Under the AIDSTAR IQC, the TBD partner (The Partner) had implemented Injection Safety (IS) programs in five states (Anambra, Edo, Cross River, Lagos, Kano) and the Federal Capital Territory (FCT) since 2004 and individual USG and GON health facilities across another fourteen states (Bauchi, Benue,

Nassarawa, Niger, Plateau, Kwara, Ogun, Borno, Delta, Enugu, Kaduna, Katsina, Kebbi and Oyo States) during the FY08. By the end of COP 08, The Partner would have trained total number of 25,226 health care workers and 10,743 waste handlers. In COP09, The Partner will be conducting injection safety activities primarily in the 5 focal states and FCT. Technical assistance will be provided to other PEPFAR IP supported sites through training of trainers, health workers, store keepers and waste handlers trainings including refresher trainings at initial sites and supportive supervision. In COP 09, IP will expand to 30 new sites in a total of 4 States.

The Partner will continue to implement the four major technical areas: human and institutional capacity building; behavioral change of healthcare personnel to promote safe injection practices and the communities to promote oral medication where possible; ensure availability of equipment and supplies; and appropriate healthcare waste management at the 789 previously supported health facilities. In addition The Partner will extend its activities to an approximated 30 public health facilities through ad hoc partnership with corresponding IPs and or Government of Nigeria. In COP09 the Partner will provide IS training to a total of 5,000 individuals using FMOH adapted WHOAFRO/JSI training curriculum. A training of trainers on supportive supervision will be provided for all IP injection safety staff to enable them consolidate the gains of the training and ensure behavioral change at implementing sites. All IP will be encouraged to advocate for and support infection prevention and committees at facility levels.

Advocacy and behavior change communication (BCC) efforts include periodic advocacy meetings with policy makers at all levels of healthcare management and dissemination of BCC materials, tools, job aids, posters and pamphlets to healthcare providers. The partner will also promote safe injection practices, and oral medication to reduce unnecessary demand for injections at community level through Community Based Organizations (CBOs) interventions and the mass media in collaboration with INTERNEWS/ENHANSE. Collaborative BCC and advocacy work will continue with national and local institutions/organizations such as NAFDAC, the National Orientation Agency (NOA) and local/community and religious organizations. NAFDAC is supporting injection safety through; media messaging to discourage the populace from demanding injections from their health providers, advocacy to pharmaceutical industries producing injectables in Nigeria to support local production of safety boxes and promoting nationwide use of auto disabled syringes. Community outreach activities are expected to foster community engagement on issues of health with emphasis on injection safety issues as it affects communities in Nigeria. In COP08, the Partner trained field staff of the NOA to deliver appropriate injection safety messaging to the grassroots. This activity will continue in COP09. The Partner will work to maintain grassroots coalitions and encourage those coalitions to advocate on issues of injection safety with focus on the reduction of the demand for unnecessary injections, ensuring the safety of all necessary injections and proper healthcare waste management to the relevant health authorities and government.

The Partner will continue to work towards commodity security. The Partner procures IS commodities such as injection devices and safety boxes through her sub-contractor; PATH (Program for Appropriate Technology). Commodities are stored at the Government Central Medical Store in Oshodi (Lagos) and distributed by USAID accredited courier distribution company SDV to the focal GON Stores. The Partner has a tracking system to collect data on consumption and stock levels along the supply chain.

The Partner will support healthcare waste management through provision of seed waste segregation commodities, building infectious waste pits and encouraging the building of incinerators for appropriate final disposal options in accordance with WHO standards such as encapsulation in rural areas. We will also support the repairs and construction of incinerators, running cost as well as maintenance whenever possible where applicable. The Partner would work through the Federal Ministry of Environment and the National Prevention Technical Working Group with other partners to map out the HCWM microplan for selected HF sites, adapt the national adopted HCWM Plan, policy and guideline at the lowest service delivery points. The Partner will procure safe IS commodities through SCMS for the USG partners in FY09. All IPs are encouraged to plan for sustainability of the program in their sites.

The Partner will continue to work with the Federal Ministry of Health (FMOH) and other major stakeholders (such as the Nursing and Midwifery Council of Nigeria and Medical and Dental Council of Nigeria). The Partner also works with training health institutions (such as Medical, Dental, Pharmacy, Nursing and Midwifery schools and Schools of health technology) to review, include and update safe injections issues in their various curricula. In addition, injection safety training is part of the continuous medical education taking place at supported sites mentioned above (old or new). Training package for new entrance health workers into the healthcare system has been developed. The package is used to capture newly employed health care workers after completion of site trainings.

The National Policy on Injection safety and Health care Waste Management will continue to be disseminated widely in COP09. The Partner will perform quarterly monitoring of all sites including the GON and USG supported sites using the previously used tools. State MOH and other PEPFAR IPs will participate at state level meetings to give feedback for service delivery quality improvement. The MMIS project operated in five focal states (Kano, Edo, Cross Rivers, FCT, Anambra and Lagos) with a view of saturation of those states with injection safety activities, while also supporting other states where PEPFAR treatment facilities were located. The range of activities included; Capacity building, HCWM, Procurement and behavior change. Based on the current funding available for injection safety, one major shift from the MMIS project would be a dramatic decrease in procurement of auto disable syringes. To bridge this commodity gap the new award will have to put in a considerable amount of effort towards the implementation of the policy by

NAFDAC that would move syringe use in country from standard disposable to auto disable. Another gap in the MMIS project which will be filled with the new award is the inclusion of phlebotomy services, which will include the revision of the National injection safety manual to include safe phlebotomy and some seed stock for demonstrations. The new component will also be looking at safe male circumcision practices in its community component. In summary; • Injection safety training will continue to be offered to treatment partner sites as well as other selected states with a view of saturation in some of them; • Phlebotomy services will be offered with provision of seed stock; • Safe male circumcision will be incorporate into the behavior change community component of injection safety; • level of effort will be increased to advocate for NAFDAC to implement the shift from standard disposable to auto disposable syringes.

CONTRIBUTION TO OVERALL PROGRAM AREA. As the Partner plans to extend coverage to some sites supported by other USG IPs; this integrated HIV/AIDS programming will improve collaboration amongst partners, will maximize the impact and will contribute to the prevention of 1,145,545 new HIV infections by 2010 and contribute towards the PEPFAR global achievement of the 2,7,10. This will also improve the equity in access to HIV prevention services to the communities most in need; both rural and urban by reducing the risk of transmission to the community as well as to health care workers. These activities would contribute substantively to NACA's National HIV Prevention Plan implementation; develop strong links between THE PARTNER services and other service provides such as PEPFAR IPs, National Primary Health care Development Agency (NPHCDA), UNICEF, the World Bank and WHO, other organizations working on HIV/AIDS issues, IS and healthcare waste management. Improved safety in the work environment and universal precaution among health providers will lead to higher quality of health services and reduction in stigma/discrimination towards PLWHA.

LINKS TO OTHER ACTIVITIES This activity also relates to activities in HIV Counseling and Testing, Laboratory, Palliative Care, TB/HIV, ART Services and OVC. Health care workers involved in these programs will benefit from the training program in injection safety and the adoption of utilization of single syringe and needle, needle stick policy and PEP protocol, all of which will improve the safety for workers involved in these other programmatic activities.

POPULATIONS BEING TARGETED

Targeted population include healthcare workers at focal health facilities; doctors, nurses, pharmacists, laboratory scientists, phlebotomists, community health officers, environmental health officers, store keepers and waste handlers. Religious and community leaders, community-based organizations are also targeted within the communities. In addition, heads of service and administrators need to be aware of the policies put in place to control medical transmission of HIV. Government policy makers, line ministries and National AIDS control program staff are also targeted for advocacy to leverage policy decisions, national guidelines and sustainability issues. Furthermore, these activities will indirectly target the general population on the community outreach program, who will be provided with information on safer injection practices, which are designed to prevent transmission of HIV and promote oral medications.

KEY LEGISLATIVE ISSUES ADDRESSED Stigma and discrimination also occur in healthcare settings, and this has been reported in Nigeria. As HIV/AIDS treatment and care programs have been expanded, the training of all levels of healthcare providers on universal precautions and the risks of medical transmission have helped reduce the stigma and discrimination that can occur in these settings due to fear of occupational hazard.

EMPHASIS AREAS Through these activities, major emphasis is placed on training of staff and institutional capacity development. This program will provide the basis for a workplace program through professional medical associations that will ensure that all treatment and laboratory specimens are handled safely, with minimal risk to healthcare providers. Minor emphasis includes policy and guidelines, information, education and communication, commodities procurement and quality assurance, quality improvement and support supervision.

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The significant change in THE PARTNER activity from COP08 to COP09 is the expansion strategy within selected sites as directed by USG and GON with inclusion of phlebotomy activities; this will entail coverage of IS at sites supported by other USG Implementing Partners (IPs) in addition to sites supported by JSI/THE PARTNER only, such as Government of Nigeria (GON), faith based and other private health facilities. THE PARTNER' support to USG IPs will be lead in IS training and coordination of all USG sites while supply of safe injection commodities and waste management will cover only non USG sites after training completion (USG sites will be required to purchase through SCMS; safe IS commodities) THE PARTNER will also support the setting up of support supervision system at sites level.

Indicators

• 4.0 Number of service outlets provided with training in injection safety 30 • 4.1 Number of individuals trained in medical injection safety 5000