In COP 10 URC will continue to consolidate the gains made in COP 09. Enugu state ,with a prevalence rate of 5.8% is 12th overall in Nigeria and 1st in the states in the South East geopolitical zone(source: NHSS: 2008), is the recognized capital of the South East, remains an important commercial, cultural and transport hub.

Within the state there continue to be pockets of higher incidence both geographically and within most at risk populations. Achi joint in Oji River has a prevalence of 12.7% according to antenatal sentinel surveillance and is one of our key intervention regions. URC recognizes the shift in PEPFAR II from an emergency response to one of consolidating gains and building local capacity. Capacity building will focus on the community health facility, local government and the State. To this end we will continue to favour a more targeted approach that maximizes the effective and efficient use of resources. This will primarily be achieved by keying into the priority response areas as articulated by the Federal Government of Nigeria's National Strategic plan and raising the profile and enhancing the coordinating function of the State AIDS Control Agency, State MOH and Local government's primary health care programme.

URC in COP 10 will continue to implement comprehensive HIV services for the prevention of the transmission of HIV from mother to child (PMTCT), HIV testing and counselling (HTC), Adult care and support, Paediatric care and support, TB/HIV integration, Adult treatment, Paediatric treatment, ARV drugs, Orphans and Vulnerable Child (OVC), Laboratory infrastructure support and Strategic information. URC will also seek to provide support to the strengthening of the health system in Enugu and to undertake work to help in efforts to combat HIV stigma and discrimination and ensure meaningful involvement of people living with HIV. Added impetus will be focused on increasing TB and HIV collaborative activities, in recognition of the twin epidemics Complementarity in terms of morbidity and mortality with closer working with the TB programme cognizant officers in the state to improving case detection, diagnosis and infection control initiatives.

Further, we note the fundamental need to continue to provide the correct mix of HIV prevention, care and support services. Long term, new infections will need to reversed and halted and this will be achieved by continued provision of preventative services. Every opportunity will be utilized to promote prevention messages for both HIV positive and negative in all URC-supported facilities and activities, using evidence-driven approaches and working in partnership with the State and other actors.

URC recognizes the importance of ensuring that all services provided as part of its comprehensive community centred approach are of the highest quality. This begins with the strengthening of the supervisory functions of the State mechanisms and adhering to nationally and PEPFAR approved quality improvement and assurance strategies. Weaknesses within the health system have further contributed to the challenges in the provision of quality services. URC will support health system strengthening initiatives including strengthening the supply chain, enhancing strategic information, adoption of national and state policies and partnering with other organizations in addressing health workers shortages, address stigma, gender, policy implementation and health sector financing.

With the shift to consolidation, ownership of services by the community will acquire increasing importance. To promote improved community participation and demand for services, URC will work to augment the interaction between health facility staff and local leaders and community structures.

Overall we will continue to enhance the established linkages between PEPFAR programme areas within and between health facilities. We will seek to leverage resources with other initiatives like the President's initiative on Malaria (PMI), Global fund, UNICEF's Safe motherhood and child programmes, the DFID funded PATHS II project all of which have a presence within the state. In addition we will seek to enhance collaboration with reproductive health, family planning, nutrition, water and sanitation programmes.

URC is committed to ensuring that support provided will be sustainable in the long term. We will concentrate our focus on increasing state led initiatives and advocate for increased funding to the health sector with emphasis on health worker retention, strategic information, supply chain strengthening, infrastructure capital investments, capacity building, pre-service training of health workers, adherence to national and state policies and a right-based approach in service provision. URC will work with PEPFAR and non-PEPFAR partners to leverage resources prevent duplication and create cross functional synergies to better enhance not only HIV services but improvement in the entire health system.

In COP 10, URC will continue to harness the power of our partnership with the State, the local government and the community. We will contribute to the HIV response by targeting all our interventions and consolidating service delivery. We will improve the continuum of services from prevention to treatment and support and target those most at risk. We will work to keep those on comprehensive services adherent to therapy, seek to shift focus towards local and state ownership through capacity building, synergize our activities and leverage resources with other partners and continually look to strengthen the overall health system. Capacity building will form the cornerstone of our approach with strong emphasis on community ownership, continuous improvement and contribution to the overall HIV response.

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ACTIVITY DESCRIPTION

CONTINUING ACTIVITY

In COP 10, URC will continue to provide care and support services to 260 HIV positive paediatric clients. We will continue to work in coordination with the state government of Enugu, the health commissioner and ENSACA, the primary HIV/AIDS program implementing agency in Enugu to provide services in 5 of the 7 health districts in the State.

We will consolidate our support to HIV care and support services. URC will continue to assist facilities to strengthen the referral system including internal and external referral linkages in order to promote access and continuum of care of enrolled PLWHA through regularly scheduled meetings between the referral focal persons of supported facilities and other implementing agencies and the state and Local Government AIDS coordinator. Not all service providers/ facilities will be able to offer care and support within their facilities. In such cases, URC will work with the State Department of Health to develop referral linkages to ensure that clients have easy access to services. We will train 20 individuals to provide care and support, including community workers and PLWHA to provide home-based care and support services for people living with HIV/AIDS.

Paediatric care and support services will the family centred and child friendly. As far as possible services will be co-located with maternal and child and immunization services that target children. Referral linkages will be greatly strengthened. All clinicians will be closely mentored to build confidence in the management of paediatric HIV. Parents and or caregivers will remain as important partners in ensuring adherence to clinic appointments and all medication. Early infant diagnosis of HIV is one of the main entry points to care and support, linkages to EID programmes and our PMTCT programme will be enhanced and continually promoted. Our PMTCT and Paediatrics Advisor will as far as possible seek to co-locate our PMTCT and paediatric services. We will create stronger links with immunization services, child health, nutritional programmes and child welfare and OVC services.

URC will address the shortcomings of supported health facilities in Enugu through on site mentorship and training of health workers and community extension workers. We will seek to support and increase the supportive supervision role of the local and state government technical officers in care and support. We will provide care services including clinical care, distribution of basic care kits, psychological, spiritual, social, preventive services, and home-based care. Clinical care will include basic nursing and end-of-life care, management of pain and other symptoms, nutritional assessment and intervention, OI prophylaxis and management, and non-Art laboratory services. All enrolled clients will receive a basic care kit which includes ITN, water vessel, water guard and ORS, latex gloves, IEC materials, condom, and soap. The minimum care package includes the basic care kit with clinical care, plus two supportive services of those listed above.

Cotrimoxazole prophylaxis will be provided to all paediatric patients and close attention will be paid to all clients to assess for sulphur allergies. URC will help with the integration of nutrition support into the care and support programme. This support will include nutritional assessment using growth monitoring charts. To achieve this, all paediatric clients will have their height and weight measured and recorded. Further all clients that qualify will have nutrition support by prescription through the provision of high energy macro and micronutrients. URC will strengthen referral linkages to nutritional support programmes and will collaborate with these programmes by providing gap support for nutritional supplements. Patient nutrition education and counselling will also form a major part of the support provided. URC will support clinicians at facility level to stage and manage patients according to national standards including determination of the appropriate time to commence ART. These will be achieved through training and on site mentorship support.

URC will work with its partner Vision Africa to support home based care activities. Through this collaboration current and volunteer providers will be accessed and trained on the provision of appropriate support within the home. This will include identification of cases for referral, psychosocial support, patient education, basic first aid and adherence support according to the nationally accepted guidelines. We will provide increased clinic-based and home/community-based activities to adults or adolescent HIV-positive individuals through the training of healthcare workers, PLWHA and community workers in adherence counselling, management of opportunistic infections, diagnosis and relief of symptoms, psychological and spiritual support, clinical monitoring, related laboratory services and delivery of other palliative care services to the community including culturally appropriate end-of-life care as per Nigeria's National Palliative Care Standards and Guidelines.

All enrolled clients will have an initial CD4 and 6 monthly CD4 monitoring to ensure that those eligible for ART after their initial assessment commence therapy on time. Laboratory services for the diagnosis of opportunistic infections will be provided for both PLWHA on ART and those not on ART. URC will work to ensure that commodity support for drugs and laboratories will support roll out and scale up of care and treatment services. Adherence counselling will be closely linked to treatment initiation and maintenance with initial, one month and six monthly counselling sessions. Close links will also be formed with home based care providers to maintain adherence within the home setting. Client and family centred approaches will be used. Defaulter registers will be maintained in the health facilities and used to track defaulters and those lost to follow up. Facility based community meetings with community gate keepers will be held to help improve community treatment literacy. As part of improving and increasing the effectiveness of care and support, URC will work together with other PEPFAR partners to support the proposed development of a national policy on task shifting. This programme, under the leadership of the Government of Nigeria, aims to shift non essential and routine follow up of clients from MDs to nurses ( for ongoing follow up of stable clients on ART) and from nurses to counsellors( for adherence counselling and support.)

URC will train 10 health care workers on site, using the national curriculums for paediatric palliative care. This training will be supplemented by on site close support mentoring to ensure proper skills transfer and usage. Local trainer of trainers will be capacitated to provide this training. In addition URC recognizes the work and role of the current implementing partners in Enugu and will use their current expertise to prevent the duplication and wastage of training and other implementation resources.

The ongoing monitoring of the programme as implemented will play a critical role in improvement initiative. The use of data, the application of quality improvement initiatives including the plan, do, study, act cycle, standard setting and tracking, best practice sites with intentional spread and collaboration is the signature hallmark of URC programmes. URC will strengthen the national data capture and reporting systems at site level. In addition on-site data collected will be analyzed and used for process and programme improvement. This support will be provided by URC's technical team in collaboration with site staff to increase sustainability and ownership.

URC recognizes the importance of ensuring uninterrupted supply of drugs, laboratory and allied commodities and will work together with its partner Crown Agents, through the Federal Government and PEPAR supported central supply systems. This support will supplement the national commodity supply. Locally sourced and USFDA/PEPFAR approved commodity will be procured through this mechanism.

CONTRIBUTIONS TO OVERALL PROGRAM

Training and support to improve the quality and integration of care and support services are consistent with FMOH and PEPFAR priorities and are permanently linked with the capacity of the health system overall, other HIV/AIDS program area capacities and the community. URC will hold workshops to promote sharing of knowledge and best practices in all HIV-related services which will allow rapid and effective spread of good practices throughout Enugu State. Our care and support program will build on our partner, Vision Africa's network in Enugu which is affiliated with dozens of FBOs, CBOs and CSOs in Enugu State, including Enugu State's branches of The Network of People Living with HIV/AIDS in Nigeria (NEPWHAN) to train community workers and PLWHAs in the delivery of home-based care services. Additionally, our work in this area will also involve training and new reporting on performance indicators as specified by PEPFAR. This activity in the region will strengthen all reporting, accountability of facilities and data collection in all areas of the health sector in Enugu State. URC will also focus part of its programming on improvement of referral systems to improve the coordination between lower and higher level public healthcare facilities as well as between the public and private sector. This will be accomplished through the scheduling of regular meetings with the primary care coordinator for each relevant LGA in Enugu, the state, private and NGO-supported facilities to jointly develop indicators that are followed so that weak areas among these facilities can be addressed.

EMPHASIS AREAS

The emphasis areas for this program activity are:

1. Linkages with other paediatric supportive services including immunization, nutritional and integrated management of child hood illnesses.

2. Capacity Building of agencies, organizations and health facilities responsible for delivery of HIV interventions

3. Collaboration and coordination to improve referral systems and availability of services

4. Community outreach and involvement as described above.

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ACTIVITY DESCRIPTION

CONTINUING ACTIVITY

In COP 09, URC will provide PMTCT services to 3,000 women in Enugu State through work at 18 sites. This will be implemented in coordination with the government of Enugu and the state SASCP. In COP 10 URC will support and strengthen PMTCT services in all 18 sites to ensure that clients have easy access to PMTCT services. URC will help set up and improve linkages between comprehensive ART sites in secondary and tertiary facilities and primary and secondary facilities attending to pregnant women in Enugu state. Following the national PMTCT guidelines, the hub and spoke model will be utilized. The comprehensive sites will form the hub and the primary cares sites will be the spokes. This will allow for increased access to diagnostic and monitoring tests for PMTCT. Stand alone PMTCT points of service at the primary care level will be liked to adult and paediatric care as part of a comprehensive PMTCT network.

At URC supported PMTCT service points 3,000 pregnant client will be provided opt-out provider initiated HIV testing, counselling and results. URC will train 20 Health care workers to provide PMTCT services using current national training manuals. HIV positive pregnant women identified in facilities without CD4 machine will be linked to those with the facility for CD4 testing and further management. The prevention for positives package will be utilized in all sites. This will provide an opportunity to interrupt heterosexual transmission, especially in discordant couples. HIV testing and counselling will be provided during routine antenatal and during labour and delivery for unbooked cases by facility supported staff.

URC will support facilities to provide highly active antiretroviral therapy (HAART) to pregnant women if their CD4 is less than 350 in accordance with the National PMTCT guidelines. For the women not requiring HAART, the current national guidelines recommended short course ARV option will be provided which includes ZDV from 28 weeks, ZDV/3TC from 34-36weeks and intra-partum NVP, and a 7 day ZDV/3TC post-partum tail. This will result in the provision of ARV prophylaxis to 186 pregnant women. All HIV+ women will be linked post-partum to an HIV/ARV point of service, which will utilize a family centred care delivery model whenever feasible, co-locating adult and paediatric care and providing a linkage to family planning services this approach will involve providing the services at the points most appropriate and convenient including maternal and child services.

URC will ensure that all HIV+ pregnant women gain access to the basic care package of insecticide treated nets, water vessels, water guard and soap. URC will support the training of 20 health workers on infant feeding using the National Infant feeding training manual. HIV+ women will be counselled on infant feeding practices pre and post natally. The options will include early cessation of breast feeding, exclusive breastfeeding with abrupt weaning and replacement feeding if acceptable, affordable, available, safe and feasible. Couple counselling will help support and sustain the infant feeding choices. Mothers will be linked to peer support groups within the community.

HIV Exposed Infants will be provided with single dose NVP at birth and ZDV for 6 weeks in accordance with Nigerian National PMTCT Guidelines. Cotrimoxazole suspension for all exposed infants will also be provided from 6 weeks until definitive HIV diagnosis. Testing of infants will be carried out using dried blood spot (DBS) specimen collection. We will actively participate in the national early infant diagnosis initiative by providing infant for DBS testing from 6weeks of age.

All capacity development undertaken by URC for its PMTCT programme will adhere to nationally approved training curriculum and will utilize the existing trainer of trainers (TOT) manual in Enugu to support the training and retraining of 20 health workers on PMTCT across all sites.

URC notes the importance of ensuring post partum follow up for completion of prophylaxis, early infant diagnosis, Cotrimoxazole prophylaxis and referral of mothers for ongoing care, support and treatment if indicated. URC with its partners Vision Africa will work with community health workers to prevent loss to follow up outside the health facility. Within the health facility, URC will encourage the formation of multidisciplinary teams to adapt national referral procedures and to oversee programme implementation and improvement. URC will ensure the use of the national PMTCT registers across all supported sites and work to strengthen data collection and transmission and encourage the use of this data at site level to improve implementation.

The PMTCT programme will work closely with the care and support programme to ensure no mothers are lost to follow up. Particular attention will be paid to community linkages through community health workers as many women obtain most of their pre and post partum support care from them. These workers will be trained and supported to improve referrals to hospitals for antenatal care and to help track and refer clients for delivery. URC's partner Vision Africa will continue its work, supported by URC, in this area.

POPULATIONS BEING TARGETED

This activity targets pregnant women who will be offered HCT, HIV+ pregnant women for ARV prophylaxis and infant feeding counselling, and exposed infants for prophylaxis and EID.

KEY LEGISLATIVE ISSUES ADDRESSED

This activity addresses Gender since treatment will be provided to women and will focus on family centric issues including male involvement in PMTCT programming.

EMPHASIS AREAS

Major emphasis of this activity focuses on training and network/linkages. Minor emphasis includes other sectors and initiatives, commodity procurement, and community mobilization/participation.

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

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