During COP10, APIN will provide program management and capacity building support for comprehensive HIV/AIDS prevention, care and treatment programs at 1 tertiary level hospital, 3 secondary level hospitals, 1 medical research institute and 1 primary health center. In collaboration with the Oyo State government and the University of Ibadan, we will support 43 DOT centers for HIV/TB activities across the state. Clinical activities will be implemented in accordance with APIN clinical protocols, which are harmonized with National protocols.

In accordance with the PEPFAR program priorities, the major goals of the APIN program are to:

1. Achieve primary prevention of HIV through expanded counseling and testing (HVCT) and prevention of mother-to-child transmission (MTCT) programs.

We will achieve this goal through collaboration with partner institutions in Nigeria to support existing programs and further scale-up HIV voluntary counseling and testing to maximize identification of HIV positive individuals for ART and care. We will be providing PMTCT services at all our clinical sites. HCT activities will focus on outreach to most at risk populations (MARPs) and be coupled with HIV prevention messages. These collaborations will include support for the expansion of PMTCT programs, through linkages with OB/GYN programs and ANC clinics and capacity building for pediatric care at our partner sites.

2. Improve and expand care and treatment of HIV/AIDS, other STDs, OIs (including TB).

Achievement of this goal will involve the provision of support for the infrastructure at our sites to provide

HIV care and ARV treatment in accordance with best clinical practices. In particular, we will continue with Health Systems Strengthening (OHSS) activities at the 43 TB DOT centers that we support in Oyo State. REDACTED. Health workers' training will also be intensified based on need.

This will include rapid follow-up of HIV-infected patients identified through our HCT and PMTCT programs to ensure that clinical criteria are met. These patients are referred to adult and pediatric ARV clinics to ensure access to care and treatment services. We will also provide prophylaxis, diagnosis and treatment of STDs, and relevant HIV-related infections including TB to reduce co-morbidity. ARV care and treatment services will be provided in accordance with the APIN clinical protocols. We will continue to support TB/HIV in 43 Oyo State DOT centers, with HCT screening, TB diagnostics and downward referral for co-infected patients. These modalities will be supported by an established centrally managed ARV drug and commodity procurement system.

In COP10, APIN will provide testing and counseling services to 14,200 women and provide complete prophylaxis to 852 HIV-positive pregnant women. At the end of COP10, APIN will have provided ART to 15,600 adults and 1,200 pediatric patients, while 23,950 adults and 2,200 pediatric patients will be provided with basic care and support and 2,500 co-infected patients, treated for TB. HVCT services will be offered to 10,200 clients, with a strategy targeting MARPs and clients at ART clinics, while 1,000 children will receive OVC services and 7,192 clients will be provided condoms and other prevention services.

In order to improve the sustainability of HIV/AIDS care and treatment activities at clinical sites, we will strengthen human resource capacity in these areas. Our training efforts will include the provision of central training in ARV services and modalities to new health care providers at partner sites and refresher trainings for existing staff. We will also provide regular site visits that are aimed at evaluating clinical quality of care and providing staff training. Additionally, we will provide clinical training to staff with a focus on expanding health care worker knowledge and skills. Expanding ARV services will also require support for capacity building in the area of laboratory services at each of the program sites. This will include the implementation of quality assurance surveys at each of the sites and refresher training for laboratory staff.

3. Strengthen systems to select, procure, store, track, distribute and provide ART.

In previous years, under the APIN Plus/Harvard PEPFAR program, Harvard has managed supply chain management of pharmaceuticals and other commodities. During COP10, we will continue the transition to APIN staff, who will directly order some drugs from Nigeria. APIN will continue to receive support from Harvard and Northwestern Universities. Such support will be aimed at ensuring that drug needs are

accurately projected and procurement proceeds smoothly. Harvard and Northwestern will continue providing staff training on Supply Chain Management Systems planning and procurement software and in drug ordering processes and conduct periodic reviews of systems. Scale-up in this area will include the hiring of additional staff to for supply chain management to ensure that systems are sufficiently robust to be compliant with U.S. government regulations and to handle increasing purchasing needs as funding levels and the numbers of sites being supported increase.

In order to build APIN's capacity for management of ARV drugs, APIN will re-build a Central Medical Stores warehouse in Lagos, at the NIMR. The facility is necessary to provide central management of commodities that are purchased for program use, including pharmaceuticals, equipment and other supplies. Under the Harvard PEPFAR program, a Central Medical Stores Warehouse which served this purpose was originally constructed at NIMR in 2006. However, in April 2008, a fire at the warehouse resulted in a complete destruction of the structure and its contents. Since that time, all drug storage and supply chain management has been through smaller storage facilities at NIMR, short-term storage space at the CDC warehouse in Abuja, and leased storage space from DHL in Lagos. The result has been fragmented logistics management and increased complexities in tracking procurements, disbursements, and storage. Thus, it is essential to reestablish a centralized storage facility to ensure smooth supply chain management for the increasing number of clinical sites managed by APIN. In addition, this facility will serve the Harvard sites. Thus, in future grant years, as Harvard sites are transitioned to APIN, there will be minimal impact on the logistics management process.

4. Strengthen the capacity of in-country data collection, reporting, surveillance, disease monitoring, clinical quality improvement and laboratory activities.

We will achieve this goal by supporting the implementation of M&E plans, which are aimed at monitoring the implementation of the described programs for clinical efficacy, at each of our sites. In addition, we will support efforts to provide ongoing training and infrastructure building for data management, which will facilitate the implementation of effective M&E programs. Data reviews, using program indicators, will be conducted by the M&E teams at the sites and by central program management staff. These reviews are aimed at ensuring that sites are meeting targets for patient enrollment and health systems strengthening. Deliberate efforts will be made to encourage data use at all APIN sites for better decision-making to improve management of processes and quality of care to patients.

In previous years, quality improvement activities have been centrally managed by Harvard, through the APIN Plus/Harvard PEPFAR program. In COP10, we will transition these activities to APIN staff. This will include training on reviews of electronic data for quality indicators. Additionally, APIN staff will be responsible for formulating the yearly quality improvement plan for site assessments. APIN will also be

responsible for leading quality reviews and the development of tools and data utilities in this area. In COP10, efforts in this area will focus on harmonization with GON and CDC quality improvement goals and building capacity for sites to conduct periodic internal reviews for ongoing monitoring of quality indicators.

5. Enhance the sustainability of program management through capacity and infrastructure building efforts for APIN as an indigenous NGO and for partner sites.

APIN will continue to build on the foundations for sustainable management that it has laid and effect corrective measures from the recent HRSA visit into its planning and operational processes for better efficiency and effectiveness. We will continue to review and adjust our administrative and financial management structures for improved performance. We will add additional program and administrative staff as indicated to ensure effective coordination of ongoing activities at our sites and integration with the USG and National ART Program. We also plan to conduct an external financial audit of APIN accounts, as well as the accounts of all partner sites, as against the first audit involving only APIN program offices. The audits will be conducted by Deloitte, a U.S.-based accounting firm, in accordance with generally accepted accounting principles. Such an audit is aimed at ensuring transparency in the financial management process as well as building capacity for robust financial controls at the sites. Our capacity building efforts will also include ongoing training and infrastructure building for collaborating partners to enhance program sustainability.

ACTIVITY UNCHANGED FROM F2009

NARRATIVE: During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital, 43 UCH Oyo State DOT Centers. APIN will maintain a strong collaboration with Harvard University. In COP10, APIN will provide support for treatment at 3 treatment sites (2 tertiary care, 1 secondary sites) located in two states of Lagos and Ogun. In COP10, APIN will provide support for ACS services at the 6 treatment sites (2 tertiary care, 3 secondary sites, 1 PHC).

This activity will provide care and support services to a total of 23850 PLWHA; (8150 ART-ineligible and 15600 ART-eligible). An additional 47700 People Affected By HIV/AIDS (PABAs) will be reached through the community and home-based care (HBC) program of the PLWHA; therefore, it is expected

that a total of 71550 people will access services. At our 2 secondary level and 1 primary level PMTCT sites, there will also be ACS provided for eligible pregnant women. Harvard and APIN will collaborate in order to ensure a smooth transition of clinical services.

Patients are identified through HCT services, including facility-based, mobile and family-centered strategies. All HIV-positive individuals are provided with care and support services in line with national guidelines and pre-assessed for ART eligibility. ART-eligible patients are provided with ART services, in accordance with a standardized programmatic protocol, which follows the current National ART Guidelines. All HIV+ patients are provided with care and support services, consistent with the National Palliative Care Guidelines. These services include clinical care (nursing care, pain management, OIs and STI prophylaxis and treatment, nutritional assessment and support and end-stage care, labs - baseline haematology, chemistry, CD4 count baseline and follow-up, OI diagnosis and pegnancy test if indicated), with basic care kits, psychosocial and spiritual support, economic empowerment, community HBC, Prevention with Positives (PwP) and other prevention services. HIV+ individuals are provided with cotrimoxazole prophylaxis according to national guidelines. Diagnostics for common opportunistic infections (OIs) may include: Candida albicans, bacteriology, protozoal infections, malaria and gastrointestinal parasites etc. All HIV+ patients are also symptomatically screened for TB and confirmed with laboratory and radiological diagnostics as indicated. APIN will support integration of syndromic management of STIs and risk reduction interventions into care All enrolled patients will be provided with a basic care kits including water vessel, water guard, ITN, soap, ORS, latex gloves, and IEC materials. Pain management assessments will also be conducted by clinicians and HBC providers and analgesics will be provided. APIN uses the hub and spoke model of care for service delivery. APIN will also expand provision of care and treatment services to the primary health centers. APIN will explore the possibility of a pilot program on cervical cancer screening among patients in some selected sites.

ART-ineligible individuals enrolled in care receive periodic follow-up to identify changes in eligibility status. Scheduled physician visits for all patients are at 3, 6, and 12 months and every 6 months thereafter. ART patients follow the same clinical visit schedule with more intensified monitoring and pick up drugs monthly. At each visit, clinical exams, hematology, chemistry, viral load, and CD4 enumeration are performed. All tertiary site labs perform the necessary lab assays. Secondary and primary sites with limited lab capability send samples to an affiliated tertiary site lab for analyses. Electronic clinic and lab records provide data for high-quality patient care and centrally coordinated program monitoring. As additional medical needs of patients are identified through clinic visits, patients are provided with the services by clinicians or referred for specialty care as necessary.

All enrolled into care will receive risk assessment and behavioral counseling to achieve risk reduction. These activities are provided through individual counseling. Activities that focus on PWP include HCT for family members and sex partners, counseling for discordant couples, disclosure, healthy lifestyles and positive living, prevention messages, provision of condoms and IEC materials . Patients are also encouraged to refer family members for HCT. ART patients are provided ART Education adherence counseling (EAC) prior to and during ART provision, which follows the National Curriculum for Adherence Counseling and includes partner notification, drug adherence strategies and other prevention measures. ART EAC is reinforced with PLWHA support groups at each site, which serve all HIV+ patients and their families. ART patients are encouraged to have a treatment support partner to whom he/she had disclosed status to improve adherence and to optimize care. APIN also partners with community based PLWHA support groups and CBOs to mobilize communities, provide psychosocial support to PLWHAs and their families, provide ART adherence counseling, and assist with patient follow-up and HBC activities. In addition, the program will identify, collaborate with and strengthen the capacities of support groups and CBOs, to deliver care and support services, including the provision of community and HBC services such as domestic support, management of minor ailments, pain management, referral services, and counseling services. Supported CBOs will provide a range of facility and HBC services, including PwP services (balanced ABC messaging as appropriate), clinical care, prophylaxis and management of OIs, lab support, adherence counseling, psychosocial and spiritual support, and active linkages between hospitals, health centers, and communities.

Facility-based and community-based HBC teams partner to provide a continuum of HBC services depending on client needs. Community HBC activities will be supervised by a site HBC team comprising of a clinician, nurse, counselor, social worker and volunteers. The community HBC teams comprise of support groups members and other volunteers. When ART patients miss scheduled clinic visits or bed ridden clients are reported by the community HBC team, the site HBC team provides follow-up according to a program based SOP, utilizing a HBC kit provided to these outreach teams. The HBC provider kit includes ORS, bleach, cotton wool, latex gloves, soap, calamine lotion, vaseline, gentian violet. The team will provide basic medical assessments of signs and symptoms, basic nursing care, nutritional assessments and psychosocial support and make appropriate referrals. HBC teams will also provide refills of cotrimoxazole, paracetamol, additional clean water kits and additional ITNs to patients and their families. The Harvard Loss to Follow Up (LTFU) utility will help in picking up patients that might soon be lost to follow up. The list generated is sent to the LTFU team and support group to initiate a process of tracking and bringing patients back into care. APIN will continue to facilitate facility and community support group activities focused on pre-ART patient retention.

All sites focus on the integration of Care and treatment services for all patients regardless of the source of funding for different components of treatment (e.g. external funding sources for services or lab

commodities). At each site, support is provided for the management of electronic data and patient medical records for use in the provision of clinical care. TB diagnosis and treatment is provided to all patients via facility co-location of DOTS centers and/or referral of HIV+ patients into ART from DOTS sites. ART-eligible patients identified through HCT conducted for all TB patients at DOTS sites will be provided with ART.

Clinical staff at APIN and Harvard sites meets monthly for updates and training. As clinical training needs are identified for new sites or new staff at existing sites, Harvard provides training on relevant topics including regimen switching. In COP09, APIN will make use of the comprehensive Quality Improvement (QI) Plan incorporated by Harvard using standardized quality indicators. This includes periodic external site assessments and chart reviews as well as quarterly internal reviews, based on electronic databases. This QI Plan has been harmonized with HIVQual activities for participating sites and will continue to be implemented in COP10. APIN will support the training of 197 health workers including PHC HCWs to provide care and treatment services to 23850 HIV-infected adults by the end of COP10 .REDACTED. A total of 13100 patients will be provided with ART services.

For patients enrolled through the GON National ART Program, we anticipate GON provision of 1st line ARV drugs and PEPFAR support for care and treatment services. As patients require alternative or 2nd line drugs, they will receive PEPFAR provided drugs. GON provision of 1st line drugs allows for additional care and treatment targets. APIN estimates that additional adults will receive ART through the leveraging of GON drugs. APIN will partner with Harvard, Clinton Foundation and Global Fund as appropriate to leverage resources for providing ARVs to patients. The site investigators and project managers will actively participate in the GON National ART program. Harmonization of data collection for M&E will be coordinated with USG and GON efforts. APIN has provided technical assistance and training expertise to the National training programs and will continue in COP10. APIN will continue to participate in the USG coordinated Clinical Working Group to address emerging topics in care and treatment service provision and to ensure harmonization with other IPs and the GON. APIN will participate in national activities including the development of the national HIV Nutritional guideline and training curriculum, national ART evaluation and task shifting policy development.

Commodities distributed as a part of the care and treatment services are procured centrally through the Abuja program office and Central Medical Stores in Lagos. Distribution of commodities to individual sites is coordinated through supply chain mechanisms in place for laboratory test kits and ART drugs. During COP09, APIN will collaborate with Harvard, SCMS for the procurement and distribution of specified OI drugs.

CONTRIBUTION TO OVERALL PROGRAM AREA ACT activities are consistent with the PEPFAR goal of scaling up capacity to provide ARV drugs, care and treatment services and lab support to serve more HIV+ people. APIN will continue to support the expansion of ARV services into more rural areas by strengthening a network of secondary or primary health care clinics providing ART services that are linked to tertiary health care facilities. These networks will ensure that facilities are able to develop linkages, which permit patient referral from primary health centers and the provision of specialty care support. A tiered structure for ARV provision and monitoring established in COP08 and COP10 provides a model for additional expansion efforts in COP09 in order to meet PEPFAR treatment goals. The program will also contribute to strengthening human capacity through training of health workers, community workers and PLWHAs and their families.

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

LINKS TO OTHER ACTIVITIES This activity is linked to ART drugs (HTXD), OVC (HKID) and Pediatric Care and Treatment (PDTX), PMTCT (MTCT), TB/HIV (HVTB), Lab (HLAB), HCT (HVCT),and SI (HVSI).

POPULATIONS BEING TARGETED These activities target HIV-infected adults and family members for care, clinical monitoring and ART. The operational elements of these activities (M&E, health personnel training, infrastructural supports, technical assistance and quality assurance) target public and private program managers, doctors, nurses, pharmacists and lab workers at PEPFAR sites. The expansion of ART services to PHCs will increase access to underserved areas.

EMPHASIS AREAS This program seeks to increase gender equity in programming through counseling and educational messages targeted at vulnerable women and girls. Furthermore, through gender sensitive programming and improved quality services the program will contribute to reduction in stigma and discrimination and address male norms and behaviors by encouraging men to contribute to care and support in the families. We provide a focus on malaria and wraparounds.

ACTIVITY UNCHANGED FROM F2009

During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital, 43 UCH Oyo State DOT Centers. APIN will maintain a strong collaboration with Harvard University. In COP10, APIN will provide support for OVC services at the 6 treatment sites (2 tertiary care, 3 secondary sites, 1 PHC). These OVC sites constitute a network of delivery points including 2 tertiary hospitals, 2 secondary hospitals, and 1 primary health center.

APIN will identify HIV-infected and -affected OVC through PMTCT, HCT, site support group activities, ART centers, as well as HBC activities and hospitals as entry point into OVC. OVC will be identified in the community through the HBC,CBOs,FBOs,Support groups for PLWHA, health care facilities, including Community development and leadership programme Most at risk children will be enrolled into the OVC program through a family centered approach using a vulnerability, need assessment checklist and Child Status Index (CSI).Those identified through an HIV-positive adult family member or caregiver (PMTCT client, adult treatment client or adult care and support client) will be offered HCT. APIN will strengthen the coordination of PMTCT, ART and OVC services for seamless movement of HIV-infected and uninfected children across the various services. The experience gained from the initial rounds of this activity will assist in more efficient implementation of OVC activities in the new centers. In addition, APIN will provide OVC services to HIV-negative children whose parents or caregivers had or have HIV/AIDS.

OVC will receive multiple services through APIN activities. Preventive care services for all OVC, including diagnostic testing for common infections (OIs) such as TB, and malaria will be performed at pre- assessment. In addition, APIN will ensure that children receive all scheduled childhood immunizations, growth monitoring and other child survival interventions according to the national policy. Preventive care kits will be distributed to all caregivers of children supported under this activity; kits include multivitamins, clean water kits, ORS (preparation and use), water guards and bed nets. All OVCs are also provided with nutritional counseling, assessments and support, psychosocial support, and referrals to other wraparound services based on identified needs such as economic empowerment for caregivers, legal protection referrals. During COP10, APIN will provide educational support for some OVC which will include educational materials (books, sandals, bags, and uniforms) as well as pay tuition for education in government-approved schools. APIN will prioritize partnering with USG-supported wraparound services in states where the activities are co-located with APIN. APIN will target adolescent OVC through outreach efforts and link them with appropriate services.

APIN will partner with persons living with HIV/AIDS (PLWHA) support groups to provide outreach to OVC and their families and caregivers through psychosocial and spiritual support, stigma reduction, risk reduction and basic child health education including danger signs, nutritional demonstration and verification of appropriate use of basic preventive commodities. APIN will collaborate with other PEPFAR donors to provide therapeutic nutritional support commodities. The program will build the capacity of the OVC support groups through training and mentoring to develop more innovative means of addressing OVC issues such as recreational, psychosocial, economic empowerment and life skills. APIN will also explore partnerships with other OVC providers in the communities in which it works for potential synergy of activities in the spirit of proper networking.

Monitoring and evaluation of all aspects of the OVC program will be conducted as a part of the SI activities which will include the use of the CSI tool. APIN will use the electronic database developed by Harvard to continue collecting electronic data on OVC clients and services which is used for site and program specific evaluation of services provided to OVC. In addition the progress of children benefiting from educational support will be monitored through registers and their school records; follow-up services with school administrators, teachers and OVC care givers will be coordinated by program staff. These data are used to conduct program evaluations and provide feedback to site investigators on a quarterly basis. On-site data managers will conduct monthly evaluations. APIN will utilize its QA/QI program to provide feedback to sites on performance and identify best practices and areas for strengthening and support.

This funding will also support training for 106 healthcare providers and caregivers of HIV-infected and affected OVC and volunteers on OVC services. Healthcare providers to be trained include pediatricians, general duty medical doctors, pharmacists, counselors and nurses in the area of OVC services. Training in this area will be coordinated with FMOH and USG following the National Guidelines on OVC. These activities will strengthen the capacity of sites to provide comprehensive OVC services to 1000 children and 732 will be provided with food and nutritional supplements.

APIN will advocate and support the state ministry of women affairs in building their capacity to provide oversight and reporting functions for OVC programs. APIN will participate in the development of the national OVC training curriculum and other instruments.

EMPHASIS AREAS: Emphasis is placed on training through activities focused on training healthcare providers and caregivers in the care of HIV-infected and affected OVC. These activities will also place an emphasis on the development of networks and referral systems in order to support the development of a comprehensive

system of care through links to community PLWHA support groups and PMTCT, HCT, TB/HIV and ART sites.

POPULATIONS BEING TARGETED: These activities seek to target OVC who have been exposed to HIV through pregnancy and breastfeeding from an HIV-infected mother through the identification of exposed infants from PMTCT programs. We will also identify OVC from other areas as targets for supportive pediatric care and family outreach. Outreach initiatives also seek to target mothers and family members of HIV-infected OVC and their siblings, including PLWHA, to ensure comprehensive support. Caregivers of OVC are also targeted to encourage HCT for potentially exposed children. APIN also targets caregivers by providing them with preventive care packages to be utilized for the benefit of the OVC. APIN will target street youth and out- of-school youth through community outreach initiatives based in HCT clinics.

CONTRIBUTION TO OVERALL PROGRAM AREA: Outreach activities through PLWHA support groups will seek to provide comprehensive psychosocial support for OVC and their families. These services are consistent with the National Plan of Action for OVC in Nigeria and the Standard Operational Guidelines for OVC services. Additionally, APIN seeks to strengthen the capacity of the PLWHA support groups through training to continue to provide psychosocial support and outreach to PLWHA and OVC. Capacity development at the community and facility levels and consistency with national guidelines will ensure sustainability. Through working with pediatric ART and PMTCT sites to provide pediatric C&S services for HIV-infected OVC, APIN will scale- up the ability of participating sites to provide comprehensive and sustainable services for this OVC population, which is consistent with national objectives and the second round PEPFAR 5-year strategy.

LINKS TO OTHER ACTIVITIES: This activity also relates to activities in PMTCT (MTCT) through a system of referrals to provide pediatric care and support services to HIV-infected pregnant women and their infants. In addition, active PMTCT programs at the sites will identify HIV-exposed infants who will require PCR diagnosis and clinical assessment to determine ART eligibility. Linkages will be made to adult and pediatric care and support (HBHC, PDCS) activities and TB/HIV activities (HVTB) in order to ensure a comprehensive system of care for OVC and their families. ART- eligible OVC will be linked to ART services funded under APIN pediatric treatment (PDTX) activities. The integration of pediatric treatment services (PDTX) and care linked to active PMTCT and adult ART (HTXS) centers will facilitate the development of the overall network of care for HIV-infected families and communities. APIN will provide linkages, care and monitoring through the pediatric care and support (PDCS) program to HIV-positive children who are on ART, HIV-positive children not yet eligible for ART, HIV-infected infants identified through the PMTCT activities, and HIV-infected children identified through

the HCT and home-based activities. Linkages to outreach initiatives and HCT (HVCT) activities seek to improve the utilization of care opportunities created through PEPFAR funding. Outreach through the PLWHA support groups will also encourage utilization of HCT services by other family members. Additionally, through SI activities (HVSI) information about efficacy of care, derived from data collected on the patients treated under this activity, may be used to develop new treatment protocols to increase the quality of pediatric OVC services. .

ACTIVITY UNCHANGED FROM F2009

NARRATIVE: During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital, 43 UCH Oyo State DOT Centers. APIN will maintain a strong collaboration with Harvard University. In COP10, APIN will provide support for treatment at 3 treatment sites (2 tertiary care, 1 secondary sites) located in two states of Lagos and Ogun. This activity will provide ART services to a total of 15600 eligible adult patients (2500 new and 13100 mainenance) by the end of the reporting period. At our 2 secondary levels and 1 primary level PMTCT sites, there will also be AT provided for eligible pregnant women. APIN and Harvard will collaborate in order to ensure a smooth transition of clinical services.

Patients are identified through HCT services, including facility-based, mobile and family-centered strategies. All HIV-positive ART-eligible patients are provided with ART services, in accordance with a standardized programmatic protocol, which follows the current National ART Guidelines. All HIV+ patients and ART ineligible are referred for care and support services, while ART eligible individuals are provided ARVs with cotrimoxazole prophylaxis according to current national guidelines. Diagnostics for common opportunistic infections (OIs) may include: Candida albicans, protozoal infections, and gastrointestinal parasites. All HIV+ patients are also symptomatically screened for TB and confirmed with laboratory and radiological diagnostics as indicated. APIN will support integration of syndromic management of STIs and risk reduction interventions. APIN uses the hub and spoke model for service delivery. APIN will also expand provision of treatment services to the primary health centers. APIN will explore the possibility of a pilot program on cervical

cancer screening among patients in some selected sites.

ART patients are monitored 6 monthly for lab exams, and pick up drugs monthly. At the 6 monthly visit, clinical exams, hematology, chemistry, viral load, and CD4 enumeration are performed. All tertiary site labs perform the necessary lab assays. Secondary and primary sites with limited lab capability send samples to an affiliated tertiary site lab for analyses. Electronic clinic and lab records provide data for high-quality patient treatment and centrally coordinated program monitoring. As additional medical needs of patients are identified through clinic visits, patients are provided treatment by clinicians or referred for specialty treatment as necessary.

Patients are also encouraged to refer family members for HCT. ART patients are provided ART Education adherence counseling (EAC) prior to and during ART provision, which follows the National Curriculum for Adherence Counseling and includes partner notification, drug adherence strategies and other prevention measures. ART EAC is reinforced with PLWHA support groups at each site, which serve all HIV+ patients and their families. Patients on ART are encouraged to have a treatment support partner to whom he/she had disclosed status to improve adherence and to optimize treatment. APIN also partners with community based organizations to support ART adherence counseling, and assist with patient follow-up. When ART patients miss scheduled clinic visits or bed ridden such clients are reported by the community HBC team for intervention.

All sites focus on the integration of Care and treatment services for all patients regardless of the source of funding for different components of treatment (e.g. external funding sources for services or lab commodities). At each site, support is provided for the management of electronic data and patient medical records for use in the provision of quality treatment. TB diagnosis and treatment is provided to all patients via facility co-location of DOTS centers and/or referral of HIV+ patients into ART from DOTS sites. ART-eligible patients identified through HCT conducted for all TB patients at DOTS sites will be provided with ART.

Clinical staff at APIN and Harvard sites meets monthly for updates and training. As clinical training needs are identified for new sites or new staff at existing sites, Harvard support training on relevant topics including regimen switching. In COP10, APIN will make use of the comprehensive Quality Improvement (QI) Plan incorporated by APIN using standardized quality indicators. This includes periodic external site assessments and chart reviews as well as quarterly internal reviews, based on electronic databases. This QI Plan has been harmonized with HIVQual activities for participating sites and will continue to be implemented in COP10. APIN will support the training of 200 health workers consisting of doctors, nurses, pharmacists, counselors providing ART services to 15,600 HIV-infected adults by the end of

COP10. REDACTED.

For patients enrolled through the GON National ART Program, we anticipate GON provision of 1st line ARV drugs and PEPFAR support treatment. As patients require alternative or 2nd line drugs, they will receive PEPFAR provided drugs. GON provision of 1st line drugs allows for additional treatment targets. APIN estimates that additional adults will receive ART through the leveraging of GON drugs. APIN will partner with Harvard, Clinton Foundation and Global Fund as appropriate to leverage resources for providing ARVs to patients. The site investigators and project managers will actively participate in the GON National ART program. Harmonization of data collection for M&E will be coordinated with USG and GON efforts. APIN has provided technical assistance and training expertise to the National training programs and will continue in COP10. APIN will continue to participate in the USG coordinated Clinical Working Group to address emerging topics in treatment service provision and to ensure harmonization with other IPs and the GON. APIN will participate in national activities including the development of the national HIV guideline and training curriculum, national ART evaluation and task shifting policy development.

Commodities distributed as a part of the treatment services are procured centrally through the Abuja program office and Central Medical Stores in Lagos. Distribution of commodities to individual sites is coordinated through supply chain mechanisms in place for laboratory test kits and ART drugs. During COP10, APIN will collaborate with Harvard, SCMS for the procurement and distribution of specified OI drugs.

CONTRIBUTION TO OVERALL PROGRAM AREA Adult treatment activities are consistent with the PEPFAR goal of scaling up capacity to provide ARV drugs, and treatment services to more HIV+ people. APIN will continue to support the expansion of ARV services into more rural areas by strengthening a network of secondary or primary health care clinics providing ART services that are linked to tertiary health care facilities. These networks will ensure that facilities are able to develop linkages, which permit patient referral from primary health centers and the provision of specialized treatment. . A tiered structure for ARV provision and monitoring established in COP08 and COP09 provides a model for additional expansion efforts in COP10 in order to meet PEPFAR treatment goals. The program will also contribute to strengthening human capacity through training of health workers, community workers and PLWHAs and their families.

Additionally, as part of our sustainability building efforts, APIN will receive technical assistance and support from Harvard to assume program management responsibility for AT activities. This will include the implementation of a plan to transition site oversight, management and training over to APIN. The goal

of these efforts is to provide for greater assumption of responsibility for management and implementation of PEPFAR programming by Nigerian nationals through an indigenous organization.

LINKS TO OTHER ACTIVITIES This activity is linked to ART drugs (HTXD), OVC (HKID) and Pediatric Care and Treatment (PDTX), PMTCT (MTCT), TB/HIV (HVTB), Lab (HLAB), HCT (HVCT), and SI (HVSI).

POPULATIONS BEING TARGETED These activities target HIV-infected adults and family members for ART. The operational elements of these activities (M&E, health personnel training, infrastructural supports, technical assistance and quality assurance) target public and private program managers, doctors, nurses, pharmacists and lab workers at PEPFAR sites. The expansion of ART services to PHCs will increase access to underserved areas.

EMPHASIS AREAS This program seeks to increase gender equity in programming through counseling and educational messages targeted at vulnerable women and girls receiving treatment. Furthermore, through gender sensitive programming and improved quality services the program will contribute to reduction in stigma and discrimination and address male norms and behaviors by encouraging men to contribute to treatment in the families. We provide a focus on malaria and wraparounds.

ACTIVITY UNCHANGED FROM F2009

NARRATIVE: During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital and 43 UCH Oyo state DOT Centers. In COP10, APIN will provide support for HCT services at the 6 treatment sites (2 tertiary care, 3 secondary sites, 1 PHC) and 43 DOT Centers.

In COP10, APIN plans to support provision of comprehensive HIV counseling and testing (HCT) services to at risk individuals, delivered through 49 service outlets (5 comprehensive sites, 1 PHC and 43 DOT

centers) in 3 states (Lagos, Ogun and Oyo). At these sites 10200 (including TB) and 4500 (excluding TB) individuals will receive HIV counseling & testing and receive their results (targeted populations include Most At Risk Populations (MARPs), clients presenting to the health care facilities, blood donors, and family members of PLWHA. Provider initiated HIV testing is utilized as an additional strategy to reach clients at the health care facilities. The sites will include DOT centers in at least one health facility in every local government area (LGA) in Oyo State. In COP09, APIN supported provision of comprehensive HIV counseling and testing (HCT) services to at risk individuals, delivered through 49 service outlets (5 comprehensive sites, 1 PHC and 43 DOT centers) in 3 states (Lagos, Ogun and Oyo).

Individuals identified as positive at APIN sites will be referred to PMTCT and ART clinics for treatment and palliative care services. Prevention for HIV positive individuals will be incorporated into HCT activities including promotion of HCT for family members and sex partners, counseling for discordant couples, counseling on healthy lifestyles and positive living, prevention messages and Information, Education & Communication (IEC) materials on disclosure. APIN sites use family counseling sessions and "love letter" strategies to encourage partners of HIV-infected patients to access HCT so that couples receive HIV counseling and testing together. Counselor training will include couple HIV counseling and testing (CHCT) to strengthen this program. Pediatric patients that are identified at testing points of service will be enrolled into the APIN supported OVC program and ART as necessary. HCT will also be offered to patients receiving TB services at each of the APIN sites throughout TB/HIV program activities. HCT is offered to blood donors as per Blood Safety activities. Patients identified as HIV-infected are provided with referrals to ART and palliative care services.

APIN will use the National "Heart to Heart" logo at supported HCT sites so as to reflect the integration within the national program. At all HCT outlets, patients are provided with IEC materials on HIV prevention and referrals for ART services and palliative care as appropriate. The materials will address HIV prevention using the "ABC" model, providing information about healthy behaviors, safer sexual practices, STI prevention, PMTCT, and condom usage. The sites will also provide HIV testing as well as pre- and post-test counseling and condom distribution.

HCT services are also provided in community settings in conjunction with projects in Lagos state that serve specific MARPs including: outpatient STI patients, bar workers, sex workers. Mobile HCT services coordinated through PHC-Iru will be used to reach these populations. Activities targeting these populations are linked with APIN sites to provide referral linkages to PMTCT, Palliative HIV/TB and ART services depending on eligibility for ART.

Condoms will be made available at all HCT sites in conjunction with the delivery of ABC messages. The

Society for Family Health (SFH) will supply condoms. Training of 20 individuals in counseling and testing will use the new National serial testing algorithm and will educate trainees on appropriate counseling messages specific to the different high risk groups with which they work. Refresher training will be provided to a subset of the target trained during the year, particularly after final revision of the National training curriculum. HIV testing is performed with rapid test assays and same day results are given. Following HIV diagnosis with the National testing algorithm, immunoblot confirmation will be provided during assessment for ART. This is done by HIV laboratories at APIN comprehensive ART treatment centers.

To meet up with the increase demand for services, non-laboratorians, including nurses, counselors and lay counselors would be trained to provide counseling and testing services at one visit using finger prick. These would be supervised by laboratory scientists and quality of testing would be ensured by proficiency testing and quarterly supervisory visits. The UCH Virology lab supported through Harvard will establish and coordinate a regular QA/QC program to insure that HIV serologic testing at APIN HCT centers meets national and international standards. This lab will also ensure coordination of HIV testing SOPs and provide regular training for new lab personnel. The USG team will be providing APIN with rapid test kits that will be managed by the pharmacy logistics team in Lagos and stored and distributed from the APIN central medical stores warehouse. APIN in collaboration with Harvard will continue to harmonize the logistics process with GON LMIS and ICS activities.

EMPHASIS AREAS: These activities will also address gender equity issues by providing equitable access to HCT services for men and women. In some cases, the activities seek to target men who may be at high risk for HIV in order to provide a mechanism for HCT as a means of prevention and access to services for their sexual partners. Male targeted counseling seeks to address male norms and behaviors in order to encourage safer sexual practices. Counseling also seeks to address sexual norms and issues of HIV related stigma and discrimination.

TARGET POPULATIONS: These activities target adults for HIV counseling and testing, particularly those from most at risk populations, as described above. Targeting these populations is important to encourage utilization of HCT services and provide ART treatment for eligible HIV infected individuals. Counseling provided through these activities also seeks to target PLWHA who are newly diagnosed by encouraging them to bring their partners and other family members in for HCT. In addition, target populations include orphans and vulnerable children.

CONTRIBUTION TO OVERALL PROGRAM AREA:

APIN HCT activities are consistent with the PEPFAR 2009 goals for Nigeria, which aim to increase uptake of HCT by supporting HCT centers, which are linked to treatment and care services, and to expand their reach through mobile testing services. By continuing to support and build the capacity of HCT centers and provide linkages to treatment and care centers, these activities will be able to meet the increasing utilization of these services, expected to result from HCT outreach initiatives identifying infected individuals. The network of HCT centers linked to HIV services and care will provide a sustainable network for infected and affected individuals in Harvard catchments areas.

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

LINKS TO OTHER ACTIVITIES: This activity also relates to activities in Adult Care and Treatment (HTXS), Pediatric Care and Treatment (PDTX), Sexual Prevention (HVAB and HVOP), TB/HIV (HVTB), and OVC (HKID).APIN will link up with the Harvard's network of community, research-based and tertiary care institutions should provide sustainable and high quality HIV and related services to the communities served. Furthermore, both primary and satellite APIN sites are linked in order to provide laboratory and specialty care support, as related to the HCT activities.

ACTIVITY UNCHANGED FROM F2009

NARRATIVE: During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital, 43 UCH Oyo State DOT Centers. APIN will maintain a strong collaboration with Harvard University. In COP10, APIN will provide support for Pediatric Care and Support services at the 6 treatment sites (2 tertiary care, 3 secondary sites, 1 PHC). Patients are identified through PMTCT and HCT services, including facility and community based, mobile, and family-centered strategies. Any pediatric patient presenting with acute history of sexual assault will be provided with post-exposure care, support and psychosocial counseling

services and monitored according to national guidelines.

All HIV-positive children are provided with care and support services in line with national guidelines referred for clinical assessment for ART eligibility. ART-eligible children are referred for services, and all HIV+ children are provided with care and support services, consistent with the National Care and support Guidelines. These services include nursing care, pain management, OIs prophylaxis , nutritional assessment and support and end-stage care, labs - baseline haematology, chemistry, CD4 count baseline and follow-up, OI diagnosis, Pregnancy test if indicated),provision of basic care kits, psychosocial and spiritual support, leverage resources support for economic empowerment for caregivers, community HBC, PwP and other prevention services. HIV+ children are provided with cotrimoxazole prophylaxis according to national guidelines. Diagnostics for common opportunistic infections (OIs) may include: Candida albicans, protozoal infections, and gastrointestinal parasites. All HIV+ children are also symptomatically screened for TB and confirmed with laboratory and radiological diagnostics as indicated. APIN through Harvard support will provide education on risk reduction interventions. All families of enrolled children will be provided with basic care kits including water vessel, water guard, ITN, soap, ORS, latex gloves, and IEC materials. Pain management assessments will also be conducted by clinicians and HBC providers and analgesics will be provided. APIN uses the hub and spoke model of care for service delivery to the primary and secondary health centers.

ART-ineligible children that are enrolled in care will have periodic follow-up until ART eligibility status changes. Scheduled clinic visits for all are every 6 months. All tertiary and secondary site labs perform the necessary lab assays. Secondary and primary sites with limited lab capability send samples to an affiliated tertiary site. Electronic records provide data for high quality patient care and centrally coordinated program monitoring. As additional medical needs are identified through HBC visits, HIV+ children will be provided with a package of preventative care services, including cotrimoxazole prophylaxis according to national guidelines and ensure immunization, growth monitoring and other child survival services. All HIV+ children will also be symptomatically screened for TB using Tuberculin Skin Test (TST), laboratory and radiological diagnostic methods as indicated. HIV+ children are also provided with nutritional counseling and supplements, including multivitamins and other micronutrients like Vit. A. Iron. All HIV+ children are linked into the system of OVC services in order to ensure a continuum of care. The Loss to Follow Up (LTFU) utility will help in tracking and picking up children that might soon be lost to follow up. The list generated is sent to the tracking team and support group to initiate a process of tracking and bringing children back into care. APIN will continue to facilitate facility and community support group activities focused on pre-ART patient retention. Home visit by the HBC teams will encourage children to continue to access care and support. APIN will strengthen the linkage between facility and community OVC services to promote retention of children.

Commodities distributed as a part of the care and support services are procured centrally through the Abuja program office and Central Medical Stores in Lagos. Distribution of commodities to individual sites is coordinated through supply chain mechanisms in place for basic care kits and other commodities. During COP10, APIN will collaborate with Harvard, SCMS for the procurement and distribution of specified pediatric OI drugs and other HBC commodities

All children enrolled into care will receive age-appropriate risk assessments and behavioral counseling to achieve risk reduction. These activities are provided through individual counseling and outreach by site PLWHA support groups. Caregivers are also encouraged to seek out HCT and refer other family members for HCT. Caregivers of HIV+ children are provided pre-ART education and adherence counseling (EAC) prior to and during ART provision, which follows the National Curriculum for Adherence Counseling. Care and support. EAC is reinforced with PLWHA caregivers support groups at each site, which serves all clients and their families. APIN will also partner with community based PLWHA support groups and CBOs to mobilize communities, provide psychosocial and spiritual support to PLWHAs and their families, provide ART adherence counseling, and assist with patient follow-up and HBC activities.

Facility-based and community-based HBC teams partner to provide a continuum of HBC services depending on client needs and assessment. When ART patients miss scheduled clinic visits or bed- ridden clients are reported by the community HBC team, the site HBC team provides follow-up according to a program based SOP, utilizing a HBC kit provided to these outreach teams. The HBC provider kit includes ORS, bleach, cotton wool, latex gloves, soap, calamine lotion, petroleum jelly, and gentian violet. The team will provide basic medical assessments of signs and symptoms, basic nursing care, nutritional assessments and psychosocial support and make appropriate referrals. HBC teams will also provide refills of cotrimoxazole, paracetamol, additional clean water kits and additional ITNs to patients and their families. The hospital HBC team comprises of a counselor, social worker, PLWHA, nurse and volunteers. The community HBC teams comprise of support groups members and other volunteers

All sites focus on the integration of pediatric care and support services (PCS) for all patients regardless of the source of funding for different components of treatment (e.g., external funding sources for services or lab commodities). At each site, support is provided for the management of electronic data and patient medical records for use in the provision of care and support services. TB diagnosis and care is provided to all patients via facility co-location of DOTS centers and/or referral of HIV+ patients into ART from DOTS sites. HIV+ patients identified through HCT conducted for all TB patients at DOTS sites will be referred to comprehensive PCS services.

APIN and Harvard care and support team meets monthly for updates planning, evaluation and training. As training needs are identified for new sites or new staff at existing sites. In COP09, Harvard incorporated standardized quality indicators into a comprehensive Quality Improvement (QI) Plan for the sites, which includes periodic external site assessments and chart reviews as well as quarterly internal reviews, based on electronic databases. APIN will support the training of 106 health workers including PHC HCWs to provide care and support services to 2200 HIV-infected children in care and support. REDACTED. For pediatric patients enrolled through the GON ART Program, we anticipate GON provision of 1st-line ARV drugs and PEPFAR provide support for PCS services. As patients require alternative or 2nd-line drugs, patients will receive PEPFAR-provided care and support commodities. GON provision of 1st-line drugs allows for additional PCS targets. . APIN will partner with Harvard and Clinton Foundation as appropriate to leverage resources for providing OI drugs to patients. The site investigators and project managers will actively participate in the GON pediatric care and support program. Harmonization of data collection for M&E will be coordinated with USG and GON efforts. APIN has provided technical assistance and training expertise to the National pediatric C and S treatment training program, which will continue in COP09. APIN will support the development of the National Pediatric Care and Support Guideline and Training curriculum. In addition to providing training of site-based HCWs to improve care at supported sites, A total of 106 health care and non-health care workers will be trained in PCS services in line with the National Pediatric Care and Treatment Guidelines and Training Curricula.

In addition, the program will identify, collaborate with and strengthen the capacities of support groups and CBOs, to deliver care and support services, including the provision of community and HBC services such as domestic support, management of minor ailments, pain management, referral services, and counseling services. Supported CBOs will provide a range of facility and HBC services, including prevention for positives, clinical care, prophylaxis and management of OIs, lab support, adherence counseling, psychosocial and spiritual support, and active linkages between hospitals, health centers, and communities. Through counselors and HBC staff, volunteers at all sites, APIN will provide referrals for TB, wraparound services and child survival programs as appropriate.

CONTRIBUTION TO PROGRAM PCS activities are consistent with the PEPFAR goal of scaling up capacity to provide OI drugs, care and support services and lab support to serve more HIV+ children. APIN will continue to support the expansion of PCS services into more local areas by developing a network model. These networks will ensure that facilities are able to develop linkages, which permit patient referral from primary health centers and the provision of specialty care support. A tiered structure for OI drug, other commodities

provision and monitoring established through Harvard provides a model for additional expansion efforts in COP09 in order to meet PEPFAR treatment goals. In addition, pediatric care and support services will be provided to HIV+ children and PABA for a total of people served. The program will also contribute to strengthening human capacity through training of health workers, community workers and HIV+ children and their families.

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

LINKS TO OTHER ACTIVITIES This activity is linked to OI drugs (HTXD), OVC (HKID), TB/HIV (HVTB), to provide OI to patients with TB, Lab (HLAB) to provide OI diagnostics, HCT (HVCT) as an entry point to ART, and SI (HVSI) will provide the GON with crucial information for use in the evaluation of the National ARV program This program is linked to PMTCT services to optimize the follow-up on children that become HIV-infected through their mothers. By training local personnel, we are also contributing to the program area of Human Capacity Development (HCD). With our focus on helping young girls, we also contribute to the Gender program area.

POPULATIONS BEING TARGETED The care and support components of these activities target HIV+ children for care, monitoring and provision of OI drugs. The operational elements of these activities (M&E, health personnel training, infrastructural supports, technical assistance and quality assurance) target public and private program managers, doctors, nurses, pharmacists and lab workers at PEPFAR sites. The expansion of care and support services to primary and secondary health facilities will increase access to underserved areas.

EMPHASIS AREAS APIN's major emphasis is on strengthening capacity of health care workers to provide high quality PCS services. Emphasis will be on child survival wrap-around programming, through the provision of clean water kits, growth monitoring, immunization nutritional supports, treatment of OIs and other illnesses, and counseling for caregivers on hygiene and nutrition for HIV-infected children.

ACTIVITY UNCHANGED FROM F2009

NARRATIVE: During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital, 43 UCH Oyo State DOT Centers. APIN will maintain a strong collaboration with Harvard University. In COP09 APIN provided comprehensive pediatric treatment (PT) services in 5 comprehensive ART sites (2 tertiary and 3 secondary facilities); located in two states of Lagos and Ogun. This will provide ART services to a total of 1200 ART eligible children at the end of the reporting period. (This includes 200 new and 1000 maintenance) ART ineligible children are referred for care and support. .

Patients are identified through PMTCT and HCT services, including facility-based, mobile, and family- centered strategies. Through linkages with PMTCT services and pediatric wards at our sites, early infant diagnosis (EID) is performed for children <18 months utilizing Dried Blood Spot (DBS) at secondary and primary sites for transportation to 2 tertiary sites where DNA PCR are carried out.

Any pediatric patient presenting with acute history of sexual assault will be provided with post-exposure prophylaxis, investigations and psychosocial counseling services and monitored according to national guidelines. . All HIV-positive children are clinically pre-assessed for ART eligibility. ART-eligible children are provided with ART services, in accordance with a standardized programmatic protocol, which follows the Current National ART Guidelines. HIV+ children are provided with cotrimoxazole prophylaxis according to national guidelines. Diagnostics for common opportunistic infections (OIs) may include: Candida albicans, protozoal infections, and gastrointestinal parasites. All HIV+ children are also symptomatically screened for TB using laboratory and radiological diagnostics as indicated. APIN through Harvard support will provide education on risk reduction interventions APIN uses the hub and spoke model of treatment for better service delivery to the primary and secondary health centers.

ART eligible children will be followed periodically with scheduled clinic visits as follows - 3, 6, 9 and 12 months and every 6 months, patients pick up drugs monthly. At each visit, clinical exams, hematology, chemistry, viral load and CD4% enumeration are performed. All tertiary and secondary site labs perform the necessary lab assays. Secondary and primary sites with limited lab capability send samples to an affiliated tertiary site. Electronic clinic and lab records provide data for high quality patient treatment and

centrally coordinated program monitoring. As additional medical needs are identified patients will be provided clinical services by clinicians or referred for specialty care as necessary. HIV+ children will be provided ARVs including cotrimoxazole prophylaxis according to national guidelines and referrals for immunization, growth monitoring and other child survival services. All HIV+ children will also be symptomatically screened for TB using Tuberculin Skin Test (TST), laboratory and radiological diagnostic methods as indicated. All HIV+ children on treatment are linked into the system of OVC services in order to ensure a continuum of care. The Loss to Follow Up (LTFU) utility will help in picking up children on treatment that might have defaulted. The list generated is sent to the tracking team to initiate a process of tracking. During COP09, APIN will collaborate with Harvard, SCMS for the procurement and distribution of specified pediatric ARVs and OI drugs.

Caregivers are also encouraged to seek out HCT and refer other family members for HCT. Caregivers of HIV+ children are provided ART education and adherence counseling (EAC) prior to and during ART provision, which follows the National Curriculum for Adherence Counseling.

When ART patients miss scheduled clinic visits or bed-ridden clients are referred to the community HBC and tracking teams, to provide follow-up accordingly.

All sites focus on the integration of Pediatric treatment (PT) services regardless of the source of funding for different components of treatment (e.g., external funding sources for services or lab commodities). At each site, support is provided for the management of electronic data and patient medical records for use in the provision quality treatment. TB diagnosis and treatment is provided to all patients via facility co- location of DOTS centers and/or referral of HIV+ patients into ART from DOTS sites. HIV+ patients identified through HCT conducted for all TB patients at DOTS sites will be referred to PT services.

Clinical staff at APIN and Harvard sites meets monthly for updates and training. As clinical training needs are identified for new sites or new staff at existing sites, Harvard support training on relevant topics including regimen switching. In COP08, Harvard incorporated standardized quality indicators into a comprehensive Quality Improvement (QI) Plan for the sites, which includes periodic external site assessments and chart reviews as well as quarterly internal reviews, based on electronic databases. APIN will support the training of 106 health workers including PHC, HCWs to provide treatment to1200 ART eligible HIV-infected children by the end of COP10. REDACTED. For pediatric patients enrolled through the GON ART Program, we anticipate GON provision of 1st-line ARV drugs and PEPFAR support for PT services. As patients require alternative or 2nd-line drugs, patients will receive PEPFAR-provided drugs. GON provision of 1st-line drugs allows for additional PT targets. APIN estimates that additional children will be placed on ART through the leveraging of GON drugs. APIN will partner with Harvard and Clinton Foundation as appropriate to leverage resources for

providing ARVs to patients. The site investigators and project managers will actively participate in the GON pediatric ART program. Harmonization of data collection for M&E will be coordinated with USG and GON efforts. APIN has provided technical assistance and training expertise to the National pediatric treatment training program, which will continue in COP10. APIN will support the development of the National Pediatric treatment Guideline and Training curriculum. APIN will also fully support the training of doctors, nurses, counselors and lab scientists working at GON and GF supported sites in early infant diagnosis techniques. A total of106 health care and non-health care workers will be trained in PT services in line with the National Pediatric Treatment Guidelines and Training Curricula.

In addition, the program will identify, collaborate with and strengthen the capacities of clinicians, nurses, pharmacist, to deliver quality pediatric treatment at all sites. APIN will provide referrals for TB, wraparound services and child survival programs as appropriate.

CONTRIBUTION TO PROGRAM PT activities are consistent with the PEPFAR goal of scaling up capacity to provide ARV drugs, and lab support to serve more HIV+ children. APIN will continue to support the expansion of PT services into more local areas by developing a network model. These networks will ensure that facilities are able to develop linkages, which permit patient referral from primary health centers and the provision of specialty treatment. A tiered structure for ARV provision and monitoring established through APIN provides a model for additional expansion efforts in COP09 in order to meet PEPFAR treatment goals. The program will also contribute to strengthening human capacity through training of health workers, community workers and HIV+ children and their families.

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

LINKS TO OTHER ACTIVITIES This activity is linked to ART drugs (HTXD), OVC (HKID), TB/HIV (HVTB), to provide ART to patients with TB, Lab (HLAB) to provide ART diagnostics, HCT (HVCT) as an entry point to ART and SI (HVSI) will provide the GON with crucial information for use in the evaluation of the National ARV program and recommended drug regimens. This program is linked to PMTCT services to optimize the follow-up on children that become HIV-infected through their mothers. By training local personnel, we are also

contributing to the program area of Human Capacity Development (HCD). With our focus on helping young girls, we also contribute to the Gender program area.

POPULATIONS BEING TARGETED The treatment components of these activities target HIV+ children for clinical monitoring and treatment. The operational elements of these activities (M&E, health personnel training, infrastructural supports, technical assistance and quality assurance) target public and private program managers, doctors, nurses, pharmacists and lab workers at PEPFAR sites. The expansion of ART services to primary and secondary health facilities will increase access to underserved areas.

EMPHASIS AREAS APIN's major emphasis is on strengthening capacity of health care workers to provide high quality PT services. Minor emphasis will be on child survival wrap-around programming, through the provision of clean water kits, growth monitoring, immunization nutritional supports, treatment of OIs and other illnesses, and counseling for caregivers on hygiene and nutrition for HIV-infected children.

ACTIVITY UNCHANGED FROM F2009

NARRATIVE: During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital, 43 UCH Oyo State DOT Centers.

In COP10, APIN will provide support for SI activities at the 6 treatment sites (2 tertiary care, 3 secondary sites, 1 PHC) and 43 DOT sites.

The activities include: data management and data quality assurance, monitoring and evaluation (M&E), health management information systems (HMIS) and operational research studies in all supported sites. Funds will also be utilized to continue building the capacity of site staff in the above areas in order to promote effective use of data to improve services and programs and to influence policy. In addition, a major goal in the coming year is to further achieve sustainability. APIN will receive technical assistance

from Harvard in the area of data management. APIN staff includes a database specialist, IT specialist, an M&E Officer and an M&E Consultant, who will assist the sites with on-site clinical, pharmacy, laboratory and project reporting. In line with the PEPFAR-Nigeria indigenous capacity-building strategy, APIN in collaboration with Harvard will strengthen local capacity at primary, secondary and tertiary health facilities. A major goal of our activities this coming year is to further: 1) build M&E capacity at the local level; 2) promote increased utilization of data in evidence-based decision making; 3) evaluation of clinical outcomes and intervention efforts; 4) evaluation of program outcomes.

The APIN program will utilize a relational database system developed through Harvard PEPFAR. The database is linked by a unique patient ID number and contains data required for patient management and monitoring (PMM). The electronic database is functional and fully harmonized with the GON PMM forms to allow for full integration into the broader Nigerian national health information systems in order to strengthen the Third One: One National M&E system. The APIN/Harvard forms collect clinical visit, pharmacy pick-up, laboratory assessment, toxicity, virological/immunological failure and discontinuation information for adult and pediatric care and treatment as well as PMTCT services. APIN will collaborate with Harvard to develop electronic databases to capture OVC services; these databases will be fully harmonized with the GON forms. APIN will use the utilities developed through Harvard to maximize the efficient use of data for improved patient management, data quality, reporting, and program management. This includes a treatment response utility, which provides a graphical display of patients' CD4 counts, viral loads, and drug pick-up history, as well as a loss to follow-up utility, which serves as an early warning system for patients that miss drug pick-ups. Information is generated and used for site and program-specific evaluation of services, such as assessment of CD4 counts, viral load, adherence, and loss to follow-up.

APIN will continue to maintain computer hardware and software provided by Harvard to support sites as services are being maintained. SOPs are in place to govern data entry, security, management and reporting based on the ARV treatment and care protocol. Refinement of instruments and databases is ongoing to accommodate program reporting requirements from Harvard, USG and the GON. The PMM forms are stored in the patient hospital folders and kept in locked file cabinets or locked rooms. National registers are also in use at APIN-supported sites. Data from PMM forms and registers are entered into the databases by trained data entry staff at the respective sites. The data are then uploaded to a password protected web server, accessible to authorized personnel and data managers at the Nigerian sites and at Harvard. Data managers prepare timely reports for GON and USG using the electronic databases and the web-based portal for data reporting: LHPMIP, where feasible i.e. electronic database system is in place. . Facility-based data are reported using harmonized national reporting system. The Boston and Nigerian data management team and the M&E officer provide regular feedback on data collected and on reports to the sites. Site M&E committees are in place to implement an annual M&E

plan; M&E results are fed back to the sites to promote systems improvement. APIN+ will facilitate good working relationships with state level M&E committees and staff and will regularly communicate on monitoring activities, thereby encouraging their active involvement. This involvement will build the capacity of the state-level staff and promote sustainability. The APIN SI team will continue to participate actively in the National M&E technical workgroup (TWG) and the USG-Nigeria SI TWG and respond to the goals of the one national reporting system.

In COP10, APIN will scale up the QI activities to all the APIN sites, building on the Harvard supported internal quality improvement (QI) initiative, designed at collecting qualitative and quantitative data regarding indicators on the provision of adult, pediatric and PMTCT services at each site. In order to continually improve and monitor data quality, each site will be visited regularly by APIN M&E staff throughout COP10; on-site TA and supportive supervision will be provided. Regular inter-site interactions will be encouraged, facilitated by APIN+/Harvard personnel. In COP09, all supported sites constituted M&E committees; these committees meet to evaluate the site M&E data and use the information towards improving quality of care and making evidence-based clinical decisions. In COP10, sites will work on fully developing QA/QI committees to conduct quarterly reviews of quality of care. During COP10, we will continue to encourage and monitor the activities of the site M&E and QA/QI teams. We are also working on developing a database utility that will allow the sites to quickly pull out data on patients that are lost to follow-up, showing signs of toxicity or failure, or that may require other focused attention, to further improve quality of care. Finally, HIVQUAL using additional QI indicators is being implemented in six selected APIN supported sites.

In COP10, 161 individuals will be trained in database management, monitoring and evaluation (M&E), surveillance, and HMIS. The trainees will include staff from the state and LGA institutions. The APIN central office will conduct 10 training sessions centrally. In addition, regional data management trainings for personnel working with medical records and patient data will be conducted on a regular basis. Data management and M&E modules are incorporated into respective technical training for other disciplines such as clinicians, nurses, pharmacists and laboratory staff etc.

EMPHASIS AREAS: These activities emphasize monitoring, evaluation, and reporting through data collection, data analysis, data use and data dissemination. Emphasis is placed on strategic information, human capacity development and local organization capacity-building.

This activity will highlight gender issues by providing gender disaggregated data on patients accessing HIV/AIDS related services. Through this analysis, we will be able to contribute to national surveillance on utilization of HIV services and impact of HIV intervention on both sexes. This data will be essential to the

development of outreach, treatment programs and education to reach an equitable number of men and women.

TARGETED POPULATIONS: The SI activities target program managers and M&E officers, site coordinators and principal investigators to provide them with skills and tools for programmatic evaluation. The data collection and management components of these activities target medical record staff, data staff, and other health care workers who are involved in the implementation of these processes. Lastly, the M&E and capacity-building efforts target implementing organizations, including private, community-based and faith-based organizations involved in the provision of ART, HCT, pediatric and adult BC&S, TB/HIV and PMTCT services.

CONTRIBUTIONS: SI activities supported by APIN are consistent with the PEPFAR goals to build indigenous capacity- building in the area of SI. APIN SI activities are consistent with these goals in that funding will be used to strengthen local capacity in the area of database management, data analysis, data use, M&E and QA/QI. APIN will also provide SI support to its local administrative office, central pharmacy and warehouse.

LINKS TO OTHER ACTIVITIES: These activities are linked to PMTCT (MTCT), OVC (HKID), TB/HIV (HVTB), HCT (HVCT), ART (HTTX and PDTX), and Basic Care & Support Services (HBHC and PDCS), where SI (HVAI) is used for M&E and QA/QI. In M&E activities, APIN will link to the National M&E TWG and Nigeria MEMS. Additionally, through the provision of IT support and data management personnel, APIN will provide linkages between all supported sites as related to data sharing and HIV surveillance in PEPFAR program areas. Through operational research studies, APIN will collaborate with Harvard, the FMOH, GON, NNART committee and the NIAID/NIH.

In COP10, as a part of the PEPFAR Nigeria effort to diversify it's portfolio of local partners, APIN will

assume responsibility for five sites providing injection safety services currently supported by Harvard

University. This shift is congruent with the plan to transition an increasing amount of Harvard-supported

sites to APIN, Ltd. Injection safety activities carried out at these sites will be a continuation of ongoing

activities currently supported by Harvard and described in their COP09 activity narrative.

None

ACTIVITY UNCHANGED FROM F2009

NARRATIVE: During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital and 43 UCH Oyo state DOT Centers. In COP10, APIN will continue Other prevention programming activities at all 6 sites in line with the overall PEPFAR Nigeria goal of providing a comprehensive package of prevention services to individuals reached with condoms and other prevention (HVOP). APIN will assist PEPFAR Nigeria in extending its reach of condom and prevention services as APIN is presently active in 3 states. Through its other program areas, APIN has a large population of HIV-positive adults, adolescents and children to which it is already providing services; this group forms part of the core target population for age appropriate messaging that is provided by APIN through its prevention with positives (PwP) activities including STI screening and management, condom provision, sexual risk reduction, disclosure, adherence, reduction of alcohol consumption, and testing of sex partners and children in the HIV clinic setting.. In addition, APIN will target activities to HIV-negative persons in its catchment areas in order to minimize their risk behaviors and contribute to an overall reduction in HIV prevalence.

In COP10, APIN will implement COP activities at both the facility and community levels utilizing the minimum prevention package strategy as contained in the National Prevention Plan. This package includes: 1) community outreach campaigns including CT, condom messaging and distribution and balanced messaging; 2) Infection control Measures in clinical setting including universal precaution and post exposture prophylaxis; 3) Prevention with Positives; and, 4) STI management/treatment. The goal of the program is to focus on targeted communities and 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 method or another, but the target group will be those individuals that will have received HVOP messaging: (1) on a regular basis; and, (2) via at least 3 of the 4 strategies employed by APIN.

APIN sites will target Most At Risk Populations (MARPs), including outpatient STI patients, border traders, fashion designers, young male market agents, and motor mechanics. APIN's HCT site at PHC- Iru on Victoria Island serves the Kuramo area, a community with a large number of MARPs where most residents are sex and bar workers, and have a HIV prevalence greater than 60%. Prevention activities at these clinics provide educational materials based on the risks that this population faces and distribute condoms. In addition to comprehensive counseling on HIV prevention and risk reduction, HIV-infected individuals identified through this activity will be referred for palliative care and evaluation for ART eligibility. An emphasis on men with high-risk behaviors through these community-based efforts will also enhance prevention efforts and facilitate access to their partners.

A focus of the program in COP10 will be continued improvement of the integration of prevention activities into the HIV care and treatment settings; specifically, healthcare providers and lay counselors in care and treatment settings will be trained to appropriately deliver integrated ABC prevention messages and incorporate the messages into routine clinic visits using IEC materials and job aids. An appropriate balance of ABC will be tailored to the needs and social situation of each individual client in its presentation. In addition to the integration of such services into the HIV-specific treatment setting, prevention activities will be assimilated into other points of service in each health facility (general outpatient clinics, emergency services, etc.), particularly into reproductive health services including, family planning counseling, STI management and counseling, and risk-reduction counseling.

This funding will also be used to support the procurement and distribution of written prevention messages and condoms. The materials will provide patients and clients with HIV prevention information using the "ABC" model, including information about healthy behaviors, safer sexual practices, PMTCT, and condom usage. Prevention messages will also include information about other STIs. Condoms will be offered to all individuals at all sites and will be provided to APIN by the Society for Family Health (SFH).

The target for Condom and other prevention) is 7197 individuals. Additional staffing and training of counselors will also be provided by this funding, including a dedicated full-time staff person. This activity will provide support for training of 99 individuals in condom promotion, STD prevention and risk reduction.

EMPHASIS AREAS ABC programming emphasizes local organization capacity building, human capacity development and efforts to increase gender equity in HIV/AIDS programs. These activities also promote a rights-based approach to prevention among positives and other vulnerable members of society and equal access to information and services. Reduction of stigma and discrimination are also key to the program. Through ABC activities, we place major emphasis on community mobilization and participation, as an element of

outreach for prevention efforts. Additionally, we place major emphasis on training as well as infrastructure and human resources in order to build the capacity of counselors and providers in a full range of prevention strategies. We also reinforce that information, education and communication are essential elements of outreach to high-risk populations, and that developing networks for linking these activities to HCT, PMTCT, and other ART activities serve as a source of prevention information.

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

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

CONTRIBUTION TO OVERALL PROGRAM AREA These prevention activities are consistent with PEPFAR's goals for Nigeria, which aim to support a number of prevention strategies as a comprehensive prevention package. In order to be maximally effective, the prevention messages developed at different sites will be tightly targeted to various high-risk groups that they serve. Furthermore, these activities are consistent with the PEPFAR 5-year strategy, which seeks to scale-up prevention services, build capacity for long-term prevention programs, and encourage testing and targeted outreach to high-risk populations. The establishment of networks and referral systems from prevention efforts at the community level to PMTCT and HIV care and treatment will help facilitate the scale-up of the overall program. LINKS TO OTHER ACTIVITIES: ABC activities relate to HCT, by increasing awareness of HIV. They also relate to adult and pediatric care and support (HBHC and PDCS) activities through dissemination of information by home-based care providers and ultimately by decreasing demand on care services through decreased prevalence. Linkages also exist to OVC programming (HKID) by targeting OVC. The provision of such services at the

community level will serve as an important platform from which general HIV/AIDS information can be provided and risk reduction strategies discussed. This program area also links to SI (HVSI) as all progress will be monitored by the SI programming and to Gender as specific programs will be targeted to be gender-appropriate.

ACTIVITY UNCHANGED FROM F2009

NARRATIVE: During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital, 43 UCH Oyo State DOT Centers.

COP10 funding will support a comprehensive PMTCT program in line with the revised National PMTCT Guidelines (2007), at 6 service outlets in 3 states (Lagos, Oyo and Ogun ). This consists of 2 tertiary, 3 secondary and 1 PHC sites. "Opt-out" testing and counseling with same-day test results will be provided to all pregnant women presenting for antenatal care (ANC), labor and delivery (L&D). The current level of PMTCT counseling and testing uptake from women presenting for ANC or L&D is 90%. All women are provided post-test counseling services on prevention of HIV infection, including the risks of MTCT. They are encouraged to bring partners and family members for on-site HCT. The program has a target of providing HCT with 14200 receiving results. PMTCT prophylaxis will be provided to approximately 852 women in line with the national guidelines. In addition, APIN will provide basic care and ARV prophylaxis to 852 HIV-exposed infants. Infant follow-up care linked with PMTCT activities includes nutritional counseling and support, growth monitoring, co-trimoxazole prophylaxis and other preventative care services. EID will be carried out using whole blood at the tertiary and DBS at the secondary and primary level in line with the national EID scale up plan.

Through this program area, APIN will provide linkages to other prevention, care and treatment services. All ART-ineligible women will be placed on zidovudine from 28 weeks, zidovudine and lamivudine from 34/36 weeks until delivery and will be enrolled into care and support services (HBHC) at the time they access MTCT services. Following delivery, mothers will be monitored in the HBHC program, where services include on-site enrollment or referrals for family planning and other reproductive health services. In addition, PMTCT services are integrated into a system of maternal and child services designed to

promote maternal and child health. All ART-eligible pregnant women will be provided with ART through the adult treatment (HTXS) program area in line with National guidelines. Children who become HIV- infected during the time they are being monitored as part of the MTCT program will be linked to the pediatric treatment (PDTX) and care programs (PDCS). Those HIV-exposed children placed on single dose nevirapine at birth and zidovudine for 6 weeks remain uninfected at 18-months following the completion of ARV prophylaxis will be linked to the OVC program (HKID) for continued care services.

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

A regular training program will be established at all sites to train and retrain health personnel involved in the PMTCT program using the National PMTCT Guidelines. Non laboratory personnel will also be trained in HIV testing. Indirect targets include training traditional birth attendants (TBAs) using an adapted curriculum in local areas, also include PMTCT counseling, training PMTCT counselors in the National PMTCT Program, providing technical assistance for the development of the National Infant Feeding Counseling Manual, and providing a zonal training of trainers with this manual

During COP10, APIN will scale up the Harvard initiated QA/QI activities to the APIN-supported PMTCT sites. The program will also continue to monitor and utilize electronic data captured through SI activities to measure the quality of services provided as well as the associated patient outcomes.

APIN will partner with Harvard and other implementing partners (IPs) in the implementation of the PEPFAR-Nigeria local government area (LGA) coverage strategy in the program areas of PMTCT, OVC and TB/HIV, designed to ensure the provision of PMTCT and TB/HIV services in at least one health facility in Oyo state. Under the coverage strategy, these facilities are all linked with primary health facilities, which provide HCT and referrals for PMTCT services for HIV-infected mothers.

EMPHASIS AREAS This activity will place major emphasis on the development of networks through expansion into more local areas through a network of secondary or primary PMTCT clinics, with rural outreach to community healthcare workers and TBAs involved in home delivery; all community workers and TBAs with whom we

work are linked to tertiary health care facilities. In addition, major emphasis will be placed on building organizational capacity in order to work towards sustainability of PMTCT centers. These system strengthening activities are led by local investigators at current PMTCT sites who participate in new site assessments, overseeing QA/QI, capacity development and training for new PMTCT centers. Minor emphasis is placed on performing targeted evaluations of PMTCT interventions, to estimate the rate of transmission with each of the ARV prophylaxis regimen used.

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

CONTRIBUTIONS TO OVERALL PROGRAM AREA Through the PMTCT program, APIN will provide T&C with test results to 14200 pregnant women. Additionally, treatment and prophylaxis will be provided to 852 pregnant women. Implementation of the National PMTCT Guidelines in 6 sites contributes to the PEPFAR goal of expanding ART and PMTCT services. Counseling will encourage mothers to bring their partners and family members for testing, to reach discordant couples and expand the reach of HCT, based on the new PEPFAR 5-year strategy. This program is implemented in geographically networked sites to optimize training efforts and provide collaborative clinic/lab services as needed. APIN will train and retrain 111 health care personnel from the PMTCT sites, including doctors, nurses, pharmacists and counselors. Training will build capacity at local sites to implement PMTCT programs and provide essential treatment support to pregnant women with HIV/AIDS. Capacity building efforts are aimed at future expansions of PMTCT programs. QA/QI will be carried out through personnel training, data collection from sites for monitoring and evaluation and supervisory visits from key program management staff, which may include representatives from the USG and GON.

The program will increase gender equity by specifically targeting pregnant females for HCT and PMTCT prophylaxis and their male partners for HCT. Data collection on PMTCT regimens provides a basis for developing strategies to ensure that all pregnant women have access to needed and optimally effective PMTCT services. This program addresses stigma and male norms and behaviors through the encouragement of partner notification and bringing other family members in for HCT. Infant feeding counseling, including on the appropriate use of exclusive breastfeeding or exclusive use of breast milk

substitute (BMS) where AFASS is available, will be in line with the National PMTCT Guidelines. Referrals to income generating activities (IGAs) will also be provided to women as a part of palliative care and counseling activities.

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

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

ACTIVITY UNCHANGED FROM F2009

NARRATIVE:

During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital, 43 UCH Oyo State DOT Centers.

In COP10, APIN will provide support for laboratory development at the 6 treatment sites (2 tertiary care, 3 secondary sites, 1 PHC) and 43 DOT sites. We also propose to add additional expansion sites by building the infrastructure and capacities of 2 labs in secondary health facilities in Lagos state to have capabilities for hematology, automated chemistry analyzers, and laser-based lymphocyte subset enumeration. In COP09, we expanded the capacity of 1 lab in a primary health facility in Lagos state. We also expanded the capacity of the lab at Sacred Heart Catholic Hospital, a secondary health facility in Ogun state, to have capabilities for hematology, automated chemistry analyzers, laser-based lymphocyte subset enumeration.

By the end of COP10, HIV rapid testing would be performed at the HCT centers with the labs providing supervisory roles. 3 ART sites will have western blot capacity to confirm HIV status prior to initiation of ART. HIV serology, hematology, chemistries, and CD4 enumeration will be supported at all secondary hospitals with referral to the tertiary labs for PCR diagnostics and viral loads. Primary health care facilities are closely partnered with secondary and tertiary care facilities, allowing for baseline and periodic evaluation with full lab monitoring. The primary facilities provide limited lab monitoring with basic clinical, hematologic and CD4 assays. We will screen for TB by sputum and/or pulmonary X-ray at all ART sites. We will also provide screening for STIs, including Syphilis and Chlamydia at all of our sites. Our 2 labs with infant PCR diagnostic capabilities (NIMR, LUTH) will continue to assist other PEPFAR IPs, using dried blood spots (DBS) to test transport specimens from distant satellite sites.

Standardized lab protocols were developed in previous COP years by Harvard to accompany the clinical protocols and computerized lab results are linked with patient records. In order to ensure continuity of care and services, these protocols will continue to be implemented at APIN sites. These protocols include provisions for the disposal of biomedical waste in accordance with good laboratory practices. Quality control/quality assurance (QA/QC) policies have been developed and detailed annual assessments of all lab activities are conducted. . In our pursuit to meet the expected quality requirements in compliance with the shift in focus from target to quality of service, APIN shall review and strengthen its existing QA/QC program and make it more aggressive. Preparatory for the WHO-AFRO accreditation exercise, APIN shall review its laboratory quality policy and guidelines to integrate the components of the WHO checklist into the existing laboratory quality system elements in our protocol. The reviewed quality policy and guidelines, alongside the PEPFAR Lab Technical Working Group (LTWG) harmonized monitoring tool, as well as the WHO checklist shall be used as the standard framework for laboratory audit and evaluation.

Internal quality assessment activities shall be enhanced with the site quality managers effectively empowered to perform daily QA monitoring; monthly site assessment visits shall be conducted by APIN lab team with technical support from Harvard, while management review meetings shall hold quarterly. . International EQA program for lab tests was established in COP07 by Harvard and is operational for CD4, HIV, HCV and HBV serology, chemistries, VL and HIV PCR diagnostics; through individual lab registration with UK-NEQAS and CAP. We intend to continue this with all APIN labs. APIN shall likewise effectively partner with the proposed national PEPFAR EQA centre in Zaria (with technical support from National Health Lab Services, South Africa) and actively participate in the national PEPFAR EQA scheme by enrolling all our supported labs. All PCR labs will participate in the CDC's DBS DNA PCR proficiency program (EID QA). We provide support for lab staff persons (based at sites), responsible for implementation of lab protocols, data entry and performance of lab tests.

APIN provide support for 3 APIN staff who provide technical assistance to sites. We will continue our efforts to increase our laboratory technical staff in order to address increased training and laboratory needs for the overall PEPFAR program. To further strengthen the capacity of the lab staff in line with the health system strengthening mandate, APIN shall review its training policy to provide for a more effective and regular lab training and retraining to allows for enhanced staff competence and the development of high quality lab standards in our PEPFAR labs. The trainings shall be networked to our secondary and primary labs with specific tailoring to the needs and skills at each level, and also based on the need to address identified deficiencies and non-conformities. In conjunction with Harvard Lab Infrastructure activities, staff at APIN sites will be linked to centralized and/or regional biannual trainings provided on specific techniques/topics integrating QA/QC, good lab practices and biosafety. On-site competency monitoring/evaluations and refresher trainings will be provided within individual labs. APIN shall continue to provides support for NIMR (Lagos) and UCH (Ibadan) which are both comprehensive hands-on training centers with lecture room capacity and personnel skilled in training. These training centers provide training in all areas, with special focus on viral load and drug resistance testing. As a result of encountered disruptions on testing activities during practicum training sessions in this centre, APIN plans to equip the training labs with dedicated equipment. PEP protocols have been implemented at each of our labs, supported under our ART drugs activities.

A laboratory information system (LIS) will be implemented at sites, with appropriate capabilities, to streamline the capture of lab data, minimize transcription errors and facilitate data entry and results output. With technical support from Harvard, using FileMaker Pro data software a program has been developed to support data generation, capturing and analysis. APIN shall continue to support for this system and ensure the provision of uninterrupted internet access at all labs, and continue in building the capacity of the lab data officers at all sites.

We will participate in the quarterly LTWG meetings to ensure harmonization with other IPs and the GON, including the development of a common lab equipment platform (appropriate for each lab level).

Procurement of lab reagents is structured in two ways. Reagents available in Nigeria will be procured directly by the sites from specific distributors. Labs will be advised to maintain a 3 month reagent buffer. Most reagents needing importation will be ordered by APIN and shipped to the APIN Central Medical Stores warehouse in Lagos. PEPFAR funding supports procurement of lab equipment, generators and water purifiers necessary for lab work at APIN sites. Equipment costs for labs can be high in the first year, but represents significant infrastructure development. REDACTED. APIN shall continue to provide service support for all equipment and ensure an effective implementation of an equipment management and maintenance policy. We shall continue to partner with equipment manufacturers and their in-country representatives/service vendors in the provision of equipment service support. Additional equipment shall be procured to provide additional back-up needs.

APIN will perform 254492 tests in COP10, including HIV diagnosis (47098) and tests for disease monitoring including CD4 (73944) enumeration, PCR diagnosis of infants (1200) and VL, which provide support for ARV treatment for 15600 adult and 1200 pediatric patients at APIN sites in Lagos, Oyo and Ogun states. In addition, we seek to train199 lab staff members in COP10.

EMPHASIS AREAS: This program is centered on laboratory system strengthening and human capacity development through training and retraining of lab personnel, provision of managerial, supervisory and technical support for sustainability. . Increased lab capacity will permit the sites to provide quality treatment for both women and men. We also place emphasis on TB services as our lab activities include the provision of support for TB and HIV diagnostics at 43 TB DOTS sites in Oyo state.

POPULATIONS BEING TARGETED: This program targets public and private health care workers with training to maintain high quality lab standards. Laboratory diagnostics and monitoring supported through these activities also target PLWHAs who are provided with treatment through our Adult and Pediatric Care and Treatment activities.

CONTRIBUTION TO OVERALL PROGRAM AREA: These activities contribute to the goal of maintaining high quality services as the PEPFAR program expands. Training lab staff will assist in building the human resource capacity of our sites to provide sustainable lab support to sites providing high quality HCT and ART treatment. Two labs at tertiary care hospital and research institute will have the capacity to perform early infant diagnosis (EID) by HIV DNA PCR. These labs are also linked to PMTCT sites, to provide a mechanism for EID as a part of the

PEPFAR supported national scale-up plan (consistent with 2009 PEPFAR objectives for Nigeria). APIN will partner with the Harvard, GON and Clinton Foundation for procurement of EID test kits and specimen collection supplies. The NIMR PCR lab will provide QA support for the EID program in the Southern half of Nigeria (through retesting). APIN shall continue to partner with FMOH in its plan to scale up the EID program and strengthen PMTCT services. Through a tiered system of labs at tertiary, secondary and primary sites we are able to ensure that patients at community based primary facilities are provided with a full complement of lab monitoring as a part of ART treatment and care. Our training activities include management and competency training, which seeks to build sustainability.

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

LINKS TO OTHER ACTIVITIES: These activities relate to activities in PMTCT (MTCT), Counseling & Testing (HVCT), Palliative Care TB/HIV (HVTB), Adult Care and Treatment (HTXS), Pediatric Care and Treatment (PDTX) and OVC (HKID). Our labs are crucial in providing adequate HIV diagnostics in PMTCT, HCT, OVC, Palliative care and ART services. Furthermore the lab provides other diagnostics such as OIs. As a part of this activity, we seek to build linkages between labs and our patient care sites in order to ensure that lab information is fed back into patient records for use in clinical care. Our SI (HVSI) activities provide support in M&E, including data management of testing results.

None

ACTIVITY UNCHANGED FROM F2009

NARRATIVE:

During COP09, APIN assumed management responsibility for 2 Harvard sites (LUTH and NIMR), in addition to the initial 4 sites - Sacred Heart Catholic Hospital in Lantoro, Ogun State and Primary Health Center-Iru on Victoria Island, Lagos, Mushin General Hospital, Onikan General Hospital, 43 UCH Oyo State DOT Centers. APIN will maintain a strong collaboration with Harvard University.

In COP10, APIN will provide support for TB/HIV services at the 6 treatment sites (2 tertiary care, 3 secondary sites, 1 PHC) and 43 DOT sites).

ACTIVITY DESCRIPTION: In COP10, APIN sites will identify HIV infected patients through PMTCT, HCT centers and ART centers and hospitals and outreaches. These sites constitute a network of delivery points in 3 states (Lagos, Ogun and Oyo) and include 2 tertiary hospitals, 3 secondary hospitals, 1 PHC and 43 DOT centers. In COP10, APIN plans to execute a universal coverage strategy in Oyo state, by providing support for TB- HIV services in all state government supported DOTS centers throughout the state. This is an essential step toward universal access to TB/HIV services, and will focus on developing programming at the secondary and primary level. All HIV-infected individuals are clinically pre-assessed for eligibility for ART treatment; it is expected that 2500 HIV positive clients will be screened for TB in COP09. TB screening is conducted according to national guidelines. The15,600 new and maintenance patients already on ART will also be monitored for TB. All HIV infected women (852 from our 6 treatment sites) will be assessed for ART eligibility and screened for TB. The TB clinics at 2 of our sites are National TB centers offering the government DOTS program. At all of our associated DOTS clinics, we will implement HCT for 5,700 clients and suspects presenting to the DOTS center (4000 registered TB patients). In all, it is expected that 2500 TB/HIV co-infected patients will be identified and will receive treatment for TB and be linked to and APIN ART clinics for evaluation of eligibility for ART and provision of care and treatment.

The National Tuberculosis Reference Laboratory (NTRL) at NIMR will provide an important resource to APIN sites in strengthening their capacity for TB diagnosis and cross-training of health care workers in TB/HIV. The NTRL will provide screening for MDR-TB. TB services provided at these clinics will be integrated with ART services and HCT in order to promote the development of a comprehensive system of care for individuals with HIV/TB co-infection. This will be part of the 148 health care workers in both HIV and TB clinical and laboratory settings to be trained in COP09. APIN TB/HIV program officers and facility staff will be provided with formal TB/HIV training to enhance their productivity, including retraining on x-ray diagnostic skills and co-management of TB/HIV for clinicians; and retraining on good sputum specimen collection and laboratory AFB sputum smear diagnosis for laboratorians. There will also be training on TB infection control and HCT. A dedicated TB program officer provides TB expertise to all Harvard and APIN sites and is responsible for training efforts and reporting of TB patients to the NTPLCP.

APIN will implement the global 3 "I"s strategy in COP10 through intensified TB case finding amongst HIV positive patients and close contact of TB patients, TB infection control in all our sites and INH Prophylaxis Therapy (IPT). APIN will prevent nosocomial transmission of TB to HIV+ patients through such measures and principles such as basic hygiene, proper sputum disposal, and good cross ventilation at clinics. Facility co-location of TB/HIV services is preferred to clinic co-location. The national guidelines on TB infection control will be implemented in all sites. Patient and staff education on infection control measures will be routinely carried out to ensure program success. APIN will upgrade facilities as needed through infrastructure support such as basic renovations and space modification to ensure effective infection control, upgrading equipment and procuring supplies and consumables (e.g. sputum containers).

To date, more than 30% of APIN+ clinic attendees present with pulmonary tuberculosis. TB/HIV Co- infected patients will be treated following National guidelines. All co-infected patients will receive cotrimoxazole prophylaxis (CPT). INH prophylactic therapy (IPT) will be provided on a case by case basis through the ART clinics following national guidelines. The TB DOTS sites will be supported to provide holistic patient care according to National and IMAI guidelines. Cross-referrals and linkages between TB and HIV programs will be strengthened.

APIN home-based care providers will track family members and contacts of TB patients who are at risk of developing TB and get them screened for TB, as well as HIV. This will result in higher TB case detection and increased HCT uptake. They will also track treatment defaulters and provide adherence support for TB and ARV drugs. Site support groups will be involved in community mobilization and will include TB education in their outreach messages.

At NIMR, APIN will provide technical assistance in the implementation of MDR-TB and XDR-TB surveillance activities in Nigeria. TB diagnostic capacity will include culture, PCR, and sequencing for resistance testing.

In COP10, APIN will work with 43 DOTS centers in all LGAs of Oyo state. These DOTS centers will be linked with two tertiary care sites for specialty care. At each DOTS center, we will provide HCT for TB patients and support the provision of broad HIV/TB services for all patients served, including referrals to ART centers for patients identified as HIV infected. To ensure continuous availability of drugs and commodities in supported sites, APIN will partner with Harvard and the USG PEPFAR team to strengthen logistics management within the states where it works.

EMPHASIS AREAS: Emphasis areas include gender, health-related wrap around activities. This activity will increase gender

equity by focusing on strategies which seek to reach an equitable number of co-infected men and women. Furthermore, it seeks to provide additional focus on support for pregnant women who have TB/HIV. Through data collection and patient surveillance from this activity, APIN will be able to show the breakdown of men and women who are accessing TB diagnostics and treatment services. Outreach activities and patient counseling also seek to address stigma and discrimination and increase access to information, education and TB diagnosis and treatment for women and girls with HIV. In addition, we will focus on providing linkages to wrap around services for TB, which will focus on MDR-TB detection and treatment. Focus will also be places on intensified case detection through developing linkages with community based health care facilities to build capacity for TB screening.

POPULATIONS BEING TARGETED: This activity targets adults and children with HIV and TB co-infection by providing a mechanism for critically important TB diagnosis and treatment both prior to the initiation of ART and also during the course of ART therapy. Newly enrolling ART patients will be prescreened for TB in COP09 and TB that develops in patients that are currently on ART therapy will be diagnosed and treated. All HIV infected pregnant women participating in APIN PMTCT programs will also be eligible for TB diagnosis and treatment under this program. TB patients/suspects at DOTS clinics will be screened for HIV. Their family members and contacts will also be targeted for TB and HIV screening.

CONTRIBUTION TO OVERALL PROGRAM: The provision of TB diagnostics and treatment within participating ART facilities is consistent with the PEPFAR goal of ensuring that all facilities offering ART develop the ability to diagnose TB and provide support to DOTS sites within their facility. There will a deliberate attempt to locate HCT services within DOTS centers so as to increase detection of co-infected TB/HIV patients. At these facilities, APIN estimates that it will provide clinical treatment for TB to 2825 patients with HIV/TB co-infection either prior to or during their ART therapy, thus contributing significantly to the 2009 PEPFAR goals. At all APIN sites referral to co-located or near by DOT centers will be provided. The provision of TB diagnosis and treatment, infrastructure building and health care personnel training under this program will work towards building and maintaining Nigerian National tuberculosis treatment capacity, which is consistent with the PEPFAR 5-year strategy.

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

LINKS TO OTHER ACTIVITIES: This activity also relates to activities in HCT (HVCT), Adult Care and Treatment (HTXS), Pediatric Care and Treatment (PDTX), PMTCT (MTCT) and OVC (HKID). Through this activity linkages between participating treatment sites and the National Tuberculosis Reference Laboratory will be provided. Additionally, linkages to potential patient populations through outreach initiatives, HCT activities, and ART services will improve utilization of care opportunities created through PEPFAR funding. This activity is linked to care and support and ART services because TB diagnosis and treatment are provided as a part of patient basic care and support at sites which also provide ART. A high TB co-infection rate has a major impact on ART management.