During COP 10 the AIDS Care and Treatment in Nigeria (ACTION) Project of UMD/IHVN addresses significant challenges in quality of care and treatment by strengthening linkages between institutional programs and community-based services at 139 sites in 23 states where it has activated comprehensive HIV/AIDS services. This linkage targets strengthening retention of adult patients in treatment and care, improving uptake of services for women engaged in the PMTCT cascade, strengthening post natal follow up of HIV exposed children to provide timely HIV diagnosis and treatment for the pediatric age group, and upgrading linkages between TB services and HIV treatment and care in close alignment with the framework of the Nigerian National Strategic Plan. The path to securing a sustainable Nigerian response that ensures a lasting legacy impact of the PEPFAR investment requires that UMD/IHVN continue to be an agent for change by stressing evidence-based quality improvement. Vital to this is strengthening of systems for accessing reliable patient level and more sophisticated program indicator data through site- based strategic information collection approaches that are aligned with PEPFAR and GON framework. The UMD/IHVN COP 10 paradigm focuses on strengthening capacity at existing sites rather than continued expansion to new sites by drilling down with in the hub and spoke model to integrate primary health care centers and community-based service delivery into the network. Meeting the human resource challenge requires an increased emphasis on task shifting and the application of quality indicators to guide training to remediate deficiencies in knowledge that adversely effect quality. The hub and spoke model employs local centers of excellence linked to IHV-N's regional offices to guide dissemination of quality services at all levels of the health care delivery system. Vital to the success of this model is the ongoing investment in strengthening laboratory services at sites through rigorous quality assessment and improvement. The ACTION program is anchored at 5 Regional Offices staffed by a highly trained

multidisciplinary Nigerian team based in the following geopolicial zones: North-West (Kano), North- Central/North-East (Jos), South-East/South-South (Benin), Federal Capital Territory (FCT - Abuja) and South-West region (Lagos) that is coordinated by the IHV-N Central Administrative Office in Abuja. The services are located in 23 states and in each of these states, there are Project Offices integrated within the facilities and administration of the sites being supported. Care and Treatment ACTION targets clinical service to 115,326 HIV+ adults and support services to an additional 214,273 persons affected by AIDS (PABAs) and ARV services to 74,037 adults and 7257 children utilizing the Hub and Spoke model. In COP10 ACTION stresses strengthening of spoke, particularly community-based venues employing hub sites as centers of excellence to promote decentralization. Novel strategies such as strengthening care team accountability for patient retention, augmenting community linkages between hub and spoke sites, promoting patient down load of stable patients from overpopulated sites to convenient community-based venues, and promotion of mobile services.. In COP10 ACTION will provide care for 14,000 Orphans and Vulnerable Children within 32 Network Communities. While Care and Support will be carried out at 139 sites, with 70 of them offering pediatric care. OVC services will be consistent with the National OVC Standard of Practice and OVC National Plan of Action. ACTION has focused its OVC services on linkage between medical points of care and community based OVC providers, providing three core services with emphasis on education, nutrition, and improving quality of care in collaboration with over 25 CBOs/NGOs/FBOs. through an institutional and a community based service that includes provision of LLITN, Water Guard and a scale up of therapeutic nutritional supplement ACTION Meal developed in COP09. Using expert staff from established POS as resource persons, site staff participate in central or regional trainings on ARV care, adherence counseling, and/or pharmacy SOPs and QIP in Adult and Pediatric ART Programs. The special challenges of pediatric management are being addressed through enhanced didactic and experiential training. An additional challenge is the emergence of a growing number of patients with drug resistance who are in need of second line therapy. The training plan for COP10 to support training of 30 Master Trainers from established ARV sites who will work with ACTION. ACTION will monitor and evaluate the services to ensure quality by expanding the modified HIVQUAL tools used in a pilot by the GON . In COP09 HIVQUAL was implemented in 20 sites. In COP10, all Care and Treatment sites will be involved in a biannual HIVQUAL exercise. The Gwagwalada Clinical Training Center established in COP09 serves as a model for demonstrating best practices to trainees from local sites employing an observational and experiential approach coupled to didactic training including specialized training in the management of treatment failure. ACTION will continue to participate actively in National Care and Treatment Guideline Committees. All sites are supported to employ treatment support specialists, who are PLWHA. ARV Drugs In COP10 ARV drugs will be procured in line with USG Guidance whereby all First Line ARVs will be procured centrally for all IPs so that ARV treatment can be provided to adults and children under treatment. To transition to self sufficiency challenges of supply chain management must be met by

empowering capacity for forecasting and procurement of ARV drugs a process to be jointly carried out by ACTION and SCMS in concert with site-based staff. Training of site pharmacists and pharmacist technicians on pharmaceutical care and pharmacovigilance will be carried out by ACTION. ACTION will pilot the involvement of Community pharmacies as patient drug counseling and pick up sites in the mobile care strategy network in COP 10 to strengthen the GON ART decentralization policy.. Laboratory Services ACTION laboratory services support ARV, Basic Care and Support (BC&S), OVC, TB/HIV, PMTCT, and HCT programs by building lab infrastructure and training staff to accurately diagnose, stage and monitor patients. ACTION monitors laboratories through its QA/QC activities to ensure high quality results while working with the USG/GON to ensure 84 labs within its network are accredited both locally and internationally in COP10. ACTION will continue to be at the forefront of supporting the FMOH Early Infant Diagnosis (EID) scale up by ensuring national coverage of viral load testing for adults and children through its 11 regional Virology Labs. Specialized laboratory infrastructures such as the BSL3 TB Culture Lab in the NTBLTC Zaria and the HIV Genotype Facility in Asokoro require ongoing engagement as the technology transfer of such facilities is a complex process that depends upon the expertise of IHV technical advisors working closely with CDC and GON staff. ACTION will continue to support the FMOH EID QA activity through its support to the Plateau State Virology Research Center PLASVIREC as a Reference Lab. ACTION has developed PCR capability at the NTBLTC and has piloted the PCR based HAINS Assay to support in country capacity for monitoring TB drug resistance. ACTION will continue to coordinate with GON through Global Fund supported initiatives in the roll out of improved TB detection and culture capacity. Strategic Information ACTION will strengthen Strategic Information (SI) under the "One M&E Framework" component of the National Strategic Framework. In COP10 it is expected that ACTION will continue to support SI activities in 139 sites in 23 states,. A key goal of this activity is to strengthen the capacity to capture patient level data that requires improved data collection and quality control at the site level. ACTION is integrating such data collection as part of the care team process at sites. ACTION is engaged in providing TA to the State ACTION Committees on AIDS (SACAs) and State Ministries of Health (SMOH) in the implementation of the Nigerian National M&E System (NNRIMS). Capacity at LACA will also be strengthened through trainings and TA. State level data for the NNRIMS is reported by the SACA to the National Agency for the Control of AIDS (NACA). ACTION is working in collaboration with the USG/GON in the implementation and piloting of the Logistics and Health Program Management Information Portal (LHPMIP) - this uses VOXIVA technology. The SI team will continue to be active participants on the SI working group established and coordinated by USG-Nigeria. Prevention: ACTION in COP10 contributes to the PEPFAR goal of preventing new infections in alignment with the NSP through dissemination of HIV counseling and testing (HCT) targeting most at risk populations and pregnant women in the context of PMTCT, prevention messaging and services targeting sexual transmission and biomedical strategies targeting the blood supply and occupational safety. The COP 10 scale back of HCT, a tool vital to effective prevention through informing the client of their HIV

status, challenges program effectiveness and requires alignment with GON-sponsored HCT programs where possible. PMTCT - 139 sites are supported to provide PMTCT services with a target of reaching 142,000 pregnant women of whom 5822 HIV positive women and their babies will access ARV prophylaxis. HCT is delivered using the opt out approach that encourages partner testing. To address the large fall off in accessing ART prophylaxis, infant feeding counseling and follow up mother-child pair linkage to services, ACTION applies a "Family-Centered" approach for strengthening linkages to existing community health programs for family planning/reproductive health services and well baby/immunization clinic programs. This model derives from a demonstration project carried out by IHVN that determined the preference of women for selecting a community over facility-based venue for delivery of their baby. To accommodate this preference ACTION has piloted a modified version of the PMTCT National Curriculum for traditional birth attendants (TBA), which focuses on HCT and referral of HIV-positive women. To reduce barriers to facility-based treatment access, mobile clinic outreach is integrated at the community level to bring PMTCT services to women. Manpower shortfalls are addressed by engaging PLWHA who successfully engaged in all PMTCT services to anchor a "Mothers to Mothers" peer education and retention support strategy in each site. Ten regional laboratory centers for DNA PCR, established by ACTION as part of the National network of EID Testing Centers apply dry blood spot testing to determine infection status. Sexual Prevention - ACTION COP 10 sexual prevention activities target services to 10,310 youth and young adults through Abstinence/Be Faithful (AB) activities and 46,364 individuals through condoms and other prevention (C&OP) activities. Sexual prevention activities targets youth/young adults aged 15-24 years with particular emphasis on young women between 15 and 18 based on data from IHV-N that documents high rates of new infections among this target population. Thus the AB comprehensive package, extended to focused communities in six states (Plateau, FCT, Benue, Kaduna, Kano and Edo) targets faith-based and school-aged populations who are less likely to have experienced sexual debut. This intervention continues partnership with the Federal Ministry of Education, and the International Institute of Christian Studies (IICS), an NGO that has worked with the Nigerian Federal Ministry of Education and has implemented effective AB services in secondary schools in Nigeria. C&OP more suitably targets most-at-risk persons (MARPs; 23,182 males and 23,182 Females) by support of 60 community based condom outlets in locations frequented by MARPs, such as bars, brothels and truck stops. C&OP services are provided in hospital based outlets co-located at HCT/ART clinics with special focus on discordant family relationship, a strategy that complements prevention with positives (PwP) services supported under basic care and support programming. ACTION employs mobile services in five regional offices to reach MARPs in high risk venues where transactional and intergenerational sex are common in collaboration with 12 CBOs. Biomedical - ACTION contributes to the 3.12.12 goals of PEPFAR in the area of prevention of new infections in collaboration with JSI by supporting prevention activities of Infection Control Committees at all sites targeting safe injection and appropriate waste disposal. Extension to the network of care involves

step down and refresher trainings at network sites and sustainability by empowerment of sites to "own" commodity logisitics. In the area of Blood Safety, in alignment with a nationally coordinated program to ensure a safe and adequate blood supply ACTION supports hospital blood banks at 32 of its implementation sites to utilize screened blood from NBTS Zonal Centers for their transfusion needs facilitated through the provision of laboratory consumables and supplies, supportive supervision, and on- site refresher training including QA/QC will be supported.. With a scale-back in HCT targets in COP10, testing services are to be co-located with Condoms and Other Prevention sites to focus on MARPs by targeting 13,500 persons at 12 points of services in 9 states. To strengthen HIV TB linkages ACTION collaborates with indigenous NGOs to extend HCT at an additional 110 TB DOTS POS reaching 25,000 persons under the TB/HIV program area. Health System Strengthening ACTION will support the efforts of the Nigerian FMOH and nursing and midwifery educational sectors in strengthening the skills of nurses and midwives for the national response to the HIV/AIDS epidemic in line with the Health Sector National Strategic Framework for HIV/AIDS. Continuous Capacity Building will be a feature of all Program Areas so that sufficient capacity is built to ensure sustainability in the coming years.

None

In addition to 11,406 HIV infected or exposed children served in the Pediatric Care and Support program area, ACTION will reach 14,000 HIV-infected and/or affected children under OVC. IHVN will train 600 providers/caregivers in COP2010.and strengthen the State Ministry of Women Affairs OVC units in facilitative supervision of OVC services

ACTIVITY DESCRIPTION: ACTION has previously focused its OVC services on linkage between medical points of care and community based OVC providers, providing three core services to over 10,000 HIV-infected, exposed, and affected children. In COP09 ACTION scaled up its services across the country at the community level providing more than three core services to 14,000 OVC with a renewed emphasis on education and nutrition service components and improving quality of care. . In COP10, ACTION will utilize OVC funding to focus on consolidation of quality OVC services across the country and at the community level, ensuring comprehensiveness. ACTION will provide OVC services to 14,000 HIV infected and affected

children including adolescents in 23 states (Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto). ACTION supports Pediatric HIV care and support in 30 networks at 90 medical points of service. ACTION will continue its collaboration with the State Ministry of Women Affairs (SMOWA) in the 23 states to build capacity of its focal person especially in advocacy for OVC services in each state. Through OVC programming, ACTION will will continue to support and engage an OVC network coordinator in each of the 30 networks to ensure that at least three core services are provided to all OVC in the network as well as linkage of all OVC to services not provided directly by ACTION ensuring comprehensive quality services. The focus of this OVC scale up will be to address the most vulnerable children living without adequate adult support, living outside of family care, or living in a situation where they are marginalized, stigmatized, or discriminated against.

The OVC Network Coordinator in each network will work in consultation with the State Ministry of Women Affairs OVC units to identify children in need of OVC services through contact with families at points of medical service and community mobile services. The Coordinator will ensure that OVC are linked to needed medical care and services including health assessments, treatment of common childhood diseases like malaria, diarrhea, respiratory track infections, etc; provision of LLITNs, water guard, water cans, laboratory supports and multivitamin supplementation. The Coordinator will link medically vulnerable children to community OVC providers and ensure that at least two additional needed core services are provided. The Coordinator will also identify HIV affected children who are vulnerable due to inadequate adult support, family care, or are marginalized/stigmatized, and link these children to community OVC providers which will be supported in each of the 30 care networks by ACTION and ensure that needed services in at least 3 core areas are provided.

ACTION will work with Faith Based organizations to build their capacity to identify and care for OVCs within the 30 Networks. These Faith Based Centers will create a sustainable mechanism for community care where there are no orphanages and so become a vehicle for transition of street based children into family care.

OVC providers will ensure that food and nutrition services are available to all OVC regardless of HIV status. Leveraging support from the Clinton Foundation, ACTION will continue to provide comprehensive nutritional support for OVC through the provision of fortified cereals, Kwashi-pap and PlumpyNut, targeting any child meeting the definition of acute malnutrition. All children will receive nutritional assessment and caregivers counseled at intake and periodically. Those meeting the definition of acute malnutrition will receive food by prescription (either Plumpy Nut or the ACTION meal soy based Kwashi- pap formulations, both vitamin fortified ready to mix nutritional supplements approved by NAFDAC) provided by ACTION under an existing clinical care protocol for short term nutritional support. In the

provision of nutritional supplements, ACTION will build the capacity of caregivers by providing raw materials and instructions so that affordable food supplements can be prepared by them at home. This caregiver instruction will be provided by medical points of service and community OVC providers using a training manual and demonstration materials provided by ACTION. For OVC with ongoing food insecurity, ACTION will prioritize partnering with USG-supported wraparound services in states where it is co-located with these activities to meet these needs through referral. ACTION will also leverage resources on improving the capacity of care givers on income generating activities (IGAs).

The 30 care networks supported by ACTION will continue to provide educational assistance through support of school fees, uniforms and educational supplies for OVC. The community OVC providers will provide residential shelter and care, and protection for OVC who cannot be placed in family care and are at risk of physical or psychological abuse. Community OVC providers will be trained in psychosocial support through training focused on developmentally appropriate adherence counseling and support of children. The curriculum has been expanded to include the establishment of kids and Adolescents clubs.

Community home-based care (HBC) for children will be available in each of the 30 networks and is implemented by a supervising community HBC nurse, health extension workers and volunteers. This activity will be linked to primary prevention and HCT programs emphasizing the home-based approach to ensure that family members at risk including other children in the household are tested and counseled. This strategy supports family engagement in HBC and identifies family members in need of HIV care. In addition, home based care staffs support parents with ART adherence for children in the home setting through education and addressing adherence barriers. They also focus on linkages to services, ensuring that clients in need of hospital care are able to access this care and linking family members to PMTCT, community immunization, family planning, and TB DOTS services. ACTION will continue to utilize different models depending upon the site preference. Extension workers will be preferentially recruited from the PLWHA support group membership. HBC will be linked to the child's medical care source, as the supervising community home based care nurse/PHC extension worker will work under the medical direction of the site physician/clinical associate. Integrated approach will be adopted in the provision of HBC and OVC services including linkages to ACTION treatment and prevention programs.

Training of Community OVC providers will continue to be conducted at site and Community level to ensure maximum coverage in the most cost effective manner. There will be 1 Central and 5 Regional 2 day Stakeholders meetings to be coordinated by the FMOWA and SMOWA supported technically by ACTION to create awareness and sensitization of the public on community responsibilities for OVCs. 30 site-based trainings of 20 staff each will be conducted for a total training target of 600. Training in the issues of HIV for NGOs engaged in OVC services and for social workers will target improved understanding of the issues including stigma surrounding HIV positive children and the need to integrate

healthy HIV positive children into mainstream social and school settings without fear due to lack of understanding of risks surrounding HIV transmission in school-aged children.

CONTRIBUTIONS TO OVERALL PROGRAM AREA: This activity provides services which are a high priority for the 3-12- 12 Emergency Program strategy by providing core OVC services to all HIV affected children. The services are consistent with the National OVC Standard of Practice and OVC National Plan of Action. Capacity development at the site level and consistency with national guidelines will ensure sustainability. Capacity development will be achieved through regional training and skills development.

LINKS TO OTHER ACTIVITIES: This activity is linked to HCT , ARV services , TB/HIV , AB , lab , and SI . HCT services will be available to HIV affected family members (PABAs) in need of HIV testing including in-home HCT through HBC services. Home based care programs will be implemented by a number of indigenous NGOs, CBOs and FBOs. Sub-agreements will be coordinated with other PEPFAR IPs to ensure non-overlap of funding and services. Some services are co-located with TB DOTS centers and ACTION staff work with sites to ensure coordination systems are in place. High quality laboratory services supported by an ACTION facilitated laboratory QA program are available at sites. This will include EID available in all catchment areas (see lab narrative).

POPULATIONS BEING TARGETED: OVC services are offered to infants and children in HIV/AIDS infected and or affected families, children orphaned by HIV, and caregivers of OVC. Doctors, nurses, social workers, care givers, teachers, family members and other health workers in the public and private sector are targeted for training. Community groups including CBOs, NGOs and FBOs will be targeted for training and system strengthening, linkages and identifying OVC.

EMPHASIS AREAS: Emphasis is placed on training and human resources as capacity development for sustainability is a key focus and much of the community linkages are through partners. In addition, community mobilization and infrastructure development of CBOs/FBOs is critical for the identification and care of OVC. Integrated approach to programming will also be emphasized.

This activity addresses the area of wraparounds as activities that will strengthen/develop linkages between HIV/AIDS services and other sectors for food resources including IGAs. The activity also addresses the key area of stigma and discrimination as training of health care workers and community volunteers will reduce stigma.

None

None

None

None

None

ACTIVITY DESCRIPTION: ACTION will continue to support the efforts of the Nigerian FMOH, Nursing, Midwifery and Community Health Practitioners educational sectors in strengthening the skills of nurses, midwives and community health practitioners for the national response to the HIV/AIDS epidemic in the country in line with the Health Sector National Strategic Framework for HIV/AIDS. Nurses, Midwives and Community Health

Practitioners constitute the highest number of health care workers in Nigeria at urban and rural settings and spend the highest number of hours with patients.

In the past couple years; some efforts have been made through HSS to address the weak nursing knowledge in HIV care that exists country wide. As the number of patients accessing ART services continues to increase especially in tertiary and secondary sites, doctors are overworked and patient access to care is sub-optimal. The increasing need to decentralize ART services to rural areas through PHCs and introduce task shifting roles for ART refills and follow up have placed additional demand to rapidly ensure these frontline HCWs provided the skills and knowledge necessary to triage, assess, monitor and follow up patients on ART while maintaining quality of care. If adequately trained and empowered to utilize learned skills, nurses, midwives and CHO could render more appropriate care for PLWHAs and contribute meaningfully to mitigating the impact of HIV/AIDS, improve patient access, as well as help sustain efforts supported by the Emergency Plan.

This activity is aimed at continuing to support a HIV care nurse and community training program at the practice and education levels to address the weaknesses that exist in the skill levels of nursing professionals in Nigeria in a sustainable manner. This training will be tied in with an integrated care strategy being implemented at the model HIV Clinical Training Center at University of Abuja Teaching Hospital at Gwagwalada. The care model employs a care team strategy that upgrades the role of the nurse in care provision and case management and nurse refill of ART & follow up for stable patients. This frees the physician to address patient management challenges rather than focusing on onerous paper work. A care team consisting of a physician, several nurses, adherence counselors, PLWHA treatment support specialists and pharmacy staff work together to facilitate efficiency and quality of patient care. A community liaison links the team and the patient to community-based services targeting improved treatment access, adherence, nutrition, safe water, linkage to other services and home-base care. This team will actively participate in practicum and preceptor roles during the training. Evaluation of this model and expanded training of other sites in an evidence-defined care model will help shape policy to operationalize the IMAI/IMC concept.

The standardized curriculum developed and piloted in COP07 & COP08 was crafted to focus on comprehensive but specific skills sets and knowledge needs identified by the Nursing and Midwifery Council of Nigeria and Nigerian nursing educators. The curriculum incorporates the FMOH/NACA adopted IMAI/IMCI approach to HIV/AIDS care with emphasis on such nursing skills as: aseptic technique, injection safety/universal precautions, nursing assessment & triage, follow up of stable ARV patients with prescription re-authorization, monitoring for ARV adverse effects and treatment efficacy, adherence/general counseling, and linkages with community care and other services. In addition, HIV

palliative care at facility and community levels, treatment of minor ailments (such as thrush, malaria, and diarrhea) using standing orders developed and approved by supervising physicians. Through the training, nursing skills are enhanced to provide counseling for prevention, HCT, disclosure/partner notification and other support services. Also in COP07 & 08, ACTION together with MSH trained 55 Nurse-leaders. ACTION also rolled out TOT using this standardized nursing curriculum training a total number of 48 master trainers/continuing education nurses from state MOH, NPHCDA, tertiary and secondary and primary health facilities to enhance HIV training and retraining. A total of 34 nursing, midwifery and community health practitioner tutors were also trained as trainers. The HIV/AIDS nursing training curriculum was adapted by the Council for incorporation into standard education of nursing & midwifery students country-wide. ACTION produced copies of the curriculum for these trainings and dissemination. In addition, nursing school administrators were encouraged to incorporate clinical rotations at ACTION and other IP supported hospital and community based sites into their curriculum to enhance hands on experience for students.

Under COP09, ACTION focused on continuing to strengthen the capacity of nursing, midwifery community health practitioner schools countrywide to improve the knowledge base of future graduating nurses and midwives in the area of HIV prevention and comprehensive care of PLWHAs and PABAs. ACTION supported 2 regional step down trainings for a total of 60 educators from a least 5 schools of nursing/midwifery & CHOs who were identified by the respective licensing organizations at 2 nursing schools in ACTION regions utilizing the master trainers from COP08. ACTION also provided TA to AIDSRelief and conducted similar TOT for 14 program nurses and 13 nursing & midwifery tutors from faith based institutions. Training Department will continue to assess, monitor quality and follow up of these trainees In COP10, ACTION will support USG & GON strategies to increase the number of HCW graduating from pre service education systems. ACTION will support 3 regional step-down trainings for 90 educators to be identified by the registration boards. ACTION will additionally provide mentoring for schools with the aim to saturate all nursing, midwifery and community health practitioner schools. ACTION will intensify advocacy and engagement of Medical & Dental Council, Nursing & Midwifery Council, Community Health Practitioner and Pharmacy Boards to take ownership for ongoing curriculum oversight & updates as well as rapidly inculcate strategies into pre-service education that will support task shifting, quality HIV care including pharmaco-vigilance, team process, leadership skills etc. ACTION will continue to provide TA and mentoring to FMOH, SMOH & NPHCDA, Implementing Partners and local service/labour organizations to ensure ongoing use and dissemination of the standardized curriculum and use expert Trainers for continuing education in practice/post service settings.

ACTION in COP08/09 has initiated discussions with the National Post Graduate Medical College for the development of a Masters Degree in HIV Medicine for doctors. In COP10 ACTION will organize a

stakeholders 5 day meeting utilizing its in-house and external facilitator to conclude the development of the curriculum. This will then be piloted using one of ACTION affiliated universities.

ACTION currently supports ARV services at a total of 139 sites structured under a hub and spoke network model. Hub sites are affiliated with smaller secondary hospital sites and additional primary health center ARV sites so that routine care of stable patients can be available at the community level. These primary health center sites already have established referral relationships with existing ARV sites at the secondary or tertiary level and will be strengthened under COP10 to provide ARV in a more accessible location. Most of these sites are staffed by nurses. ACTION anticipates that at least 16 of the primary health centers will be developed as "nurse managed" ART sites with oversight from the affiliated hubs. These are ideal settings for student rotations. ACTION support for nurse HIV and AIDS training will not be limited to ACTION supported sites or states, as the program is designed to provide supports across PEPFAR and beyond.

Sites were selected in line with the National ARV Scale-Up Plan with the goal of universal access. They include: Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto.

CONTRIBUTIONS TO OVERALL PROGRAM AREA: Curriculum development and implementation will lead to capacity development at the site level and nursing schools. This is consistent with national guidelines to ensure sustainability. ACTION staff will ensure that there is a step down training with trainees from various hospitals using the Training Centers in Benin, Kano, Jos and Abuja. The GON and other IPs will also utilize the curriculum and other trainers developed to further step down the trainings with development of a cohort of trainers across the country.

EMPHASIS AREAS: This activity focuses on training, as capacity development for sustainability is a key focus. This activity also focuses on training curriculum and module development, provision of additional training resources for trainers and trainees for step down training in hospitals, and human resources, as manpower shortfalls to address HIV care needs will be addressed.

None

None

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: AB targets have been adjusted per notional targets for 2010. Increased activities of AB will target younger girls in High Schools through Faith Based Institutions. .

ACTION COP 10 sexual prevention activities will continue to provide prevention services to 10,310 youth and young adults (4,074 males and 6,236 females) through Abstinence/Be Faithful (AB) activities. AB programming activities will be implemented by ACTION in line with the overall PEPFAR Nigeria goal of providing a comprehensive package of prevention services to individuals through a balanced portfolio of AB prevention activities. In order for ACTION as a partner in her PEPFAR Nigeria services, AB services will be extended to focused communities in six states (Plateau, FCT, Benue, Kaduna, Kano and Edo). In COP09, ACTION reached over 10,000 individuals using a combination of abstinence and/or being faithful prevention messaging approaches. Targeted intervention of AB activities will be provided to youth/young adults aged 15-24 years, as this is the highest prevalence age group. In COP10, ACTION will additionally target young girls aged 10 -17 in Faith Based organizations like the Girls Brigade (GB) and Jamaatu Nasril Islam (JNI) with religiously appropriate AB messages.. Many young adults are in tertiary educational institutions where they can be reached with appropriate AB messages. The other ACTION program activities will reach a large population of HIV-positive adults, adolescents and children through care and treatment services. In addition Prevention with Positive (PwP) services will be provided to HIV- affected partners and family members of these clients.

The focused AB activities at tertiary educational institutions (polytechnic schools and universities) are located in cities where individuals are reached with AB messages and those who voluntarily visit a TCH center and test positive will be referred or linked to care and treatment facilities, as necessary. ACTION will work principally at educational institutions but will also provide services at the community through a combination of multiple strategies in line with the Government of Nigeria/U.S. Government (GON/USG) minimum care package. These will include: community awareness campaigns specifically focusing on small group discussions (SGD) organized within departments; a school based approach that will leverage

existing curricula developed jointly by the Federal Ministry of Education and the Society for Family Health; and peer education plus activities focusing on drama groups. Peer education plus activity dance drama groups will perform in the targeted institutions. These dramas will have culturally and age group relevant scripts written by a professional consultant using input from the SGD. In COP09 content was piloted and was found to be acceptable and accurate for AB messages. ACTION will continue to collaborate with the International Institute of Christian Studies (IICS), an NGO that has worked with the Nigerian Federal Ministry of Education and has implemented effective AB services in secondary schools in Nigeria. ACTION will also partner with the Girls Brigade and JNI to leverage the existing development goals entrenced in these FBOs.

AB program activities conducted at the local level by ACTION will be reinforced through national mass media campaigns by other USG partners, such as the successful Zip-Up campaign. Where appropriate both AB and condoms and other prevention messaging will be balanced and integrated with other PEPFAR program area services in proximal areas. The goal of AB interventions is to saturate targeted communities with messages conveyed using different strategies. Utilizing such a methodology, a large number of people will be reached with messages received via one method or another, but the target group reached will be those individuals that will have received AB messaging on a regular basis and via the three strategies ACTION will employ (community awareness campaigns, school based programming and peer education plus activities). Using these strategies ACTION will reach 10,310 individuals with intensive messaging campaign. A total of 500 persons made up of teachers, guidance counselors, school health care workers, FBO Officers and peer educators will be trained to provide effective prevention interventions inclusive of AB messaging from 166 outlets. In COP10, ACTION will strengthen the linkages between appropriately balanced ABC services, condoms and other prevention activities, HIV counseling and testing, and HIV treatment activities. Since lecturers have access to this age group on a regular basis, they will incorporate HIV AB messages in order to institutionalize the AB services. In addition, prevention activities will be incorporated into points of health care service in each institution, including family planning counseling, sexually transmitted infection management and counseling, and risk-reduction counseling.

CONTRIBUTIONS TO OVERALL PROGRAM AREA: This program will contribute to the global HIV/AIDS strategy by reaching 10,310 people with AB messaging and 5,740 people with abstinence only messaging in a comprehensive approach. As high risk and "bridge" populations contribute to HIV transmission, C&OP activities will support the Nigerian Federal Ministry of Health (FMOH), and emergency plan goal of reducing new infections and thus decreasing the overall disease burden of HIV in Nigeria by enhancing HCT with targeted prevention messages and interventions. Integration of AB activities with prevention , treatment and care services will be

emphasized. Use of the community awareness campaigns, school based programs, and peer education plus activities (community drama, dance events, etc.) allows dissemination of AB messaging, including integration with condom messaging, from socially-credible sources of information (educators, healthcare workers and related populations of PLWHA).. Targeted efforts to promote correct and consistent condom use and STI management for MARPs can reduce the risk of HIV infection. The activities will also address issues of stigma and discrimination through the education of individuals and communities.

LINKS TO OTHER ACTIVITIES: The populations being targeted often do not access services via traditional treatment venues. AB and C&OP activities relate to HCT, basic care and support (through dissemination of information by home based care providers), OVC programming (through specific targeting), and SI. A challenge of this program is to successfully link identified HIV-positive individuals with services.. The program will create a means to strengthen linkages and will identify through the hub and spoke model innovative strategies for creating access to treatment in convenient venues. Targeting MARPs will help to identify persons who need referral into care, ARV services and prevention for positives counseling, which will be an important component of post-test counseling of HIV-positive persons as part of HCT services and the basic package of care. Combination prevention messages targeting behavior change will complement HCT for all, irrespective of HIV status. OVCs will be taught family life and sexual initiation delay/abstinence negotiation skills.

POPULATIONS TARGETED: AB will be targeted at youth (particularly university and polytechnic students), teachers, and adults accessing HCT services, The other major focus is school-based youth and young girls in FBOs.

EMPHASIS AREAS: Emphasis will be on human capacity development for AB and equal access to information and services. Reduction of stigma and discrimination are also key features of the program. Community development through strengthening of structures for information dissemination to youth groups are also emphasize

None

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: Early infant diagnosis (EID) is referenced and reader is referred to Pediatric Care and Treatment narrative. Increased focus on Community Based Interventions to improve coverage

ACTIVITY DESCRIPTION: Utilizing a network model with PMTCT care centers linked to secondary and tertiary "hub sites" that provide more complex PMTCT care and lab testing, in COP10 125,000 pregnant women will receive PMTCT counseling & testing and receive their results. A total of 139 PMTCT sites established by the end of COP09 will be maintained in COP10. Sites are located in 23 states: Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, and Sokoto. In COP09, ACTION paid particular attention in Nasarawa state as the Lead IP to support the development and implementation of the PMTCT LGA (local government area) coverage strategy that ensures there is at least one PMTCT point of service in each LGA. In COP10 ACTION-supported PMTCT services will be focused at quality improvement in ANC sentinel sites including the primary health center level and will increase coverage through the establishment of community-based PMTCT interventions, within the networks of ACTION care& treatment services.

In this networks, PMTCT stand alone points are linked to adult and pediatric ARV care through utilization of a PMTCT consultant coordinator in each network based at the hub site, network referral standard operating procedures (SOPs), monthly PMTCT network meetings, and incorporation of team approaches to care in all training and site monitoring. Through this SOP, HIV-positive pregnant women who require HAART are linked to an ARV point of service. Particular emphasis is placed on the involvement of community health workers who are the primary source of care for women in the pre and post-partum period and are integral to a program that seeks to engage women where they seek care. This program will work closely with the care and support team to maximally engage community based PMTCT model of care and ARV linkages. In addition to receiving PMTCT services, each HIV-positive pregnant woman will be referred to OVC services in order to facilitate care for all of her affected children. ACTION has worked with sites in COP09 to identify and train site staff with full responsibility for Network Coordination. These staff will be provided with Technical support by ACTION to ensure care is linked and to reduce to the barest minimum loss of clients along the PMTCT Cacade

Opt-out testing and counseling with same day test results will be provided to all women presenting for ANC and untested women presenting for labor and delivery. The same approach will be adopted for mobile PMTCT services to women in hard to reach communities. All women are provided pre-test counseling services on prevention of HIV infection including the risks of MTCT. Partner testing is offered

as part of PMTCT services or through referral to on-site HCT centers where available. A step down training of couple counseling and prevention with positives (PwP) package (combination prevention package) will be utilized in all sites. This will provide an opportunity to interrupt heterosexual transmission, especially in discordant couples and will facilitate partner involvement in care, treatment and support. Master trainers for HCT will train labor and delivery staff in the use of HIV rapid tests for women who present at delivery without antenatal care.

An anticipated 5,822 HIV-positive pregnant women will be identified and provided with a complete course of ARV prophylaxis (based on ACTION's current program prevalence of 4.5% and loss to follow up). HIV- positive women will have access to lab services including CD4 counts without charge. This will be available on-site or within the network through specimen transport. Women requiring HAART for their own health care are linked to a network ARV center. For the anticipated 2/3 of women not requiring HAART, the current Nigerian PMTCT guidelines recommended short course ARV option will be provided which includes ZDV from 28 weeks or ZDV/3TC from 34/36wks, intra-partum NVP, and a 7-day ZDV/3TC post-partum tail. Women presenting in labor will receive SDNVP and a 7-day ZDV/3TC post-partum tail. All HIV-positive women will be linked post-partum to an HIV/ART point of service, which will utilize a family centered care delivery model whenever feasible, co-locating adult and pediatric care and providing a linkage to family planning services. Women frequently face barriers to facility-based treatment access as a result of demands on them for childcare and to contribute to the family economic capacity. To address this, mobile clinic outreach as described in the adult care and treatment narrative will be integrated at the community level to bring PMTCT services to women who otherwise will opt-out of care and treatment.

HIV-positive women will be counseled pre- and post-natally regarding exclusive breast feeding with early cessation or exclusive breast milk substitute (BMS) if AFASS using the WHO UNICEF curriculum adapted for Nigeria. Couples counseling or family member disclosure will be utilized to facilitate support for infant feeding choices. Consistent with national policies on importation of infant formula and recent concerns regarding appropriate use of BMS, ACTION will not utilize EP funds to purchase BMS. As part of OVC programming ACTION will provide safe nutritional supplements including safe weaning for exposed infants as well as water guard, bed nets and other home based care items. HIV-positive women will be linked to support groups in the facility and their communities, which will provide both education and ongoing support around infant feeding choices, early infant diagnosis (EID), ART, adherence and PwP. PLWHA are currently employed at ACTION-supported ARV points of service as treatment support specialists. In COP09, the use of dedicated treatment support specialists (mentor mothers) for PMTCT in the clinic was implemented based upon the successful "Mothers to Mothers" model in Southern and East Africa. This model will be expanded to all PMTCT sites. This will ensure that HIV-positive women remain in care throughout pregnancy and receive appropriate services for herself and her infant. This concept

was used in the establishment of community-based PMTCT programs in COP09.

In accordance with Nigerian National PMTCT guidelines, Infant prophylaxis will consist of single dose NVP with ZDV for 6 weeks. Cotrimoxazole suspension will be provided to all exposed infants pending a negative virologic diagnosis. Ten regional laboratory centers for DNA PCR have been established by ACTION. Testing of infants will be carried out using dried blood spot (DBS) specimen collection. In COP09, ACTION actively participated in the national early infant diagnosis initiative by providing DNA PCR testing of dried blood spots (DBS) at ACTION-supported labs. The source of DBS samples will include ACTION and non-ACTION supported PMTCT sites. A systematic coordinated approach to program linkages will be operationalized at the site level and program level including linkages to adult and pediatric ART services, OVC services and basic care and support. Quality monitoring will be undertaken through site visits using an existing assessment tool and routine monitoring and evaluation indicators. As part of ensuring sustainability of PMTCT in Nigeria, ACTION will continue to provide Technical Support to Federal, State and Local Government personnel in appropriate support supervision so that the National scale up will have the appropriate ownership and funding by the various levels of government. In each state ACTION will carry out its activities along with responsible Officers in the state.

ACTION will re-train HCWs from each of the PMTCT sites in COP10 including community-based health workers in the provision of PMTCT services and infant feeding counseling. The revised and updated national PMTCT training curriculum and the infant feeding curriculum will be utilized. Under COP08, ACTION has adapted and piloted a modified version of the PMTCT National Curriculum for traditional birth attendants (TBA), which focuses on HCT and referral of HIV-positive women. ACTION piloted this with 20 TBA in COP07 , 50 in COP08 and additional 100 in COP09, targeting TBAs based on a community needs assessment that has been carried out in COP08 identifying points of deliveries for women in the community. Site-based step down trainings will be carried out in conjunction with the Ministry of Health (MOH) utilizing Master Trainers that were trained on infant feeding in COP08. There will be a minimum of 10 trainees per site for a total of 300. Thus, the total direct training target is 400. ACTION will continue to collaborate with the government of Nigeria (GON) and the Clinton Foundation to increasing access to early diagnostic services for infants. This activity is described under Pediatric Care and Treatment.

In addition to routine monitoring and evaluation activities, ACTION will contribute to a Multicountry PHE that will evaluate best practices and document best program models for increasing the number of HIV- positive pregnant women who receive HAART. The aim is to identify which models of ART service delivery to pregnant women result in the best uptake for PMTCT and maternal treatment interventions.

CONTRIBUTIONS TO OVERALL PROGRAM AREA:

This activity will provide counseling & testing services to 125,000 pregnant women, and provide ARV prophylaxis to 5,822 mother and infants pairs. This will contribute to Nigeria's goal of increasing PMTCT coverage by 80% by 2010 and the EP goal of supporting this effort.

LINKS TO OTHER ACTIVITIES: This activity is linked to adult and pediatric care and treatment, OVC, laboratory infrastructure, condoms & other prevention, AB, and SI where ACTION will continue to provide TA for the National PMTCT MIS. PwP messages will be integrated within PMTCT care for HIV-positive women. The basic package of care provided to all HIV-positive patients will be available to HIV-positive pregnant women. ACTION lab staff will ensure that HIV testing provided within the PMTCT context is of high quality by incorporating PMTCT sites into the laboratory QA program. ACTION will collaborate with UNICEF and other implementing partners in the support of PMTCT services at some sites & states, leveraging resources without duplication and creating a more sustainable service support structure.

POPULATIONS BEING TARGETED: This activity targets pregnant women who will be offered HCT, HIV-positive pregnant women for ARV prophylaxis, infant feeding counseling and family planning. The exposed infants will be offered prophylaxis and early infant diagnosis services. Family members will have access to prevention, care and support services.

EMPHASIS AREAS The key emphasis area is training and quality care, as most supported personnel are technical experts. A secondary emphasis area is commodity procurement as ARVs for prophylaxis and laboratory reagents for infant diagnosis will be procured. Another secondary emphasis area is the establishment of community-based PMTCT with network/ referral systems as networks of care will be supported, which are critical to ensuring quality of care at the PHC level, identifying women in need of HAART, and ensuring access to HAART within the network. In addition, partners and PABAs will be identified for linkage to care and support services. This activity also addresses gender since treatment will be provided to women and will focus on family centric issues including male involvement in PMTCT programming.

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

None

None

None