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BUDGET CODE 1 Narrative: PMTCT (MTCT)

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: As a result of significantly reduced funding (less than 30% of award level), the project's planned expansion to Akwa Ibom State will be shelved in COP10. As an alternative, ZAIHAP will consolidate its activities in the existing HVCT sites in Zamfara State and activate 2 additional HCT sites.

Activity Description This activity is linked to HCT (HVCT). The Zamfara Akwa Ibom HIV/AIDS Project (ZAIHAP) will use evidence-based technical and programmatic approaches to improve access to quality PMTCT services in Zamfara State. In the first years of the project (COP08), 3 health facilities in Zamfara State were supported to provide PMTCT services. In COP09 and another 2 PMTCT sites will be supported to make a total of 5 ZAIHAP PMTCT sites. Given the significant reduction in program budget from its award level, the planned expansion of the ZAIHAP project to Akwa Ibom State in COP10 will again be further delayed. Rather, ZAIHAP will consolidate its foothold in Zamfara State in COP10.

The overall goal of the proposed project is to establish sustainable approaches for the reduction of morbidity and mortality due to HIV/AIDS among vulnerable populations. By using platforms of integrated health services and community outreach to scale-up PMTCT and HCT programs, ZAIHAP will strengthen the capacity and expansion of primary prevention of HIV infection.

ZAIHAP will continue to work with the State Ministry of Health (SMOH) and State Agency for Control of AIDS (SACA) to increase access to and use of high quality PMTCT services at facility and community levels in Zamfara States. Using a network approach with basic PMTCT secondary health care centers linked to primary health care centers, ZAIHAP will provide a hub and spoke model of PMTCT services across all supported sites.

Group health information will be provided to all antenatal clients. HIV testing and counseling using the opt-out approach will be provided to all pregnant women at the time of antenatal booking. All points of service will provide same-day results. An estimated 7385 pregnant women accessing ANC services in ZAIHAP supported health facilities will have known HIV status following the addition of 2 PMTCT sites in Zamfara States. Partner testing will be offered as part of counseling at the PMTCT site. Women who are HIV-negative will be counseled on how to remain negative, safer sexual practices, safe delivery and safe motherhood. Healthcare providers from these sites will participate in the national couple counseling training.

An estimated 294 known positive pregnant women will be provided with a complete course of ARV prophylaxis in Zamfara State. Pregnant women who are found to be infected with HIV will also receive other services at PMTCT sites including medical evaluation, laboratory analysis including CD4 count (onsite or within HIV Care and Treatment Network in the states through specimen transportation), and treatment of opportunistic infections (OIs). For women not requiring HAART, the National PMTCT Guideline consisting of ZDV from 28 weeks or ZDV/3TC from 34 weeks will be prescribed. They will also be placed on intrapartum NVP and a 7-day ZDV/3TC postpartum tail. Infant prophylaxis will consist of single dose NVP at birth and ZDV for 6 weeks. Cotrimoxazole prophylaxis will be given to exposed infants at birth till HIV infection can be excluded.

All HIV positive women will be counseled on appropriate Infant Feeding options. This counseling will be done using the National PMTCT Guidelines where unbiased counseling will be offered and informed choice made between Exclusive Breastfeeding (EBF) and Replacement Feeding. All HIV exposed infants will be followed up and referred diagnosis using DNA PCR or Antibody tests as appropriate. Jhpiego will participate in the next phase of National Early Infant Diagnosis program scale-up and all PMTCT sites will be linked for Dry Blood Spot (DBS) sample collection. HIV exposed infants will also be linked to the nearest OVC services if needed.

Pregnant women requiring HAART for their own health will be referred for Care, Treatment and Support based on the National Treatment Guidelines at Comprehensive sites within the HIV Care and Treatment Network in Zamfara State. Women will be linked to PLWHA support groups within the Care and Support network which will provide both education and ongoing support around Infant Feeding choices.

Jhpiego will train 20 health workers from the two (2) new sites in Zamfara State on the provision of PMTCT services using the National PMTCT Training Curriculum. ZAIHAP will apply the Community Action Cycle (CAC) and Partnership Defined Quality (PDQ) methodologies which will bring service providers and community members together to define quality of care, identify and prioritize problems and create solutions. This will empower and mobilize local communities to support and increase demand for uptake of PMTCT services. Support groups for mothers will be established/ strengthened to promote uptake of PMTCT and other maternity services and adherence to treatment protocols, using the Mothers- 2-Mothers Model.

The project will ensure that after delivery, all HIV+ women are properly referred for treatment and directed to wrap-around services such as health and psychosocial support, gender-based violence prevention and response, support for formal and informal education, skills and vocational training and income generation.

Jhpiego will use national PMTCT Registers across all our sites and train twenty-five (25) healthcare workers (including staff of new PMTCT sites and Local Government M&E Officers from ZAIHAP LGAs) in Zamfara State using the National PMTCT MIS System. The Local Government M&E officers will play a critical role in building the capacity of the LGA M&E System and will also send Monthly Reports which will be sent to the SASCP.

Contribution to Overall Program Area Jhpiego's work at her PMTCT sites will contribute to achieving the PEPFAR/USG COP10 12-2-3 Legislative Goals of preventing 12 million new HIV infections, providing care to 12 million people infected

or affected by HIV/AIDS and providing treatment for at least 3 million people. To measure and report on progress toward achieving program objectives, Jhpiego will implement a detailed Monitoring and Evaluation (M&E) plan which acknowledges the critical importance of collecting and reporting on the PEPFAR program-level indicators and will institute reporting on the Next Generation Indicators. Program-level indicators will be collected routinely and reported quarterly, semi-annually and annually during site visits through available project records, Client Registers, and the Nigerian National Response Information Monitoring System (NNRIMS), as appropriate. Jhpiego's Training Information Monitoring System (TIMS) will also be used to track persons trained and facilitate follow-up.

While recognizing that data from the Jhpiego-supported sites will be reported to the Federal Ministry of Health to calculate the outcome indicators on a national level, Jhpiego will also calculate these indicators on a project level to ensure proper project implementation and management.

Understanding the importance of the 'Three Ones', Jhpiego will work with the Federal Ministry of Health, UNAIDS, and other donors to implement the National M&E Plan and support the National HIV/AIDS Strategy.

Links to Other Activities Jhpiego is currently working in Zamfara State to implement the ACCESS Program which focuses on strengthening primary and secondary health facilities to provide Emergency Obstetric and Newborn Care (EmONC) services as well as increasing demand for these services through community mobilization activities. The ZAIHAP project is leveraging support from the ongoing ACCESS program in Zamfara State which has strong community mobilization and demand generation interventions. ZAIHAP will continue to take advantage of ACCESS/MCHIPs existing community mobilization network and add messages on the benefits of PMTCT, the existence of PMTCT services to reduce the likelihood of HIV transmission to infants, and appropriate infant feeding choices. The PMTCT activities can serve as a platform through which other family members are targeted for HCT services. ZAIHAP activities will be linked to other important services such as HIV care and treatment, and other services including psychosocial support and economic empowerment schemes, through referral to nearby services. The National HCT (Heart-2-Heart) Logo will be conspicuously displayed at all PMTCT sites.

ZAIHAP is partnering with two (2) local NGOs in Zamfara State, Federation of Muslim Women's Associations of Nigeria (FOMWAN) and Community Health Development Project (COHEDEP) to further mobilize communities through advocacy to political and traditional rulers, community dialogue, community rallies and development of radio messages to be aired across the state. This partnership will be maintained to the extent that it remains beneficial to the ZAIHAP project.

Target Population The target population is pregnant women and their infants. These women will be reached through both facility based (antenatal clinic) and community based activities. Women reached through community activities will be encouraged to utilize antenatal care services in the health facilities.

Key Legislative Issues This activity addresses the key legislative issue of gender as pregnant women will be provided with ARV prophylaxis and treatment. Data from these women will demonstrate this.

Emphasis Areas The activity includes a major emphasis on local organization capacity building, quality assurance, quality improvement, supportive supervision and minor emphases on commodity procurement and infrastructure.

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