ECEWS will be a continuing partner in COP10 and will implement activities in eight technical areas

including STP,HTC,TB/HIV,Adult BC&S, Peds BC&S,OVC and SI.Activities will provide continued access to services for cliets already recruited in COP09. ECEWS will contribute to the renewed PEPFAR ll of 3- 12-12 of treatment ,prevention and Care via activities in Akwa Ibom ,Cross River and Abia states. ECEWS will maintain services to clients recruited in COP 09 in 67 target community sites.The National sentinel survey (2008) puts the National prevence at 4.6% with all our sites having prevalence of Akwa Ibom -9.7%, Cross River-8.0% and Abia- 6%. An estimated 2.95 million PLWH and 2.23 million AIDS orpharns are in need of services in Nigeria. ECEWS will work closely with other IPs in building the capacity of GON in SI and other technical areas to respond adequately.ECEWS will be a continuing partner in the program area of Abstinence/Be Faithful (AB) in COP10. ECEWS will implement its AB programming activities in line with the overall PEPFAR Nigeria goal of providing a comprehensive package of prevention services to individuals reached (thereby improving the effectiveness of this messaging) through a balanced portfolio of prevention activities including condoms and other prevention.The target for this intensive AB messaging campaign is 4,546 individuals. In addition, age appropriate abstinence only messaging and secondary abstinence messaging will be conveyed to 2,000 children and adolescents, particularly focused on in-school youths and orphans and vulnerable children (OVC) receiving home based support.In COP10 ECEWS will continue to provide community outreach to individuals identified as high risk for HIV and direct them to counseling and testing while promoting prevention through activities other than abstinence and be faithful messages. This activity will focus on condom use promotion in most at risk populations and referral to ECEWS supported and/or other local PEPFAR-supported HCT sites. Condoms and other prevention activities will continue in 31 sites (7sites developed under COP07 and 18 sites developed under COP08 and 6 sites in COP09) targeting 9,091 most at risk persons (MARPs) which include GOPD and STI patients, PLWHA, incarcerated populations, youth, police, customs workers, immigration workers and commercial sex workers in Akwa Ibom and Cross River states. In COP 10 ECEWS will continue and maintain activities in HIV counseling and testing (HCT) and will provide services to 2,500 people who will be counseled, tested, and receive their results. These HCT services will be provided at 10 fixed points of service (POS), including 7 public health care facilities and 3 private health care facilities, and 1 mobile point of service that will target most at risk persons (MARPs) including incarcerated populations, youth, police, customs workers, immigration workers and commercial sex workers, for a total of 11 points of service in the states of Akwa Ibom and Cross River. Staff and volunteers on the mobile team will actively visit communities where MARPs are located through community outreach HCT activities.In COP10 ECEWS will Continue to provide palliative care to 2,500 HIV+ adults/adolescents and 5,000 HIV- PABAs for a total of 7,500 adults reached with care services. This will be provided in 24 sites (10 HCT sites, 4 TBHIV sites and 10 community based sites) in 2 states (Akwa Ibom and Cross River). The care services available to all HIV+ adults includes: prevention with positives services, access to appropriate TB diagnostics and linkage with DOTS programs described under TB/HIV, access to laboratory services (including CD4 count, chemistry, hematology) instruction in

appropriate water purification and provision of water guard, provision of ITNs, linkage to psychosocial support through participation in PLWHA support groups and individual counseling, and access to community home based care services.In COP 2010, ECEWS will continue to provide Pediatric Care and Support to 250 HIV exposed and HIV/AIDS infected children ( 0-14 years) and 500 PABAs for a total of 750 reached with care services. At 4 TB DOTS points of service directly supported by ECEWS, 900 newly presenting TB suspects and patients developing symptoms will be screened for HIV and provided appropriate counseling based on results. It is estimated that approximately 90 of these TB suspects will have TB, and that through HCT 30 will be identified as TB/HIV co-infected. ECEWS' programmatic goals are to ensure adequate and prompt linkage of TB patients and their household contacts to HIV counseling, testing, care and treatment services, to ensure that all HIV patients are screened for TB, and to enable all HIV-infected patients with TB to access services at DOTS and ART clinics. In addition, ECEWS will continue to support TB DOTS sites to provide holistic patient care according to National and IMAI guidelines. States where activities will be conducted include Akwa Ibom and Cross River. This care service will continue to be provided in 14 facility-based sites in 2 states( Akwa Ibom and Cross River States) aiming at extending and optimizing quality of life for HIV-infected children from the time of diagnosis throughout the continuum of illness, through provision of clinical, psychological, social, spiritual and prevention services. In COP 10 ECEWS will continue its OVC activities by providing preventive care packages to HIV infected children, to families with an HIV infected parent/caregiver, and/or to orphans of HIV/AIDS. ECEWS will provide the full spectrum of OVC services to 2,300 OVC, including HIV+ children, children orphaned by HIV, and caregivers in a minimum of 10 community based sites in Akwa Ibom and Cross River states. In its OVC programming, ECEWS will focus on providing health services, nutrition, psychosocial support, and education to OVCs that it serves. ECEWS will guide OVCs and caregivers to providers of other services such as protection, shelter and care, vocational training, and/or Income Generating Activities (IGA).In COP10 ECEWS will continue activities under the Strategic Information (SI) program area. ECEWS will be supporting the SI activities that will occur across 7 program areas (HCT, TB/HIV, Adult care & support, Pediatric care & support, OVC, AB and COP) for a total of 67 sites in 3 states (Akwa Ibom, Cross River and Abia state ). ECEWS staff and the NGO staff that partner with ECEWS for activities at a variety of these sites will be involved in these site-level SI activities. ECEWS will strengthen Strategic Information (SI) under the "One M&E Framework" by supporting standardized HIV indicator reporting systems at program sites and registering sites in the national M&E system. For facilities where there is other donor support, data collection and indicator reporting will be harmonized and one reporting system will be used in accordance with the national guidelines and indicators. ECEWS will work with USG and GON to include ECEWS-supported facilities in the National Public Health data system launched in 2007 (Voxiva platform) where applicable. ECEWS will be an active participant on the USG SI working group supporting PEPFAR in developing and maintaining a unified national data platform for HIV services in Nigeria.

In line with the renewed PEPFAR II 3-12-12 goal of providing services including prevention, care and treatment services ECEWS will contribute to the overall Nigeria targets. A total of 157 individuals will be trained in ECEWS COP10 activities including 57 HCWs, this will further the overall goal of task shifting and ownership.Strengthening SI will enable timely, transparent, and quality data reporting of 2010 EP targets for Nigeria and through collaboration with the GON will establish one standardized system to monitor National HIV programs. Planned targeted evaluations will guide decisions in improving program implementation and scale-up and will be defined and coordinated with the USG team in-country. Of interest is evaluating barriers and access to care for HIV positives identified and referred through HCT. ECEWS emphasisa will be capacity building and gender in COP10 with priority in maintaining services to persons previously reached with PEPFAR supported services accross her supported sites.

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ACTIVITY DESCRIPTION

In COP 10 ECEWS will continue and maintain activities in HIV counseling and testing (HCT) and will provide services to 2,500 people who will be counseled, tested, and receive their results. These HCT services will be provided at 10 fixed points of service (POS), including 7 public health care facilities and 3 private health care facilities, and 1 mobile point of service that will target most at risk persons (MARPs) including incarcerated populations, youth, police, customs workers, immigration workers and commercial sex workers, for a total of 11 points of service in the states of Akwa Ibom and Cross River. Staff and volunteers on the mobile team will actively visit communities where MARPs are located through community outreach HCT activities.

The national "Heart to Heart" branding logo will be utilized at HCT points of service for easy recognition. Counseling and IEC materials will focus on abstinence, be faithful, and consistent and correct condom use (ABC), providing this messaging in a balanced approach appropriate for each individual client. For clients testing HIV positive, prevention with positives services will be provided, including HCT for family members and sex partners, counseling for discordant couples, counseling on healthy lifestyles and positive living, prevention messages and IEC materials on disclosure. Posttest counseling for those testing negative will focus on prevention using the ABC approach as well, and partner testing will be encouraged when necessary. Based on risk assessment, a follow-up testing interval will be recommended.

Facility based HCT services will ensure that services are available to all high risk individuals within the institution and the catchment area, for example HCT services in a given facility will be available at TB DOTS, inpatient wards and the general outpatient clinics including where STI patients are seen. HCT

staff will round regularly on the wards and, where applicable, with the medical staff will identify inpatients in need of HIV testing. Each of the ECEWS facility POS will be linked to comprehensive treatment hospitals and facilities for referring HIV positive patients for full evaluation including eligibility for ART. Additional strategies such as equipping home based care teams with HCT capacity to implement home based testing and prevention outreach will be evaluated to target high risk discordant couples and family members. ECEWS mobile HCT services will reach substance abuse populations in selected locales. HIV testing will be carried out by counselors using the nationally approved algorithm with results available immediately.

In appropriate settings and in line with GON, testing will be carried out by staff who are not trained laboratory scientists. Where this is the case, ECEWS master trainers will train and work with these staff to ensure that HIV testing provided within the HCT context is of high quality by incorporating HCT sites into the laboratory QA program. Whenever feasible, client witnessed testing will be carried out to encourage client confidence in the result. QA for HIV testing will be carried out regularly and will include retesting of blood samples and routine site assessments. ECEWS will partner with PEPFAR IPs specializing in lab programs to facilitate QA programs to ensure quality of services.

Using established SOPs and a standardized National training curriculum, new counselors will be trained either centrally or at the site level, and refresher courses for existing counselors will be conducted. Counselors will be trained to counsel clients concerning disclosure to spouse and/or sexual partners and to encourage disclosure, while exploring and addressing potential negative consequences. ECEWS will also seek out training opportunities for counselors on couples counseling using a standardized curriculum. ECEWS will train, either itself or through leveraging training programs provided by other PEPFAR IPs, 10 counselors in the provision of HCT. The quality assurance (QA) strategy for counseling will include posttest client surveys and periodic refresher training. Existing site staff will be used as counselors. At high throughput centers, temporary additional staff support may be provided, but sites must agree to include funding for any new position in the next fiscal year site budget.

Condoms, supplied by other donors and provided to all IPs through Society for Family Health will be available at ECEWS-supported centers at no charge or a limited charge. Test kits and disposables for testing will be warehoused by ECEWS, and where feasible in collaboration with the state Ministry of Health. They will be provided to sites based on a pull system using a site level inventory control system linked to the ECEWS warehouse logistics management information system. The current system can be easily harmonized with the national test kit logistics management information system and inventory control system once implemented.

The M&E system will utilize the National HCT registers to maximize time devoted to service provision and

facilitate services at primary health center and community mobile settings. National patient management and monitoring (PMM) forms will also be used. Aggregate site data will be summarized and reported to the national M&E program officer monthly. HCT services will be provided at 11 sites (10 fixed and 1 mobile) in the following 2 states: Akwa Ibom and Cross River.

Contribution to Overall Technical Area This activity supports the national HCT scale up plan by promoting the accessibility of HCT services using an FMOH approved training curriculum and procedures. HCT services are essential to identify HIV+ people to meet national prevention goals and the national ARV/HIV care scale up goals. HCT services will target most at risk persons to maximize this impact.

Link to Other Activities This activity is linked to AB (15656.09), Condoms and Other Prevention (5656.09), Care and Support (15657.09), Orphans and Vulnerable Children (15659.09), TB/HIV (15658.09) and SI (15674.09). Prevention for positives counseling will be integrated within posttest counseling for HIV+ persons, thereby providing this care service at HCT POS. Other at risk family members including vulnerable children will be identified through HCT and referred to services such as OVC programming.

Populations Targeted This activity serves children, youth and adults in the general population who will be offered HIV counseling and testing. However, most at risk persons including commercial sex workers, discordant couples, uniformed service men, out of school youth, mobile populations, and partners/clients of commercial sex workers will be specifically targeted. Other health care workers and community volunteers will be targeted for training.

Legislative Issues This activity addresses the key legislative issue of "Stigma and Discrimination", since HIV counseling reduces stigma associated with HIV status through education.

Coverage Areas (Focus Countries Only) Akwa Ibom

Cross River

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ACTIVITY DESCRIPTION

ECEWS will be a continuing partner in the program area of Abstinence/Be Faithful (AB) in COP10. ECEWS will implement its AB programming activities in line with the overall PEPFAR Nigeria goal of providing a comprehensive package of prevention services to individuals reached (thereby improving the effectiveness of this messaging) through a balanced portfolio of prevention activities including condoms and other prevention. Through the involvement of ECEWS in this activity, PEPFAR Nigeria will further its development of an integrated comprehensive prevention portfolio.

ECEWS' goal for its new activities in the AB program is to contribute to a reduction in HIV prevalence among youths, particularly in the most at risk age group of 15-24 year olds, and to promote mutual fidelity among married adults. The 2005 ANC survey in Nigeria indicates that among age cohorts in Nigeria, the 20-29 year old age group has the highest HIV prevalence (4.9% compared to a national prevalence of 4.4%). In addition, the 2005 National HIV/AIDS and Reproductive Health Survey (NARHS) demonstrated a low risk perception (28%) among the general population and significant reports of transactional sex (11%) among young women aged 15-29 years. This age cohort for both men and women represents the working age group in Nigeria; it is expected that a combination of prevention messaging approaches will ensure they are effectively reached with prevention interventions.

This activity will be implemented at the community level and will be reinforced through national level mass media campaigns by other USG partners such as the successful Zip-Up campaign. In COP10, ECEWS will implement AB programming in underserved areas in Nigeria and will couple these activities with condoms and other prevention program services and with counseling and testing program services. The implementation of the AB activities will utilize a combination of multiple strategies, including community awareness campaigns, peer education models, peer education plus activities, and a school- based approach.

AB messages will be balanced with concurrent condoms and other prevention messaging where appropriate and will be integrated with services provided by ECEWS in a total of 20 sites ( 10 school based sites and 10 FBO sites developed in COP08 and 09) in 3 states (Akwa Ibom ,Cross River and Abia states).However AB messaging only will be provided to 10 target community sites including FBOs/CBOs, and A only prioritized only to 10 school based sits in Akwa Ibom ,Cross river and Abia states

The goal of the program is to be focused on the communities targeted and to saturate those communities with messages conveyed in multiple fora. Utilizing such a methodology, a large number of people will be reached with messages received via one strategy or another, but the target group will be those individuals that will have received AB messaging: (1) on a regular basis and (2) via at least three of the four strategies ECEWS will employ (community awareness campaigns, peer education models, peer education plus activities, and school based activities). The police and other uniformed service men, incarcerated persons, and in-school and out-of-school youth will be reached with AB messages. The target for this intensive AB messaging campaign is 4,546 individuals. In addition, age appropriate abstinence only messaging and secondary abstinence messaging will be conveyed to 2,000 children and adolescents, particularly focused on in-school youths and orphans and vulnerable children (OVC) receiving home based support.

In COP 10 a total of 20 counselors, teachers, peer educators, religious leaders will be trained to conduct effective prevention interventions inclusive of AB messaging. Retraining will however be conducted for 80 individuals previously trained under COP 09 and COP 08.

ECEWS will collaborate with community based organizations (CBOs), faith based organizations (FBOs), and PLWHA support groups in the communities in which it will be conducting other PEPFAR programmatic activities. These support groups will also serve as appropriate partners in the dissemination of ABC messaging to other PLWHA utilizing the peer education model. The CBOs and FBOs will serve as appropriate partners in reaching wider audiences through the peer education plus model and community awareness campaigns conducted under the supervision of ECEWS and will include activities such as drama presentations, musical events, and road shows/rallies.

ECEWS also has experience in conducting school based approaches to HIV education and under this program will serve 10 schools in its communities. School based programs will include interactive learning activities that focus on acquisition of skills-based HIV education.

CONTRIBUTIONS TO OVERALL TECHNICAL AREA:

The funding in this activity area will contribute to the overall PEPFAR goals of preventing further infections and reducing HIV rates in Nigeria. It will also help to lay the foundation for more sustainable programs.

LINKS TO OTHER ACTIVITIES: This activity will be integrated with Counseling and Testing (#15660.09), Basic Care and Support (#15657.09), Other Prevention (#5656.09), and TB/HIV (#15658.09).

POPULATIONS BEING TARGETED: The focus population for this activity will be youth, young adults and particularly, young women and girls, and in school youths. It will also target community/religious leaders and parents.

COVERAGE AREAS: Akwa Ibom, Cross River and Abia States

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ACTIVITY DESCRIPTION

In COP010 ECEWS will continue TB/HIV services, maintaining its HCT services to DOTS sites in line with the National TB and Leprosy Control Program (NTBLCP) to focus on strengthening the integration of high quality TB and HIV care delivery. At 4 TB DOTS points of service directly supported by ECEWS, 900 newly presenting TB suspects and patients developing symptoms will be screened for HIV and provided appropriate counseling based on results. It is estimated that approximately 90 of these TB suspects will have TB, and that through HCT 30 will be identified as TB/HIV co-infected. ECEWS' programmatic goals are to ensure adequate and prompt linkage of TB patients and their household contacts to HIV counseling, testing, care and treatment services, to ensure that all HIV patients are screened for TB, and to enable all HIV-infected patients with TB to access services at DOTS and ART clinics. In addition, ECEWS will continue to support TB DOTS sites to provide holistic patient care according to National and IMAI guidelines. States where activities will be conducted include Akwa Ibom and Cross River.

DOTS site personnel will be trained in HIV diagnosis using HIV rapid test kits and educated in referring HIV+ individuals to comprehensive care for assessment including for antiretroviral treatment eligibility. Provider-initiated HIV counseling and opt-out testing will be employed with TB patients and suspects, respectively.

Nosocomial transmission of TB will be mitigated through attention to principles of TB infection control, including administrative and environmental control measures such as clinic design, good ventilation, appropriate patient triage, staff training, and enforcement of basic hygiene and proper sputum disposal. Patient and staff education on infection control measures will be routinely carried out to ensure program success. The national guidelines on infection control will be implemented in all ECEWS supported sites. ECEWS will bear in mind these principles for any facilities upgrades that may be needed such as basic renovations. ECEWS will also provide support to the sites through procuring supplies and consumables (e.g. sputum containers) where deficiencies are noted.

ECEWS will continue to partner with PEPFAR IPs specializing in lab programs to facilitate QA programs to ensure quality of services. ECEWS master trainers will train and work with TB DOTS staff to ensure that HIV testing provided within the TB DOTS context is of high quality by incorporating TB DOTS sites into the laboratory QA program. An ongoing TB diagnostics QA program will be conducted including: joint site visits with the FMOH or relevant state MOH for observation/retraining, selective review of completed smear examinations, training on X-ray diagnosis / TB treatment and proficiency testing with "unknown" slides provided by the QA team. Refresher/retraining of clinical staff on x-ray diagnostics where appropriate will also be done. Regarding quality of TB treatment being provided, ECEWS will work in close collaboration with the German Leprosy and TB Relief Association (GLRA) to ensure that TB DOTS staff are following the National TB treatment algorithm. ECEWS will support training for 4 staff in COP10, including refresher training, for a total of 12 staff (4 staff in COP 08, 4 staff in COP 09 and 4 staff in COP 10)in TB treatment.

The ECEWS M&E staff will work with sites to ensure that incident TB cases are properly reported to the SMOH and FMOH. ECEWS will network with Global Fund in implementing these plans to avoid duplication of services to be developed under Global Fund. TB/HIV co-infected patients will be referred for appropriate clinical management of their HIV and other opportunistic infections within the network of care and treatment. Cotrimaxozole Preventive Therapy (CPT) will be provided to eligible TB/HIV patients as a component of the ECEWS basic care and support program. HCT in DOTS sites will be established at the secondary and primary health center levels with linkages to tertiary centers to provide accessibility of services to patients.

CONTRIBUTIONS TO OVERALL TECHNICAL AREA Training and support to improve the quality and integration of TB/HIV services are consistent with FMOH and EP priorities. Goals are co-location of HCT services in the TB DOTS setting, an increased number of TB suspect patients screened for HIV, appropriate referral for care and support of HIV+ clients, and improvement of overall TB services (i.e., diagnostics and treatments) at supported sites. An overarching focus on technical capacity development will ensure sustainability. Smear microscopy QA will be carried out collaboratively with the FMOH or the relevant State MOH to promote sustainability through capacity development and integration into the health sector system.

LINKS TO OTHER ACTIVITIES This activity is also linked to Counseling and Testing (15660.09), Basic Care and Support (15657.09), OVC (15659.09), Abstinence and Be Faithful (15656.09), and Condoms & Other Prevention (5656.09). Linkage to TB diagnosis and treatment is an important component of adult Care and Support and OVC services.

POPULATIONS BEING TARGETED TB suspects and patients, PLWHA, and their families and household members who may be at greater risk for TB.

Coverage Areas (Focus Countries Only)

• Akwa Ibom

• Cross River