I. PROGRAM DESCRIPTION

The overall goal of the AIDSRelief program is to ensure that PLHIV have access to ART and high quality

medical care. By the end of COP09, AR will have 35,860 people on treatment and 50,000 in care.

Treatment success is measured by durable therapeutic outcomes and quality of life indicators. An

analysis of Patient Level Outcomes in 2009 found a viral load suppression rate of 84% among sample

patients.

Aids Relief operates in the 16 states of Abia, Adamawa, Anambra, Benue, Ebonyi, Edo, Enugu, FCT,

Imo, Kaduna, Kano, Kogi, Nasarawa, Ondo, Plateau, and Taraba. Patients are those presenting at Local

Partner Treatment Facilities (LPTF's) for Opportunistic Infections (OI's) or those referred from C+T, TB,

and PMTCT programs. Patients are generally prioritized for treatment by CD4 count under 350; 88% of

the 2009 PLO sample had a CD4 count under 350.

The grant document outlines program objectives:

Objective 1: Existing ART service providers rapidly scale up delivery of quality ART.

a) AidsRelief works to prevent the spread of HIV/AIDS in the following areas: PMTCT, Abstinence and

Behaviour Change, Blood and Injection Safety, and

Counselling and Testing.

b) AidsRelief provides treatment for those infected by working in the following areas:

Adult and Pediatric Treatment, TB/HIV, ARV Drugs, Lab Infrastructure. Because of the quality of these

services, AidsRelief has high retention rates: 90% in a 2009 sample and 85% for the population at large.

Given resource constraints, only replacement patients will be enrolled and total enrolment will remain at

35,860.

Objective 2: The number of health care facilities providing quality ART is increased and capacity at

sites… is increased to allow initiation of ART. Given resource constraints, no additional LPTF's are being

added.

Objective 3: Expand community-level services providing quality ART to vulnerable and low-income HIV-

infected people. At the community level, AidsRelief works in the following areas: Adult and Pediatric Care

and Support, and

OVC.

Objective 4: Create and strengthen health care treatment networks to support capacity building within

countries and communities.

AidsRelief currently works through 34 comprehensive health facilities, 9 PMTCT centers, and 33

TB/DOTS satellites. Of the 34 comprehensive sites, 3 are public hospitals and 1 is a local NGO. The

balance is made up of a network of faith-based institutions including those representing the Catholic (24),

Protestant (4), and Islamic (2) traditions. PTMTC have mixed ownership and TB/DOTS sites belong to the

government. The PEPFAR grant has increased the capacity of these institutions to implement HIV/AIDS

and other health services.

Meanwhile, given a Congressional mandate to transition activity to a local organization by 2012,

AidsRelief is working to sustainably indigenize the program as quickly as possible. By the end of COP09,

AidsRelief will have identified (an) organization(s) capable of and willing to assume AidsRelief's role in the

future. COP10 activities will include carrying out capacity building activities that will enhance the ability of

the named Local Partner(s) to eventually manage the program independently.

This network of faith-based organizations (FBO's) supplements HIV/AIDS work by national and state

governments. This is acknowledged in the 2005-9 National Strategic Framework which calls for increased

collaboration with "civil societies" and in discussions on the new framework now being developed. In

addition to capacity building in the faith-based network, AidsRelief also supports capacity improvements

in the public institutions, especially in the technical areas of clinical care and strategic information.

II. MONITORING AND EVALUATION

AidsRelief's monitoring system covers both patient management and monitoring (PMM) and indicators

necessary for program managers to track progress against PEPFAR and national plan indicators. Monthly

collection of this information will continue at all sites in COP10. The emphasis in the monitoring system

has been on creating a culture of Data Demand and Information Use, with the objective of making

information useful to grant decision makers at all levels. As part of its "Continuous Quality Improvement"

program, AidsRelief also conducts periodic "Patient Level Outcome" studies (PLO) and one will be

conducted in 2010. These analyses are used to make systematic changes to the clinical management of

the program where these are appropriate.

III. COST EFFICIENCIES/RESOURCE MOBILIZATION

AidsRelief recognizes that global resources for HIV/AIDS are constrained and in COP10 will contribute to

the drive to greater cost efficiency in four ways:

a) AidsRelief has benefitted, and will continue to benefit, from cost reductions from the conversion of

proprietary to generic drugs. Reserving a portion of the drug budget for local use allows for unforeseen

circumstances that lead to stock-outs. However, the program plans that centralized procurement will

constitute up to 80% of new ARV purchases.

b) Training, technical assistance, and equipment cost reductions will come with conversion of the program

from "scale-up" to "maintenance" mode. Although AidsRelief will continue to address staff turnover and

equipment obsolescence at the LPTF level, investments in new capacity building at that level will be

reduced.

c) Various initiatives will be undertaken with a view to improving program quality at lower cost. These will

include, among others, a Performance Based Funding pilot to analyze costs and test relationships with

partners that are based on quality output rather than resources paid. AidsRelief is also exploring a pilot

effort to extend Level of Effort analysis of LPTF staff by providing information on per unit outpurs.

Marginal costs of these pilots are minimal.

d) In the short term, the plan to transition the program to grant management by Local Partner(s) will

require resources for travel and capacity building (training, equipping, technical assistance). However,

ultimately transition to local partners will reduce travel and overhead costs.

In parallel with the effort to be more cost efficient, AidsRelief will emphasize resource mobilization next

year. Part of that emphasis will lie in enhanced relations with the MOH and an exploration of resource

sharing. Collaboration with other donors, including the Global Fund and bilateral donors, will be explored.

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ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

AIDSRelief (AR) provided support in COP09 for counseling and testing (HCT) services to a total of 84 sites. This comprised the current 34 Local Partner Treatment Facilities (LPTFs), 19 ART/PMTCT satellites and 31 TB/DOT sites in 16 states (Abia, Adamawa, Anambra, Benue, Ebonyi, Edo, Enugu, FCT, Imo, Kaduna, Kano, Kogi, Nasarrawa, Ondo, Plateau, and Taraba). AR will continue to build the capacity at LPTFs to enable them integrate HCT services within care and treatment systems. AR will continue to emphasize support for decentralization clinics and testing of family members of in-care clients. AR will target the provision of HCT services mainly to PABAs - especially children, as well as to STI patients and TB DOT clients at the LPTFs and satellite clinics. At rural satellite clinics, AR will also target women of reproductive age with combined HCT and STI screening. AR also will provide HCT services as a routine component of blood transfusion services. All HCT clients will be linked to prevention services, as well as treatment, care and support services where applicable. 7,500 (specialized categories for TB cases, pediatrics, index case family members, provider initiative for sick patients) persons will benefit from HCT and receive their results.

All HCT service outlets will continue to be branded with the "Heart to Heart" logo. AR will continue to encourage Provider Initiated Testing and Counseling (PITC) in all supported healthcare facilities. This approach to HCT will be actualized by AR technical and programmatic staff through onsite mentoring of providers and the engagement of leadership at AR-supported facilities. AR also will scale-up couples counseling and testing in all supported sites through organized training, family-centered testing and on- site mentorship.

AR will promote HCT as a necessary and important arm of HIV prevention in terms of averting new infections and providing treatment for those in need, and post-test counseling will be strengthened to lay emphasis on prevention for positives. Post test counseling will include full and accurate information on all prevention strategies. Referrals to outlets that provide other prevention services not available at AR- supported facilities will be provided. All HCT sites will provide same day results and will use the current National serial testing algorithm. For infants and children less than 18-months Early Infant Diagnosis (EID) will be available at PMTCT sites according to the national scale up plan; lab testing for EID will be done in conjunction with other IPs.

The USG will provide AR with rapid HIV test kits and AR will be responsible for their warehousing, storage and distribution to LPTFs. Sites will be actively linked to the Government of Nigeria and other donor agencies to access extra kits and supplies needed, and supported to maintain their regular usage and feedback through the above mentioned strategies. This will help increase uptake of HCT services in all points of service in the facilities. Newly identified HIV positive patients will be actively linked to care and treatment in facilities with capacity to enroll new patients. Sites will be supported and retrained on forecasting and stock control using bin cards and will maintain a three month buffer stock. LPTFs will report on inventory and forecasting to the AR central office on a monthly basis.

AR will provide refresher training for 90 LPTF staff on counseling and testing using the GON HCT training curriculum. Counselor training will include couples counseling to strengthen this aspect of the program. This will ensure the availability of a pool of trained counselors to promote continuity. In addition, providers will be sensitized on the adoption of PITC and point of service testing in their facilities. Non-laboratorians will be used at multiple points of service for facility based HCT where appropriate and when allowed by national policy. To this effect AR will continue to train HCW (counselors, nurses and outreach workers) that will be supervised by onsite laboratorians to assure quality. To expand HCT services within the network of faith based organizations and increase rural access to HCT, AR community based HCT will continue to advocate for greater use of non-laboratory staff to conduct testing in the community setting as well.

AR will carry out quarterly monitoring visits which focus on quality assurance and onsite mentoring. There will be evaluations of counseling techniques, HCT testing algorithms, the utilization of the National CT Register, proper medical record keeping, referral coordination, patient flow, and use of National HCT tools. On-site TA with more frequent follow-up monitoring visits will be provided to address weaknesses when identified during routine monitoring visits. Semi-annual partner meetings will provide an additional forum for sharing of new information between sites and communities.

AIDSRelief will continue to collaborate with faith-based and community-based organizations, in particular the 7-Dioceses program of Catholic Relief Services, in carrying out community based and mobile HCT services. AR will also continue to collaborate with state and local government HCT programs by carrying out joint trainings, monitoring visits and leveraging resources to test those who may require testing outside the USG supported numbers.

CONTRIBUTIONS TO OVERALL PROGRAM AREA: AIDSRelief will continue to support HCT services at 84 sites at the primary, secondary and tertiary levels in rural and previously underserved communities to provide services to 7,500 clients including 4,000 children thus contributing to the PEPFAR and GON targets for increasing access to HIV counseling and testing. HCT services will enable the identification of HIV positive individuals in a timely manner and will direct them into care and treatment services. HCT will add to the prevention strategies of averting new infections through efficient and effective posttest counseling and patient education. HCT will further contribute to the national goal of universal access to HIV/AIDS services. By continuing to support the building of LPTF capacity, AR will continue to contribute to the sustainability of HCT activities at these sites and in Nigeria.

LINKS TO OTHER ACTIVITIES: This activity relates to activities in ARV services, ARV drugs, laboratory, care and support, PMTCT, OVC, AB, TB/HIV and SI. Linkage of HCT to treatment, care and support services will continue to be strengthened within and across programs and between other implementing partners using standard referral tools. AR will continue to support referral linkages with National TB DOTs centers to ensure that TB patients are routinely screened for HIV and those testing HIV+ are referred to AR LPTFs for HIV/AIDS care and treatment. The LPTFs will ensure integration of the AR-supported HCT program with other departments to provide routine HCT services to all patients and to ensure that those testing HIV+ are referred for appropriate care.

POPULATIONS BEING TARGETED: This activity targets the general population and in particular PABAs (especially children), STI patients,

and TB suspects/patients.

EMPHASIS AREAS This activity has emphasis on training including supportive supervision and quality assurance/quality improvement. REDACTED

The expansion of free HCT services will ensure gender equity in access to HCT services in rural and previously underserved communities. It will also ensure that HIV-positive people are identified and linked to timely life-saving ART services and HIV-negative clients are educated on the importance of avoiding risky behaviors.

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

In COP09 AIDSRelief (AR) provided pediatric care and support services in 34 Local Partner Treatment Facilities (LPTFs) and 19 satellite sites in 16 states (Abia, Adamawa, Anambra, Benue, Ebonyi, Edo, Enugu, FCT, Imo, Kaduna, Kano, Kogi, Nasarawa, Ondo, Plateau, and Taraba). In setting and achieving COP10 targets, consideration has been given to consolidating on AR's COP09 accomplishments in order to maintain continuous quality improvement

Key to increasing pediatric enrollment into care and support will be to strengthen linkages among all service components in AR's LPTF as well as to expand community outreach. This activity will require sustaining staff training/retraining and strengthening referral linkages., AR will consolidate on its multi- pronged approach to increase the number of children enrolled into care and support: organization of services to provide family centered care and treatment, PITC (provider initiated testing and counseling) and community mobilization. AR will pilot the use of less invasive and less technical methods (OrasureR) for increasing access to pediatric HIV testing in communities where children and caregivers are clustered. All exposed infants delivered in the LPTF or identified through the family centered approach will be enrolled into the HIV Comprehensive Care clinic and linked to community based OVC programs for care and support.

The package of care services provided to each HIV positive or exposed child includes a minimum of clinical service with basic care kit and two supportive services in the domain of psychological, spiritual, and PwP delivered at the facility, community, and household (home based care) levels in accordance

with the PEPFAR and Government of Nigeria (GON) national care and support policies and guidelines. The basic care package for HIV positive child/care givers in AR's partner sites include Basic Care Kit (ORS, LLITN, water guard, water vessel, soap, IEC materials, and gloves); Home-Based Care (client and caregiver training and education in self-care and other HBC services); Clinical Care (basic nursing care, pain management, OI and STIs prophylaxis and treatment, nutritional assessment- weight, height, BMI, micronutrient counseling and supplementation and referrals, Laboratory Services (which will include baseline tests: CD4 counts, hematology, chemistry, malarial parasite, OI and STI diagnostics when indicated); Psychological Care (adherence counseling, bereavement counseling, depression assessment and counseling with referral to appropriate services); Spiritual Care (access to spiritual care); Social Care (support groups' facilitation, referrals, and transportation) and Prevention Care (Prevention with Positives). All HIV positive or exposed children's nutritional status will be assessed at contact and on follow-up visits, micronutrients will be provided as necessary, and those diagnosed as severely malnourished will be placed on a therapeutic feeding program. This will be done through wraparound services as well as direct funding. AR will procure basic care kits through a central mechanism and OI drugs will be procured through mechanisms that ensure only NAFDAC approved drugs are utilized. Cotrimoxazole prophylaxis will be provided for exposed and infected children according to the national guidelines.

All LPTFs will be strengthened in their capacity to provide comprehensive quality care and support services through a variety of models of care delivery. This includes quality management of OIs, a safe, reliable and secure pharmaceutical supply chain, technologically appropriate lab diagnostics, treatment preparation for patients, their families and supporters and community based support for adherence. This technical and programmatic assistance utilizes on-site mentoring and preceptorship. It also supports the development of site specific work plans and ensures that systems are in place for financial accountability.

AR will continue to build and strengthen the community components by using nurses and counselors to link health institutions to communities. AR Community Based Treatment Services (CBTS) specialists will continue to support extension of support services to the home and community level. The CBTS Specialists will develop a community volunteer structure in collaboration with the Volunteer Services Organization (VSO) in COP10 to ensure sustainability of services at LPTFs to include mental health support (psychotherapeutic, psychosocial, depression and substance abuse management) and home based care. New and refresher training will be provided for LPTF staff in adherence monitoring. Each LPTF will appoint a specific staff member to coordinate the linkages of patients to all services. This will also build the capacity of LPTFs for better patient tracking, referral coordination, and linkages to appropriate services. All children in care and support will be served with home visits to assess need for intervention. Psychosocial support will continually be enhanced for all infected children by linkages with support group activities and provision of age specific educational/recreational kits. AR will support

expansion of kid support groups to all LPTFs and expand their activities to include periodic social/recreational and educational activities to address issues of stigma and discrimination. AR will support LPTFs to provide step down trainings onsite in this regard.

Efforts will be made to strengthen adolescent friendly services for infected and affected children including linkages to reproductive health.

Non-ART eligible children will be enrolled into care for periodic follow-up, including laboratory analysis at least every 6 months, to identify changes in ART eligibility status. All enrolled children will be linked to the AR OVC program to access an array of services including nutritional support, preventive care package (water sanitation/treatment education, ITN) and psychosocial support. Educational support and food supplements will be leveraged from other partners particularly the CRS SUN program and Catholic Secretariat of Nigeria USG funded SUCCOUR program.

In COP10 AR will train and retrain an additional 68 health service providers according to the National Pediatric HIV Training curriculum. Training will maximize use of all available human resources including a focus on community nursing and community adherence to ensure care is decentralized to the home level. AR will establish sustainable structures and models for training health care providers. This will include consolidating support for tertiary institutions within the AR network and supporting specialty clinics to manage salvage and complex pediatric cases as part of support for AR's transition sustainability plan for capacity building. These institutions will provide for various cadres of health care workers, hands-on training and case conferences in the management of pediatric HIV.

AR will collaborate with the GoN and other stakeholders to implement and scale up task shifting strategies to enable nurses and community health officers provide Pediatric ART. AR will strengthen existing nurse refill services at 3 LPTFs and scale up to 10 additional LPTFs in accordance with AR decentralization and decongestion strategies. AR nurse educators will continue to support the integration of community nursing/Home based nursing services with facility services through training and ongoing mentoring. AR will support expansion of its current pre-service peer education and introduction of nurse curriculum as aspects of pre- and in-service trainings in 10 LPTFs with existing schools of nursing and midwifery. This activity will help in building the capacity of 300 pre service nurses in support of nursing council of Nigeria's approach to improving pre and in service nurse training.

AR will work closely with the USG team to monitor quality improvement at all sites and across the program. AR will actively participate in and facilitate activities to review best practices in Pediatric HIV care and support particularly GoN technical working group meetings. AR will continue its support for GoN in rolling out the national pediatric HIV care and support guideline, and training curriculum.

AR will offer HIV early infant diagnosis (EID) in line with the National Early Infant Diagnosis scale-up plan from 6 weeks of age using DBS. Implementation and scale out of the EID scale-up will be done under the guidance of the GoN and in conjunction with other IPs who will be conducting the laboratory testing. AR will provide support DBS commodities and transport logistics support for the EID program in collaboration with GoN. Exposed infants will be actively enrolled into pediatric care and support. PMTCT focal persons at all AR LPTFs will keep records of all exposed infants at enrollment soon after birth; informing HIV+ mothers of the 6 weeks the exact dates for DBS collection. AR will encourage parent LPTFs to step down DBS collection at affiliate PMTCT satellite sites and thus decentralize EID activities at these sites. Parent LPTFs will ensure supplies of DBS collecting kits from their own stock to these satellites and the samples collected returned to the parent sites for dispatch to the testing labs. AR will train members of PMTCT support groups in HCT skills. AR will engage PMTCT support groups and the larger support group(s) in tracking unbooked pregnant women and infants in the community, linking them to sites where they can access HCT. AR will strengthen linkages with other health care providers; public and private, proximal to AR LPTFs, with full fledged ANC activities. This will encourage two-way referrals of HIV+ mothers and their infants from these providers to AR LPTFs and thus benefit from EID/ART activities at AR sites. LPTF EID focal persons will ensure prompt dissemination of results to providers and mothers as soon as they are available.

In COP10, AR will continue to strengthen its expanded Quality Improvement Program (QIP) consisting of the annual cross sectional Outcomes & Evaluation (O&E) exercise, the GON/USG supported HIVQual monitoring and the quarterly Continuous Quality Improvement (CQI) activities in order to improve and institutionalize quality interventions. AR QIP specialists will be responsible for spearheading QIP activities in their respective regions working with identified and trained LPTF quality management teams. The quality management teams will be supported to conduct in-house self evaluations with AR developed Quality of Care (QoC) indicator tools using the Plan-Do-Study-Act Model to develop strategies for program strengthening. AR will support experience-sharing and dissemination of CQI intervention strategies amongst LPTFs through site-to-site, regional quality committee TWG meetings and the biannual peer forums. Monitoring and evaluation of the AR care and support programs will be consistent with the national plan for patient monitoring. The QIP specialists will conduct team site visits at least quarterly during which there will be evaluations of the status of their standardized medical records keeping, infection control, the utilization of National PMM tools and guidelines, efficiency of clinic services, referral coordination, and use of standard operating procedures across all disciplines. On-site technical assistance (TA) will continually be provided to address weaknesses when identified during routine monitoring visits. Data generated will be used to provide mortality/morbidity reviews and biannual life table analyses that identify factors associated with favorable outcomes. Each of these activities will highlight opportunities for improvement of clinical practices.

Sustainability lies at the heart of the AR program, and is based on durable therapeutic programs and health systems strengthening. AR will focus on the transition of the management of care and treatment activities to indigenous organizations by actively using its extensive linkages with faith based groups and other key stakeholders to develop a transition plan that is appropriate to the Nigerian context. It will also include strengthening regional training institutions to provide long term training support and capacity development to other LPTFs. The plan will be designed to ensure the continuous delivery of quality HIV care and treatment, and all activities will continue to be implemented in close collaboration with the GoN to ensure coordination, information sharing and long term sustainability. For the transition to be successful, sustainable institutional capacity must be present within the indigenous organizations and LPTFs they support; therefore, AR will strengthen the selected indigenous organizations according to their assessed needs, while continuing to strengthen the health systems of the LPTFs. This capacity strengthening will include human resource support and management, financial management, infrastructure improvement, and strengthening of health management information systems.

CONTRIBUTION TO THE OVERALL PROGRAM AREA: By adhering to the Nigerian National ART service delivery guidelines and building strong community components into the program, this activity will support the Nigerian government's universal access to ART by 2010 initiative. By putting in place structures to strengthen LPTF health systems, AR will contribute to the long term sustainability of the ART programs.

LINKS TO OTHER ACTIVITIES: This activity is linked to HCT services to ensure that people tested for HIV are linked to ART services; it also relates to activities in ARV drugs, laboratory services, and care & support activities including Sexual Prevention, PMTCT, OVC, AB, TB/HIV, and SI.

AR will collaborate with the 7-D program of CRS to establish networks of community volunteers. Networks will be created to ensure cross-referrals and sharing of best practices among AR and other implementing partner sites. Effective synergies will be established with the Global Fund to Fight AIDS, Tuberculosis and Malaria through harmonization of activities with GoN and other stakeholders.

POPULATIONS BEING TARGETED: This activity targets children infected with HIV and their caregivers/HCWs from rural and underserved communities.

EMPHASIS AREAS: This activity will include emphasis on human capacity development specifically through in-service

training. These ART services will also ensure gender and age equity in access to ART through linkages with OVC and PMTCT services in AR sites and neighboring sites. The extension of ARV services into rural and previously underserved communities will contribute to the equitable availability of ART services in Nigeria and towards the goal of universal access to ARV services in the country. The provision of ART services will improve the quality of life of infected children and thus reduce the stigma and discrimination against them.

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ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

In COP09, AIDSRelief (AR) is providing PMTCT services in 34 comprehensive Local Partner Treatment Facilities (LPTFs) and 17 satellite facilities in 16 states (Abia, Adamawa, Anambra, Benue, Delta Ebonyi, Edo, Enugu, FCT, Imo, Kaduna, Kano, Kogi, Nasarawa, Ondo, Plateau, Rivers and Taraba). AR will continue to implement a local government area-wide service coverage strategy in Anambra and other states with AIDSRelief presence. In setting and achieving COP10 targets, consideration has been given to consolidating on AR's rapid PMTCT COP09 accomplishments in order to maintain continuous quality improvement.

AR will continue to provide counseling, testing and results to 47,200 pregnant women. Antiretroviral (ARV) prophylaxis will be provided to 2,000 women and an additional 500 clients will be placed on HAART for their own disease for a total of 1,800women receiving antiretrovirals (4% positivity rate and 75% retention in care based on historical data at AR supported LPTFs). This activity will include routine provider initiated opt-out HIV counseling and testing (HCT) for all women presenting in antenatal clinics (ANC),labor and delivery wards (L&D) in addition to immediate post-delivery settings for women of unknown HIV status. Counseling will be provided using group and individual pre/post- test counseling strategies and rapid testing based on the National testing algorithms. Same day results will be provided to clients. As part of PMTCT services, partner testing and couple counseling will be strengthened with the provision of a "Partners' Slip" and initiation of a facility based monthly "Couples Forum" to enhance disclosure and male involvement. Through its community and faith-based linkages, AR will continue to utilize community and home based care services to promote partner testing. Clients will be provided access to free laboratory services including CD4 counts, STI screening (VDRL), Urinalysis, MP and Ultrasound Sound Screening (USS). Free medications including those for OIs and hematinics will also be provided. Access to cervical screening will be provided to HIV positive women enrolled into PMTCT services. Strong referral systems that incorporate active follow-up will be strengthened to ensure that women requiring HAART are not lost during referral for ARV services. Referral coordinators will be identified in all our sites and the communities with their capacities built in collaboration with other IPs.

For the anticipated number of women not requiring HAART for their own health, the current WHO- recommended short course ARV option will be provided (ZDV from 28 weeks with intra-partum sdNVP and a 7-day ZDV/3TC post-partum tail or ZDV/3TC from 34-36 weeks with intra-partum sdNVP and a 7- day ZDV/3TC post-partum tail). AR will also offer the option of HAART from 1st week of 2nd trimester in facilities with capacity to deliver HAART. Infant prophylaxis will consist of single dose NVP and ZDV for 6 weeks. AR will use its community linkages, mother-to-mother support groups and the provision of incentives to encourage HIV+ pregnant women to deliver in a health facility. The incentive package

("Mama and Baby Packs") contains basic delivery consumables and immediate baby care items including suctioning bulbs, cord clamps, disinfectant, mackintosh, baby soap and face flannel. All infants of HIV positive woman will be referred to OVC services in order to facilitate care to all affected children.

AR will facilitate establishment of MCH teams within facilities to ensure continuum of care by strengthening linkages between the PMTCT and ART, pediatric and OVC programs. For those HIV+ women who deliver at home, the MCH team and community volunteers will follow-up and ensure delivery of required postpartum services.

AR will support the utilization of traditional birth attendants (TBAs) in referral services in addition to the mother-to-mother support groups to reach HIV+ women who deliver outside of the health facility. This activity will help increase referrals, patient tracking and universal precautions to improve PMTCT outcomes. In this regard, a pilot of TBA service training will be done in 3 states in collaboration with the LPTFs. A focal person at each LPTF will be responsible for tracing HIV+ mothers and their infants in the community and re-integrating them into care. AR Community Based Treatment Services (CBTS) specialists will continue to support extension of treatment services to the home and community level. The CBTS Specialists will develop a community volunteer structure in collaboration with the Volunteer Services Organization (VSO) in COP10 to ensure sustainability of services at LPTFs to include psychosocial support and home based care.

HIV+ women will be provided infant feeding counseling in prenatal and postnatal periods with options of exclusive breast feeding with early cessation or exclusive BMS if AFASS criteria can be met using the WHO UNICEF curriculum adapted for Nigeria. AR will support couple counseling and family disclosure that will enhance adherence to infant feeding choices. Full and accurate information will be provided on family planning and prevention services. Women accessing family planning services will be offered HIV Counseling and Testing. Infants of positive mothers will be linked to immunization and well child care services. Cotrimoxazole prophylaxis will be provided to infants from 6 weeks of age until definitive HIV status can be ascertained.

AR will provide training in three cycles to 60 healthcare workers and retraining of additional 30 staff on PMTCT/EID according to the national curriculum. AR will establish sustainable structures and models for training health care providers. Targeted regional LPTF exchange MCH team visits (PMTCT, Pediatrics and OVC focal personnel) within a region to ensure facility ownership of the PMTCT programs will be supported as a stimulus for self evaluation and capacity building. This will include consolidating support for tertiary institutions within the AR network and supporting specialty clinics to manage complex PMTCT cases as part of support for AR's transition sustainability plan for capacity building. Trained LPTF staff will be used as facilitators to step down trainings to other Health Care Workers in their facilities and in nearby

government health facilities as a human capacity development and sustainability activities.

AR will collaborate with UNICEF-supported PMTCT sites and the CRS 7D programs for community and home based PMTCT initiatives in its scale-up plans.

In COP10, AR will continue to strengthen its expanded Quality Improvement Program (QIP) consisting of the annual cross sectional Outcomes & Evaluation (O&E) exercise, the GON/USG supported HIVQual monitoring and the quarterly Continuous Quality Improvement (CQI) activities in order to improve and institutionalize quality interventions. AIDSRelief QIP specialists will be responsible for spearheading QIP activities in their respective regions working with identified and trained LPTF quality management teams. The quality management teams will be supported to conduct in-house self evaluations with AR developed Quality of Care (QoC) indicator tools using the Plan-Do-Study-Act Model to develop strategies for program strengthening. AR will support experience-sharing and dissemination of CQI intervention strategies amongst LPTFs through site-to-site, regional quality committee TWG meetings and the biannual peer fora. Monitoring and evaluation of the AIDSRelief ART program will be consistent with the national plan for patient monitoring. The QIP specialists will conduct team site visits at least quarterly during which there will be evaluations of the status of their standardized medical records keeping, infection control, the utilization of National PMM tools and guidelines, efficiency of clinic services, referral coordination, and use of standard operating procedures across all disciplines. On-site technical assistance (TA) will continually be provided to address weaknesses when identified during routine monitoring visits. Monitoring and evaluation of the AIDSRelief PMTCT program will be consistent with the national plan for patient monitoring. Data generated will be used to provide mortality/morbidity reviews and biannual life table analyses that identify factors associated with good PMTCT outcomes. In addition, at each LPTF an annual cross sectional evaluation of program quality shall consist of a 10% random sample of linked medical records, adherence questionnaires and viral loads to examine treatment compliance and viral load suppression for adult patients who have been on treatment for at least 9 months. A similar process will be undertaken to evaluate outcomes of PMTCT strategies. All these activities will highlight opportunities for improvement of clinical practices.

CONTRIBUTIONS TO OVERALL PROGRAM AREA: This activity will provide counseling and testing services to 47,200 pregnant women, and provide ARV prophylaxis to 2,000 and 1,800 clients on ART. With 34 operational sites in 16 states, AR PMTCT program supports the rapid scale up of PMTCT services desired by the FMOH.

LINKS TO OTHER ACTIVITIES: The PMTCT services will be linked to HCT, basic care and support, ARV services, ARV drugs, OVC,

TB/HIV, laboratory services and SI. Pregnant women who present for HCT services will be provided with information about the PMTCT program and referred accordingly. ARV treatment services for infants and mothers will be provided through ART services. Basic pediatric care, including TB care, is provided for infants and children through OVC activities. All HIV+ women will be registered for adult care and support services.

AR PMTCT activities will focus on strengthening community and home-based care services to pregnant women where appropriate and in collaboration with the CRS 7-Diocese program and other family- centered care services provided by UNICEF, GON and the Catholic Secretariat of Nigeria. The AR senior PMTCT specialist will offer technical assistance to 7-Diocese facilities. AR will collaborate with other IPs, particularly IHV-ACTION, working at tertiary institutions for infant diagnosis using dried blood spot (DBS) technology.

POPULATIONS BEING TARGETED: This activity targets women of reproductive age and their partners, infants and PLWHAs. This activity also targets training of health care providers, TBAs and mothers who will work as peer educators.

EMPHASIS AREAS This activity has an emphasis on training, supportive supervision, quality assurance/improvement and commodity procurement. Emphasis also is placed on development of networks/linkages/referral systems. In addition, integrating PMTCT with ANC and other family-centered services while ensuring linkages to Mother-Child-Health (MCH) and reproductive health services will ensure gender equity in access to HIV/AIDS services.

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