ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: TB and HIV constitute major public health problems in Nigeria, a country with a population of about of about 140 million people (2006 census). Nigeria presently ranked 4th among the 22 high TB burden countries in the world and first in Africa with an estimated incidence of 311 of all forms of TB per 100, 000 populations per year and prevalence of 521 per 100, 000 populations per year (WHO Global TB Report 2009). The National Programme currently implements the WHO recommended Stop TB strategy, a total of 90,311 TB cases were notified in 2008, representing a case notification rate of about 61/100,000 population.

The high National HIV prevalence (4.6% in 2008 National HIV sentinel survey) further complicates the

burden of TB, the prevalence of HIV/AIDS among TB patients increased from 2.1% in 1991 to 19.1% in 2003 (National HIV sentinel survey), and now estimated to be 27% (WHO Global TB Report 2009) which indicates that the TB situation will continue to be HIV-driven. The estimated incidence of all forms of TB among HIV patients is 83/100,000 population translating to the fact that about 123,000 TB-HIV co- infected patients occurs annually in the country (WHO Global TB Report 2009).

The deadly interaction of TB and HIV affects millions of people in Nigeria, threatens public health, and stretches the already weak infrastructure of the health sector. HIV is the most powerful known risk factor for reactivation of latent tuberculosis infection to active disease. HIV also increases the risk of recurrent tuberculosis; the rise in tuberculosis cases in PLWHA poses an increased risk of tuberculosis to the wider community. TB on the other hand is the leading cause of morbidity and mortality among People Living with HIV/AIDS. About 62% (56,053) of the notified TB cases in 2008 were tested for HIV (2008 NTBLCP report), 15,301 (27.3%) of whom were HIV positive. The access to HCT among TB patients is still far below the universal access target hence the need for further expansion and sustenance of TB/HIV services.

The emergence of multi-drug resistant TB (MDR-TB) and extremely drug resistant (XDR-TB) further create threat which if not properly controlled may erode all the gains made over the years in TB and HIV control. MDR-TB accelerate the morbidity and mortality among HIV/MDR-TB co-infected patients faster that ordinary TB, the difficulties in achieving cure among MDR-TB cases and the burden to hospital services as well as the affected households makes MDR-TB a health issue that must be given priority attention especially among PLWHAs.

There are very few data for multi-drug resistant TB (MDR-TB) in Nigeria; WHO estimates of MDR-TB prevalence for 2009 is 1.8% among new smear positive cases and 9.4% among retreatment TB cases (WHO Global TB Report 2009). A total of 80 MDR-TB cases were notified from 3 laboratories (NIMR, UCH, and Zankli) from 2006 to 2008. The ongoing DRS may further create an extra pool of about 250 MDR-TB patients which will require second line drugs some of whom may also be HIV positive. Additional cases are also expected as the capacity in-country to diagnose MDR-TB increases. Currently there are no second line anti-TB drugs in the Programme for treating MDR-TB; the GLC few weeks ago gave an approval for the NTBLCP to access second line drugs for the initial cohort of 80 patients at a concessionary price(about 99% reduction price compare with those in the open market). It is becoming more and more imperative for the programme to provide 2nd line anti-TB drugs for treating the expected MDR-TB cases among PLWHAs and the general population in view of the public health importance and human right issues and to provide effective Logistic management system for second line anti-TB drugs

Goal and Objectives of COP 2010 grants:

In view of the above, the planned activities for COP 2010 are therefore linked to the goal of reducing the burden of TB/MDR-TB and HIV in dually affected populations and the three objectives of the National strategic framework for the implementation of TB/HIV collaborative activities which are to: 1. Establish mechanisms for coordination at all levels, 2. Reduce the burden of TB/MDR-TB in HIV patients and 3. Reduce the burden of HIV among TB/MDR-TB patients.

The key intervention areas for COP 2010 will be to: 1. Strengthen capacity at National, State, LGA and facility levels to effectively coordinate and manage TB/HIV collaborative activities 2. Scale up of patients centered TB/HIV collaborative activities and ensuring continuous support for existing services. 3. Strengthen MDR TB Control and Management. 4. Strengthen implementation of TB infection control measures

The summaries of key activities that will be supported by this grant are highlighted below under each strategic direction:

1. Strengthen capacity at National, State and LGA levels to effectively coordinate and manage TB/HIV collaborative activities. Funds from COP 06 - 09 through TB CAP/WHO was used in establishing and ensuring functionality of TB/HIV working groups at National level and in 23 states, the COP 08 and 09 grants was also used in collaboration with Scientifico di Tradate, Italy to develop the skills of the national facilitators from NTBLCP and NASCP in building capacity for TB/HIV management and leadership in Nigeria. The COP 010 will therefore be used to provide continuous support for the quarterly meetings of the TB/HIV working groups at National and in 23 states and also at health facility level. Capacity of programme staff from NTBLCP, NASCP and the state on TB/HIV leadership and management will also be enhanced.

2. Scale up of patient centered TB/HIV collaborative activities to 42 additional DOTS centers in 21 LGAs and ensuring continuous support for the existing TB/HIV services in 23 states. The COP 010 will be used to support FMOH in scaling up services to 42 additional DOTS centers from 21 LGAs in line with the NTBLCP & NASCP scale up plan and in close collaboration with the International Federation of anti-Leprosy Associations (ILEP) members and other collaborating partners. The goal of this activity is to increase access to TB/HIV services in the 23 states currently receiving support from FMOH with PEPFAR grants through WHO/TB CAP in the implementation of TB/HIV collaborative activities while maintaining activities in the existing centers. Provider initiated HIV testing and counseling services will be established in 42 additional DOTS centers. 84 general health workers from these facilities

will be trained to provide health care provider initiated testing and counseling for TB suspects and patients, the workers will also have the capacity to diagnose HIV in TB suspects, treat HIV positive persons with active TB, provide CPT and referral to ART clinics and care and support services. The national HCT training curriculum will be used for CT training. In addition 42 laboratory staff from the identified 21 TB microscopy centers will be trained on how to carry out HIV testing in line with the national HIV testing algorithm and provide supervision back up for GHWs involved in multi point HCT service deliveries at DOTS centers. Capacity of the State TBL Control officers and State HIV/AIDS Programme Coordinator (SAPC) will also be strengthened to support TB/HIV services. WHO and FMOH staff at National and zonal levels will be supported to provide technical assistance to national, state and local government in mentoring, supervision and coordination of TBHIV activities at all levels. In collaboration with the FMOH, joint monitoring and supervision will be conducted from all levels and FY 2010 funds will also be utilized as required for on-going revision, printing and dissemination of national TBHIV reporting and recording forms to track progress towards the set targets.

3. Strengthening the control and Management of MDR TB The COP09 grant was used to support the review, finalization and printing of SOPs for management and control of MDR TB patients. The APA4 was used in supporting renovation of MDR TB wards in 2 referral hospitals while renovations of other wards are also been supported by other partners. The APA 5 funds will also be supporting the training of personnel from MDR-TB treatment centers on effective MDR-TB Management and continue functioning of the National MDR-TB committee. The availability of second line anti TB drugs in the National programme for use at these MDR-TB treatment facilities is still a major gap; the COP 2010 will therefore be used in filling this gap by supporting availability and also effective Logistic management system for second line anti-TB drugs. The standard regimen currently approved by the National guidelines (6 Km-Cs-Lev-Pto-Z/18 Lev-Cs-Pto-Z) entails treatment of MDR-TB for 24 months, the first 6 months of which patents will be in the hospital, resources will be provided to support logistic management for second line drugs.

4. Strengthen implementation of TB Infection control Measures. Ensuring appropriate Infection control measures in health facilities is one of the major challenges in the scaling up of TB/HIV services nationwide, these activities becomes vital in view of the emerging threat of MDR-TB, the increasing burden (rates of morbidity and mortality) of TB among co-infected patients. WHO in collaboration with other implementing partners will support the FMOH to scale up implementation of appropriate TB infection control measures in health facilities especially those with ARVs and TB services. The TB-IC will be used as an entry point for strengthening other infection control measures in the facility. The activities to be supported include:

? Dissemination of the national guidelines and SOPs on TB infection control.

? Organize Training of National (National focal person for TB-IC), State, WHO/TB CAP and other partners' staff from TB and HIV/AIDS control Programme on TB infection control. ? Conduct of Facility assessment in 12 sites with ART/HIV and DOTS services. ? Development of Infection control plan in 12 health facilities with ART and DOTS services ? Capacity building for facility staff from the 12 Health facilities on TB Infection control measures and the developed plan. ? Support formation and regular meetings of TB-IC committees in the 12 health facilities. ? Basic renovation and upgrading at the health facilities (OPD, AFB laboratories, DOTS centers) to conform to good TB-IC measures. ? Procurement of 10 Binocular Olympus microscopes to enhance diagnosis of TB among PLWHAs. ? Quarterly Supervision and monitoring of TB/Infection control activities. This will be integrated into the existing supervisory structures. TB-IC IEC materials (e.g. on cough hygiene will be developed).

Target Populations: The target populations for the COP 2010 activities include: ? HIV positive persons receiving treatment, care and support and HIV positive persons with active TB. ? HIV patients who hitherto had no access to TB screening and care. ? TB suspects and patients from TB/DOTS centers who represent a high-risk population for HIV/AIDS (TB is the commonest Opportunistic Infection (OI) among PLWHA in the country). ? MDR-TB patients co-infected with HIV. ? MDR-TB patients with HIV status unknown. ? Through implementation of good TB-IC practice, the Health facility staff, visitors and patients in health facilities are also part of the target groups for some of the planned activities.

Geographical coverage: The COP 010 will be used to support implementation of TB/HIV collaborative activities in 42 DOTS facilities from 21 LGAs in 7 states from the existing 23 states (Ogun, Osun, Ondo, Ekiti, Adamawa, Taraba, Niger, Nassarawa, Plateau, Kogi, Benue, Kwara, A-Ibom, Rivers, Enugu, Ebonyi, Imo, Abia, Sokoto, Katsina, Kebbi, Zamfara and Bayelsa) and also provide support for the existing TB/HIV service services in the 23 states.

Monitoring and evaluation plans: The review, printing and dissemination of the National TB/HIV reporting and recording formats will be supported with funds from COP 2010; this is to enhance availability of these formats and to ensure quality data capturing at all levels. The M&E plan of this support is in line with the National M&E plan. Monitoring

and supportive supervision activities will be enhanced at all levels through support for: ? Updating of monitoring and supervisory tools where necessary. ? Monthly supervision of health facilities providing TB/HIV services by the LGA supervisors. ? Quarterly supervision LGA and health facilities by the State TB and HIV/AIDS Programme managers (STBLCO &SACP). ? Quarterly supervision to states by the Zonal NPOs. ? Joint Quarterly supervision by FMOH, WHO and partners to states. ? Leveraging of resources from partners such as GFATM Round 5 TB grants for Quarterly meetings at the state and Zonal levels to collate analyze and provide feed back.

Contributions to Overall Program Area: The COP 2010 activities will contribute to the goals of the Government of Nigeria towards reaching the Stop TB targets, MDG targets and the Emergency Plan targets of providing HIV care. By linking TB and HIV services, this activity contributes to the Federal Governments strategy to have DOTS clinics and ART sites in the same facility or close by with a very strong referral mechanism. This activity also offers both TB and HIV patients a longer life free of the morbidity and mortality caused by TB and HIV interactions, thus allowing dually infected patients to contribute positively to the economic development of the country thereby contributing to the poverty alleviation Programme of the Government.

Contribution to health system strengthening: Planned activities supported with COP 2010 will contribute to strengthening quality of services provided at health facilities and capacity of service providers in providing such services. The support for facilities to implement appropriate TB-IC measures will be used as an entry point for strengthening other necessary general infection control measures for other conditions. The COP 2010 is also supporting procurement of equipments such as Microscopes which can be leverage in the facility for diagnosis of other disease conditions such as malaria.

Links to other USG resources and /or other donor support: This activity is linked to ART, palliative care and community based care and support services which are funded with PEPFAR funds through other implementers. This activity is also linked to ART services supported with the Round 5 GFATM HIV/AIDS grants. This activity will also leverage nutritional support in areas where organizations such as MTN foundation are providing such support. This activity is also linked to the strategic direction of the National TB and Leprosy Control Program (NTBLCP).

The planned activities for COP 2010 by WHO are linked to the goal of reducing the burden of TB/MDR- TB and HIV among dually affected populations and the three objectives of the National TB/HIV strategic framework for implementation of TB/HIV collaborative activities which are: ? Establishing and strengthening mechanisms for coordination at all levels. ? Reducing the burden of TB/MDR-TB in HIV patients and ? Reducing the burden of HIV among TB/MDR-TB patients.

Emphasis are also place on the issue of TB infection control measures while scaling up services to prevent transmission of TB and MDR-TB and also on enhancing linkage of MDR-TB/HIV co-infected patients to second line anti-TB drugs.

The WHO/TB CAP will use COP 2010 to support the Federal Ministry of health (NTBLCP and NASCP) in the following key intervention areas in addition to ensuring continuous support for existing activities instituted with COP06 - COP 09 through WHO and TB CAP: 1. Strengthen capacity at National, State, LGA and facility levels to effectively coordinate and manage TB/HIV collaborative activities 2. Scaling up implementation of patients centered TB/HIV collaborative activities and ensuring continuous support for the existing centers in 23 states.

3. Strengthen MDR TB Control and Management.

The implementation of these key intervention areas will be in line with the existing National strategic framework for TB/HIV collaborative activities and will be guided by the following principles: ? National/State ownership and leadership of the strategies: ? Partnership and collaboration with communities and other stakeholders at all stages of Programme development and implementation to increase acceptability of interventions, expand access to services, and broker additional human resources for Programme implementation. ? Equitable access to patients centered TB/HIV/AIDS interventions.

The Key activities that will be supported by this grant are discussed below under each strategic intervention:

1. Strengthen capacity at National, State and LGA levels to effectively coordinate and manage TB/HIV collaborative activities.

The FMOH and SMOH were supported with funds from COP 06 - 09 through TB CAP/WHO in establishing and ensuring functionality of TB/HIV working groups at National level and in 23 states (Ogun, Osun, Ondo, Ekiti, Adamawa, Bayelsa, Taraba, Niger, Nassarawa, Plateau, Kogi, Benue, Kwara, A-Ibom, Rivers, Enugu, Ebonyi, Imo, Abia, Sokoto, Katsina, Kebbi, Zamfara). This groups among other achievements, has help in strengthen coordination of partners involved in the implementation of TB/HIV collaborative activities at National and state level. The COP 08 and 09 grants was also used in collaboration with Scientifico di Tradate, Italy to develop the skills of the national facilitators from NTBLCP and NASCP in building capacity for TB/HIV management and leadership in Nigeria. The COP 010 will be used to support the following activities under this strategic intervention:

? Quarterly meetings of the National TB/HIV working group. ? Quarterly meetings of State TB/HIV working groups in 23 states (Ogun, Osun, Ondo, Ekiti, Adamawa, Bayelsa, Taraba, Niger, Nassarawa, Plateau, Kogi, Benue, Kwara, A-Ibom, Rivers, Enugu, Ebonyi, Imo and Abia). ? Formation and monthly meetings of facility based TB/HIV coordinating committees. ? Capacity building for State TBL Control Officers, State TBL supervisors and State HIV/AIDS Programme Managers from 12 states on TB/HIV Leadership and management using the existing pool of facilitators. ? Capacity building for 2 newly recruited programme staffs each from NTBLCP and NASCP on TB/HIV leadership and management using the existing pool of facilitators.

2. Scale up of patient centered TB/HIV collaborative activities to 42 additional DOTS centers in 21 LGAs and ensuring continuous support for the existing centers in 23 states.

There are 2,742 DOTS centers as at end of 2008, about 18% (500) of which are currently providing TB/HIV services, the COP 010 will be used to support FMOH in scaling up services to 42 additional DOTS centers from 21 LGAs in 7 states (from the 23 supported states) in line with the NTBLCP & NASCP scale up plan and in close collaboration with the International Federation of anti-Leprosy Associations (ILEP) members and other collaborative partners. The goal of this activity is to increase access to TB/HIV services in the 23 states currently receiving support from FMOH with PEPFAR grants through WHO in the implementation of TB/HIV collaborative activities while maintaining activities in the existing centers. The COP 2010 will be used to support the following activities under this strategic intervention

? Selection of 42 DOTS facilities to provide HCT services for TB suspects and patients from 21 LGAs ? Training 84 GHWs (2 GHWs per facility from 42 facilities) on provision of health care provider initiated testing and counseling for TB suspects and patients. The workers at the end of this training will have the capacity to recommend HCT to all TB suspects and patients, diagnose HIV in TB suspects, treat HIV positive persons with active TB, provide CPT and referral to ART clinics and care and support services. The national HCT training curriculum will be used for CT training. ? Selection of 42 AFB laboratory staff from identified 21 AFB microscopy centers. ? Training of 42 AFB laboratory staff (2 Lab staff per lab from 21 laboratories in 21 LGAs) will be trained on how to carry out HIV testing in line with the national HIV testing algorithm and provide supervision back up for GHWs involved in multi point HCT service deliveries at DOTS centers. The national strategy for HIV counseling and testing that will be implemented in these sites adopts a total and comprehensive approach to client management. ? Production and dissemination of IEC materials to raise awareness about the availability of the TB/HIV services in the facilities and communities to increase service utilization. ? Re-orientation of State TBL Programme managers and the SAPC from 23 states on provision, monitoring and supervision of TB/HIV collaborative activities. This will enhance quality of services provided, improve supportive supervision and quality of data generated and reported by states. ? Quarterly joint monitoring and supervision of TBHIV activities at all levels, in collaboration with the FMOH, joint monitoring and supervision will be conducted from all levels ? Monthly supervision by LGAs supervisors of TB/HIV activities at facility level. ? Revision, printing and dissemination of national TBHIV reporting and recording forms to strengthen collection, collation and analysis of required data and indicators thus ensuring quality programme tracking of progress towards the set targets, objectives and goal. ? Leveraging/procurement of Cotrimoxazole for CPT among PLWHAs at DOTS centers.

? Leveraging/procurement of HIV test kits for rapid HIV testing of TB suspects and patients in line with National algorithm. ? Procurement of consumables for HIV testing ? Support salaries of WHO-TB-CAP staff at National level to provide technical assistance to national, state and local government in mentoring, supervision and monitoring of TB/HIV collaborative activities. ? Support participation of National, State and WHO/TB CAP staff at international conferences and ? Piloting of Patient centered TB/HIV services in 12 LGAs in 6 states for effective roll out of 6months RH containing regiment.

3. Strengthen control and Management of MDR TB Provision of effective management of MDR-TB and MDR-TB/HIV is one of the key challenges to National TB and HIV programmes efforts at reaching the set National and global targets including the MDG. In order to address this challenge, the WHO/TB CAP with COP09 grant supported the review, finalization and printing of SOPs, Guidelines and operational plans for management and control of MDR TB in Nigeria. The APA4 was used also to support renovation of MDR TB wards in 2 referral hospitals while renovations of other wards are also been supported by other partners. The APA 5 funds will also be supporting the training of personnel from MDR-TB treatment centers on effective MDR-TB Management and continue functioning of the National MDR-TB committee. The availability of second line anti TB drugs in the National programme for use at these MDR-TB treatment facilities is still a major gap; the WHO in collaboration with other partners supported the FMOH in securing an approval for the procurement of 2nd line anti-TB drugs from GLC. COP 2010 will therefore be used in filling this gap by supporting effective Logistic management system for second line anti-TB drugs. The standard regimen currently approved by the National guidelines (6 Km-Cs-Lev-Pto-Z/18 Lev-Cs-Pto-Z) entails treatment of MDR-TB for 24 months, the first 6 months of which patents will be in the hospital, resources will be leverage from FMOH and partners to provide social support for MDR-TB patients. The COP 2010 will therefore be used to support the following activities:

? Quantitative assessment of drug requirements, management of procurement, distribution, assurance of drug quality and ensuring rational drug use of second line drugs in-country. ? Setting up an inventory management system to ensure a safety stock and optimal stock movement, and to provide an accurate source of information for drug demand forecasting ? Provision of Air-conditions to ensure appropriate storage of second line drugs as some of the second line drugs may require to be preserved at ambient or controlled temperature (25°C, air conditioned room) or in Refrigerator. ? Training of pharmacists and pharmacy technicians from MDR-TB treatment facilities on pharmacy best practice for second line drugs. ? Production of laminated drug charts for second line anti-TB drugs.

? Production of laminated charts on adverse effects of MDR-TB/ARVs co-treatment and their management.

4. Strengthen implementation of TB Infection control Measures. The practice of appropriate TB Infection control (TB-IC) measures is key to reducing the burden of TB and MDR-TB among PLWHAs. Studies of recent have shown that nosocomial transmission of TB and MDR-TB is on the increase especially in congregate settings such as HIV service delivery centers where good infection control measures are not observed, the result of this has been fatal in some societies often resulting to a more severe Extremely Resistance TB(XDR-TB). The implementation of good TB-IC measures is becoming more important in view of the emerging threat of MDR-TB even among PLWHAs and the increasing burden (rates of morbidity and mortality) of TB/MDR-TB among co-infected patients in Nigeria. WHO in collaboration with other implementing partners will support the FMOH to scale up implementation of appropriate TB infection control measures in health facilities especially those with ARVs and TB services. The TB-IC will be used as an entry point for strengthening other infection control measures in the facility. The activities to be supported include:

? Dissemination of the national guidelines and SOPs on TB infection control. ? Organize Training of National (National focal person for TB-IC), State, WHO/TB CAP and other partners' staff from TB and HIV/AIDS control Programme on TB infection control. ? Conduct of Facility assessment in 12 sites with ART/HIV and DOTS services. ? Development of Infection control plan in 12 health facilities with ART and DOTS services ? Capacity building for facility staff from the 12 Health facilities on TB Infection control measures and the developed plan. ? Support formation and regular meetings of TB-IC committees in the 12 health facilities. ? Basic renovation and upgrading at the health facilities (OPD, AFB laboratories, DOTS centers) to conform to good TB-IC measures. ? Procurement of 10 Binocular Olympus microscopes to enhance diagnosis of TB among PLWHAs. ? Quarterly Supervision and monitoring of TB/Infection control activities. This will be integrated into the existing supervisory structures. TB-IC IEC materials (e.g. on cough hygiene will be developed).