Guard in our basic care kits. We address the area of gender by streamlining access to services for women and the issue of gender- based violence through our system of referrals as well as provision of PEP to victims of rape. The key issue of TB is addressed through HBHC, PDCS and TB-HIV through the screening, treatment and monitoring of co-infected patients.

During COP09 and continuing into COP10, we have been employing various strategies to achieve improved economies in procurement. In line with OGAC's recommendations, we will continue to work with SCMS for purchasing of first-line ARV regimens for our program sites. In order to reduce costs on procurement of laboratory supplies, Harvard has established contracts with local vendors and will work with APIN through COP10 to ensure a smooth system of purchasing. In the past, each site had separately established maintenance contracts for major laboratory equipment and during COP10, Harvard and APIN will leverage bargaining power to work towards negotiating a single contract covering all program sites at a more economical rate.

During the first year of our program, a database system containing all information required in the course of care and treatment was developed. This system is used at all clinical sites, and is updated as needed to ensure that it supports the provision of high quality clinical care and is responsive to GON indicators. The Harvard electronic record system facilitates access to pharmacy pick-up data, lab results, and other clinical information. During COP10, information from these databases will be used for site and program- specific evaluation of services provided in each of our program areas, including evaluations of CD4 counts, loss to follow-up and viral suppression. Through our work at 68 Military Hospital, we will also conduct a focused analysis on military populations. In addition, Harvard will support APIN in their

collaboration with the National M&E working group and their participation in experience sharing. Our goal is to develop the capacity for an integrated M&E system that is responsive to stakeholders and supports the sustainability of Nigeria's ART program.

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ALTHOUGH THE SEXUAL PREVENTION NARRATIVE FROM COP09 HAS BEEN SPLIT INTO SEPARATE NARRATIVES (HVAB AND HVOP) FOR COP2010, THIS ACTIVITY IS UNCHANGED FROM FY2009.

NARRATIVE: In COP10, Harvard will continue to provide sexual prevention programming activities in line with the overall PEPFAR Nigeria goal of providing a comprehensive package of prevention services to individuals reached, thereby improving the effectiveness of this messaging, through a balanced portfolio of prevention activities including abstinence and be faithful messaging (HVAB) along with condoms and other prevention (HVOP). By the end of COP09, Harvard was conducting HVAB activities in 9 states, including Benue, Borno, Enugu, Kaduna, Lagos, Oyo, Ogun, Plateau and Yobe. Through its other program areas, Harvard has a large population of HIV-positive adults, adolescents and children to which it is already providing services; this group forms part of the core target population for age-appropriate HVAB messaging that is provided by Harvard through its prevention with positives (PwP) activities, including STI screening and management, sexual risk reduction, disclosure, adherence, reduction of alcohol consumption, and testing of sex partners and children in the HIV clinic setting. In addition, Harvard will target activities to HIV-negative persons in its catchment areas in order to minimize their risk behaviors and contribute to an overall reduction in HIV prevalence.

In COP10, Harvard will implement HVAB activities at both the facility and community levels utilizing the minimum prevention package strategy as contained in the National Prevention Plan. This package includes: 1) community outreach campaigns; 2) peer education; 3) infection control activities; and, 4) STI management/treatment. The goal of the program is to focus on targeted communities and to saturate those communities with messages conveyed in multiple forums. Utilizing such a methodology, a large number of people will be reached with HVAB messages.

HVAB activities conducted at the local level by Harvard will be reinforced through national level mass media campaigns by other USG partners, such as the successful Zip-Up campaign. HVAB messages promoting abstinence, mutual fidelity and addressing issues of concurrent and multiple sexual partnerships will be balanced with concurrent condoms and other prevention messaging where appropriate and will be integrated with treatment and care services at 66 sites and be implemented by 2 stand-alone HCT providers.

A key age group for HVAB activities is youth/young adults aged 15-24 years as this encompasses the highest prevalence age group. The 2005 ANC survey in Nigeria indicated that the 20-29 year old age group has the highest HIV prevalence (4.9% compared to a national prevalence of 4.4%). In addition, the 2005 National HIV/AIDS and Reproductive Health Survey (NARHS) demonstrated a low risk perception (28%) among the general population and significant reports of transactional sex (11%) among young women aged 15-29 years. This age cohort for both men and women represents the working age group in Nigeria; it is expected that a combination of prevention messaging approaches will ensure they are reached with prevention interventions. Harvard will reach beneficiaries through community awareness campaign, peer education models and peer education plus activities within the year.

A community awareness strategy will also be employed to serve the catchment areas of the hospital facilities, which will be linked with community mobilization efforts promoting HCT. During static and mobile HCT services, counselors will be disseminating HVAB messages to recipient communities and clients through focused group discussions and interpersonal communication. With an HCT target of 14,000 clients getting CTR, a minimum of this many clients will receive HVAB messaging through this approach. The key messages that will be conveyed are delay in sexual debut, secondary abstinence, mutual fidelity, prompt and complete treatment of all STIs and promotion of need to ascertain HIV serostatus through HCT.

Harvard will also use the peer education model to target job peers who are healthcare workers. Healthcare workers at each site will be trained using established National peer education curricula and each will be requested to form peer groups of approximately 10 members from the healthcare worker community for dissemination of HVAB messaging. It is anticipated that these healthcare workers will continually serve as conduits for age-appropriate prevention messaging not only for their work peers, but also for their social peers and all clients with whom they come in contact.

The target for the AB messaging campaign is 4,355 individuals. Additional staffing and training of counselors will also be provided by this funding, including a dedicated fulltime staff person. This activity will provide support for training of 366 individuals in AB messaging.

EMPHASIS AREAS ABC programming emphasizes local organization capacity building, human capacity development and efforts to increase gender equity in HIV/AIDS programs. These activities also promote a rights-based approach to prevention among positives and other vulnerable members of society and equal access to information and services. Reduction of stigma and discrimination are also key to the program. Through ABC activities, we place major emphasis on community mobilization and participation, as an element of outreach for prevention efforts. Additionally, we place major emphasis on training, infrastructure and human resources in order to build the capacity of counselors and providers in a full range of prevention strategies. We also place emphasis on IEC as an essential element of outreach to high-risk populations, and on developing networks for linking these activities to HCT, PMTCT, and other ART activities to serve as a source of prevention information. Emphasis areas also include military populations, through support for ABC activities at 68 Military Hospital and Military Hospital Ikoyi, Lagos.

These activities address gender equity issues by providing equitable access to prevention services for men and women. In some cases, our activities seek to target men who may be at high risk for HIV in order to promote condom use as a means of prevention and access to services for their sexual partners. Male targeted counseling seeks to address male norms and behaviors in order to encourage safer sexual practices. Strong prevention programs that accommodate the array of societal and cultural norms can also help reduce stigma and discrimination. Providing services at the community level will serve as an important platform from which general HIV/AIDS information can be provided and risk reduction strategies discussed.

POPULATIONS TARGETED: Key populations targeted are the healthcare community in treatment facilities, PLWHA, youths and adults accessing HCT services at either static or mobile within catchment areas of the treatment sites, support group members and immediate families of PLWHA. Other target populations include religious leaders. Targeting these populations is important to encourage HCT and use of prevention measures. Health care workers will also be targeted for training on the most effective prevention measures for various risk groups.

CONTRIBUTION TO OVERALL PROGRAM AREA These prevention activities are consistent with PEPFAR's goals for Nigeria, which aim to support a number of prevention strategies as a comprehensive prevention package. In order to be maximally

effective, the prevention messages developed at different sites will be tightly targeted to various risk groups that they serve. Furthermore, these activities are consistent with the PEPFAR 5-year strategy, which seeks to scale-up prevention services, build capacity for long-term prevention programs, and encourage testing and targeted outreach to high-risk populations. The establishment of networks and referral systems from prevention efforts at the community level to PMTCT and HIV care and treatment will help facilitate the scale-up of the overall program. Additionally, as part of our sustainability building efforts, Harvard will provide technical assistance and support for APIN to assume program management responsibility for all ABC activities. This will include the implementation of a plan to transition site oversight, management and training over to APIN. The goal of such efforts is to provide for greater assumption of responsibility for management and implementation of PEPFAR programming by Nigerian nationals through an indigenous organization.

LINKS TO OTHER ACTIVITIES: HVAB activities relate to HVOP. They relate to HCT (HVCT) by increasing awareness of HIV. They also relate to Adult Care and Treatment (HTXS and HBHC) and Pediatric Care and Treatment (PDTX and PDCS) activities through dissemination of information by home-based care providers and ultimately by decreasing demand on care services through decreased prevalence. Linkages also exist to OVC programming (HKID) by targeting OVC. These activities are also linked to TB-HIV activities in that prevention messaging will be disseminated to individuals who are provided with HCT in a TB setting. Through training of personnel, these activities also link to Health Systems Strengthening (OHSS). As certain activities focus on gender-related issues, this program area also links to the cross-cutting area of Gender.

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ACTIVITY UNCHANGED FROM FY2009.

NARRATIVE: COP10 funding will support a comprehensive PMTCT program in line with the revised National PMTCT Guidelines (2007), at 64 service outlets in 9 states (Benue, Borno, Ebonyi Enugu, Kaduna, Lagos, Oyo,

Plateau, and Yobe). This consists of 10 tertiary, 21 secondary and 33 primary sites. "Opt-out" testing and counseling with same-day test results will be provided to all pregnant women presenting at antenatal care (ANC) or labor and delivery (L&D). The current level of PMTCT testing and counseling uptake from women presenting for ANC or L&D is 90%. All women are provided post-test counseling services on prevention of HIV infection, including the risks of MTCT. They are encouraged to bring partners and family members for on-site HCT. The program has a target of providing C&T results to 65,500 women. PMTCT prophylaxis will be provided to approximately 3,275 women in line with the national guidelines. Infant follow-up care linked with PMTCT activities includes nutritional counseling and support, growth monitoring, co-trimoxazole prophylaxis, HIV testing, and other preventative care services. It is estimated that of the infants tested for HIV infection, 131 will be HIV-positive; these infants will be referred to the pediatric basic care and support program. EID will be carried out using whole blood at the tertiary and DBS at the secondary and primary level in line with the national EID scale up plan.

Through this program area, Harvard will provide linkages to other prevention, care and treatment services. All ART-ineligible women will be placed on zidovudine from 28 weeks and or zidovudine and lamivudine from 34 weeks until delivery and will be enrolled into palliative care services (HBHC) at the time they access MTCT services Following delivery, mothers will be monitored in the HBHC program, where services include on-site enrollment or referrals for family planning and other reproductive health services. In addition, PMTCT services are integrated into a system of maternal and child health services designed to promote maternal and child health for all women. All ART-eligible pregnant women will be provided with ART through the adult treatment (HTXS) program area in line with the PMTCT guidelines. Children who become HIV-infected during the time they are being monitored as part of the MTCT program area will be linked to the pediatric treatment (PDTX) and care and support programs (PDCS). Those HIV-exposed children placed on single dose nevirapine at birth and zidovudine for 6 weeks that remain uninfected at 18-months following the completion of ARV prophylaxis will be linked to the OVC program (HKID) for continued care services.

Counseling on infant feeding options will be conducted during the antenatal period, at L&D and/or at infant follow-up visits using the National PMTCT and Infant Feeding Guidelines. Infant feeding counseling will be performed in an unbiased manner and women will be supported in their choice of method. Clients will also be counseled on the beneficial effect of couple/partner HCT/disclosure on adherence to infant feeding choice. A follow-up team consisting of counselors and a home-based care (HBC) support group of PLWHAs will assist in home and community tracking of positive mothers to provide nutritional support and ascertain infant diagnosis. This funding will support the ANC, labs, ARV prophylaxis intervention to mothers and babies (not ART), and personnel involved in PMTCT.

A regular training program will be established at all sites to train and retrain 363 health personnel

involved in the PMTCT program using the National PMTCT Guidelines. Non-laboratory personnel will also be trained in HIV testing. Indirect targets include training traditional birth attendants (TBAs) using an adapted curriculum in local areas near sites in PMTCT counseling, training PMTCT counselors in the National PMTCT Program, providing technical assistance for the development of the National Infant Feeding Counseling Manual, and providing a zonal training of trainers with this manual. This training supports PMTCT efforts at all national PMTCT centers; Harvard proposes that all pregnant women tested and receiving results at national PMTCT sites are indirect targets.

During COP08-COP09, Harvard piloted a clinical quality assessment (QA) for PMTCT activities at a number of our sites. During COP10, Harvard will continue to conduct QA activities to improve quality of care in our PMTCT programs. The program will also continue to monitor and utilize electronic data captured through SI activities to measure the quality of services provided as well as the associated patient outcomes and transmission rates.

Harvard has partnered with other implementing partners (IPs) in the implementation of the PEPFAR- Nigeria local government area (LGA) coverage strategy in the program areas of PMTCT, OVC and TB/HIV, designed to ensure the provision of PMTCT and TB/HIV services in at least one health facility in every LGA of 6 identified states. Per patient costs reflect the expansion to at least 33 new sites and scale up as a part of this LGA coverage strategy in Plateau State. Under the coverage strategy, these facilities are all linked with primary health facilities, which provide HCT and referrals for PMTCT services for HIV- infected mothers. Harvard will leverage FMOH, UNICEF and other IP support in capacity building/training in identifying new PMTCT sites in its scale-up plans. Harvard will strengthen the Benue state PMTCT committee as part of the LGA coverage strategy. Harvard will support one quarterly PMTCT task team meetings as part of the support to the GON.

EMPHASIS AREAS This activity will place major emphasis on the development of networks through expansion into more local areas through a network of secondary or primary PMTCT clinics, with rural outreach to community healthcare workers and TBAs involved in home delivery; all community workers and TBAs with whom we work are linked to tertiary health care facilities. In addition, major emphasis will be placed on building organizational capacity in order to work towards sustainability of PMTCT centers and further expansion of the Nigeria PMTCT program in conjunction with the FMOH and USG. These system strengthening activities are led by local investigators at current PMTCT sites who participate in new site assessments, overseeing QA/QI, capacity development and training for new PMTCT centers. Minor emphasis is placed on performing targeted evaluations of PMTCT interventions, to estimate the rate of transmission with each of the ARV prophylaxis regimen used. Emphasis areas also include military populations, through support for PMTCT activities staff at 68 Military Hospital and Military Hospital Ikoyi, Lagos.

POPULATIONS BEING TARGETED In addition to providing PMTCT services for pregnant women that know their HIV infection status, this program also targets women who may not know their HIV status and may be at greater risk for MTCT. Furthermore, it seeks to target infants, who are most at risk of becoming infected from an HIV-positive mother during the antepartum, intrapartum and postpartum periods. Through the HCT program area, Harvard seeks to target a broader group of adults by encouraging women to bring their partners and family members in for HCT. Furthermore, training activities will train public and private health care workers on the implementation of PMTCT protocols and HIV-related laboratory testing.

CONTRIBUTIONS TO OVERALL PROGRAM AREA Through the PMTCT program, Harvard will provide HCT with test results to 65,500 pregnant women. Additionally, treatment and prophylaxis will be provided to 3,275 pregnant women. Implementation of the National PMTCT Guidelines in 64 sites (new and continuing) contributes to the PEPFAR goal of expanding ART and PMTCT services. We have increased the numbers of sites by adding secondary and primary level sites in the radius of Harvard tertiary care institutions; the tertiary centers will continue building the network capacity and coverage in of target states. Counseling will encourage mothers to bring their partners and family members for testing to reach discordant couples and expand the reach of HCT, based on the new PEPFAR 5-year strategy. This program is implemented in geographically networked sites to optimize training efforts and provide collaborative clinic/lab services as needed. Harvard will train and retrain 363 health care personnel from the PMTCT sites, including doctors, nurses, pharmacists and counselors. Training will build capacity at local sites to implement PMTCT programs and provide essential treatment support to pregnant women with HIV/AIDS. Capacity building efforts are aimed at future expansions of PMTCT programs. QA/QI will be carried out through personnel training, data collection from sites for monitoring and evaluation and supervisory visits from key program management staff, which may include representatives from the USG and GON.

The program will increase gender equity by specifically targeting pregnant females for HCT and PMTCT prophylaxis and their male partners for HCT. Data collection on PMTCT regimens provides a basis for developing strategies to ensure that all pregnant women have access to needed and optimally effective PMTCT services. This program addresses stigma and male norms and behaviors through the encouragement of partner notification and bringing other family members in for HCT. Infant feeding counseling, including on the appropriate use of exclusive breastfeeding or exclusive use of breast milk substitute (BMS) where AFASS is available, will be in line with the National PMTCT Guidelines. Referrals to income generating activities (IGAs) will also be provided to women as a part of palliative care and counseling activities.

Additionally, as part of our sustainability building efforts, Harvard will provide technical assistance and support for APIN to assume program management responsibility for our PMTCT activities. This will include the implementation of a plan to transition site oversight, management and training over to APIN. The goal of such efforts is to provide for greater assumption of responsibility for management and implementation of PEPFAR programming by Nigerian nationals through an indigenous organization.

LINKS TO OTHER ACTIVITIES This activity is also linked to counseling and testing (HVCT), OVC (HKID), adult treatment (HTXS), pediatric treatment (PDTX), adult care and support (HBHC), sexual prevention (HVAB, HVOP), biomedical prevention (HMBL, HMIN), SI (HVSI), health capacity development (HCD), health systems strengthening (OHSS), and gender. Pregnant women who present for HCT services will be provided with information about the PMTCT program and referred to the PMTCT program if they are eligible for these services. ART services for HIV-infected infants and mothers will be provided through adult and pediatric treatment services. Basic pediatric care and support, including support for chosen feeding option and TB care, is provided for all infants and children through our OVC activities; all exposed infants identified through PMTCT services will be linked to these OVC services. Pregnant women are at high risk for requiring blood transfusion. Personnel involved in patient care will be trained in universal precautions as a part of injection safety activities. Additionally, these activities are linked to SI, which provides support for monitoring and evaluation of the PMTCT activities and QA/QI initiatives.

In COP10, under 'PEPFAR Nigeria's accelerated PMTCT plan', Harvard, 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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