In FY12, URC will enhance efforts to transition responsibility of HIV services to the states MOH and empower officials to take over supervision of health care workers and monitoring of services in collaboration with other partners. In addition, we will encourage state governments to increase their financial contribution in line with the partnership framework by procuring laboratory reagents and supplies to augment the PEPFAR funded supply. These efforts will extend to the LGA who are responsible for PHCs. Consistent with the national decentralization agenda, HACCI will build HCW capacity in PHCs to provide PMTCT services according to the new guidelines, provide ARV refills for patients initiated on ART in the hubs, and manage simple OIs and side effects of ARVs. The project will also initiate IPT for PLHIV in whom active TB has been excluded. HIV education, PITC for TB patients, and cotrimoxazole preventive therapy for co-infected patients will be integrated into services at DOTS centers. All service points will intensify efforts to screen for TB and refer suspected cases for diagnosis and treatment. HACCI will continue to implement comprehensive HIV services and work closely with government counterparts to improve health worker supervision, extend referral systems and enhance program monitoring to improve enrollment, retention, and clinical outcomes. Community volunteers mobilize and educate community members about HIV, create demand for services, help reduce stigma and promote ownership. We will increase volunteer linkages with community structures and health facilities to enable them to be sustainable HIV champions. Finally, we will work with the Enugu and Ebonyi MOH to develop strategies and approaches to integrate HIV services with general health care services.

In FY 12, HACCI will provide care and support services aimed at optimizing the quality of life for HIV-infected clients through the provision of comprehensive services including clinical care including medical needs assessment and provision of necessary interventions; psychological support services including counseling and disclosure support; prevention services including behavioural risk assessment and the promotion of ABC messages and measures; social support services such as alcohol and substance abuse assessment and counseling; improvement of food security by conducting nutritional assessment and counselling as well as provision of supplements; and general health support services including health education at both the household and community levels. HACCI will conduct trainings and refresher trainings for 35 HCWs in order to build and maintain their capacity to provide quality care and support services. In addition, HACCI staff will provide regular site mentorship visits to promote and entrench best practices. Client retention will be achieved by utilizing empowered support group members and home based care volunteers through weekly monitoring and review of clients clinic attendance, the follow-up of identified instances of missed appointments and referal of clients through telecommunication, bi-directional referral forms and tracking. Periodic clinical audits will be carried out to monitor the quality of care. We will strengthen linkages between supported facilities and tertiary hospitals providing HIV care and treatment services to improve access for patients requiring specialist services. We will continue to facilitate the formation of PLHIV support groups as an avenue to provide psychosocial and other support to PLHIV and their families. Select members of support groups will be mentored to serve as adherence counsellors and expert patients to help educate and support newly diagnosed patients enroll and stay on treatment. To facilitate sustainability and ownership HACCI will conduct quarterly joint monitoring and supervisory visits with the state Ministry of Health officials to build their capacity to autonomously carry out such supervision after the completion of the project.

The goal of the project in its last activity year is to enable the Enugu State Government and target communities to continue to provide needed services to OVC and their families. Since the beginning of the OVC program in 2009, the project has used a rights-based approach to equally serve 125 male and female OVC aged 0-17 years in Awgu, Aniniri and Oji River LGA of Enugu State. The project has an excellent working relationship with the OVC focal person in the Enugu State Ministry of Women Affairs. We also work very closely with the social welfare officers of Awgu, Aninri and Oji River Local Government Areas. HACCI also has strong relationships with the MOH and MOE and has been working together with these ministries in support of the OVCs currently enrolled in our program. These strong relationships with government counterparts will facilitate the transition towards the State and communities overseeing the care of targeted OVC. The project will further its efforts to build the capacity of the government counterparts as well as the communities and caregivers to provide OVC care and support. The project will continue to aid communities to establish and strengthen systems to support OVC. The HACCI-trained OVC community volunteers will continue to receive coaching from project staff to reinforce what was originally learned during training sessions. These volunteers were selected in consultation with their communities leaders and contribute to the sense of ownership of the program as the HACCI project comes to a close. The child protection committees formed during COP11 will continue to raise awareness about OVC needs, monitor abuse and provide protection for all OVCs in the communities in a sustainable manner. The project will continue to build the economic capacity of caregivers to provide for the needs of their children; retaining them in school, and working with local governments and community to establish strong child welfare and protection systems. HACCI will build upon linkages established between the communities and the facilities through the community volunteers and a strengthened referral system. HACCI will continue to strengthen the relationship between OVC volunteers/caregivers and PHCs to ensure OVC receive needed child survival health care services. PHC staff will continue adolescent programs for infected and affected children. The project will ensure OVC receive HCT services and if found positive, be enrolled in HIV care, support and treatment.

In FY 12, HACCI will further our partnership with the Enugu and Ebonyi state MOH to strengthen collaboration between TB and HIV at the state, LGA and health facility levels to ensure that all TB patients have access to HIV services and PLHIV have access to TB diagnostic and treatment services. At facilities, co-location of services will occur where possible and safe; where co-location is not possible or unsafe, the project will strengthen linkages between HIV and TB DOTS clinics. HIV education, PITC for TB patients, and cotrimoxazole preventive therapy for co-infected patients will be integrated into services provided by DOTS clinics. All persons evaluated for TB at the supported TB clinics will receive HCT services as part of routine care. At HCT, Pre-ART and ART clinics, all PLHIV will be routinely screened for TB using a screening questionnaire at every clinical encounter. This will facilitate early identification and treatment of TB cases. Clients with positive TB screens will be linked to diagnostic services for AFB microscopy. Smear negative cases will be referred to radiology to ensure that PLHIV with TB are not missed during clinical evaluations. Diagnosed TB patients will be treated according to the national guidelines. IPT will be provided to PLHIV in whom active TB has been excluded and TB infection control measures will be strengthened. HACCI will reinforce initial training of facility medical officers on IPT and the diagnosis of sputum smear negative TB with regular mentorship. Emphasis will be on administrative and environmental control measures as well as the appropriate use of personal protective equipment. To facilitate community level ownership, HACCI will train existing community volunteers to promote TB sensitization and case detection. Volunteers will speak to family members during home visits and to group gatherings about TB. They will educate them about the symptoms and encourage them to go to TB DOTS clinics for evaluation when they present symptoms. Where feasible, volunteers will escort suspected TB cases to clinics for evaluation. The project will strengthen referral networks by motivating support group members to accompany new clients and ensure completion of the referral process.

In FY12, HACCI will support the GON to increase enrollment in pediatric services to close gaps in coverage. We will work with CHAI and other partners to link our PMTCT sites to the national EID network to facilitate early diagnosis of HIV infected children. The project will strengthen linkages between PMTCT sites and care and support sites ensure children diagnosed through EID are promptly enrolled in care and treatment. We will also work with members of adult support groups to test their children for HIV and enroll those who test positive. To promote integration with routine pediatric care, nutrition services and MCH services, we will use provider-initiated HCT targeting of children in pediatric wards, child welfare and under 5 clinics to identify and enroll HIV positive children. We will strengthen referral linkages between child welfare clinics, labor wards, postnatal clinics and comprehensive sites to ensure children identified at these points of service are enrolled in care and support services. HACCI will further support the creation and maintenance of childrens play/support groups at PHCs. Cotrimoxazole prophylaxis will be provided according to national guidelines and children will also be linked to OVC services based on need. Another aspect of the pediatric care and support program is to conduct community outreach programs in markets and schools to sensitize, test, and enroll HIV positive adolescents. HACCI will continue to address ongoing prevention needs for all clients including assistance with disclosure, counseling for intimate partners of sexually active adolescents, ongoing risk reduction counseling, provision of condoms, and lifestyle counseling and STI screening for sexually-active adolescents. For all those who are enrolled in pediatric care and support services, we will provide a need-based package of services including clinical care, basic care kits, preventive services and psychosocial support. Clinical care will include OI prophylaxis and management, growth monitoring and immunization, assessment and management of pain and other symptoms, and nutritional assessment and treatment. PWP is a key component of care and support and will be continued.

HACCI will intensify efforts to transfer the five fully-equipped laboratories in the comprehensive sites to the responsibility of the Enugu and Enonyi MOH. We will encourage the state to take over increasing responsibility for lab services and be actively involved in the maintenance of equipment and forecasting of lab reagents. The goal of the HLAB program is to achieve accreditation of the supported labs by the end of the project. Project staff will continue to work with the Enugu and Ebonyi Ministries of Health and the laboratory scientists/technologists in charge of supported laboratories to institutionalize an internal improvement process, which addresses gaps in requirements and maintains accreditation standards. This process will ensure all the supported laboratories have all necessary documentation, perform annual and semi-annual laboratory audits, continue to participate in proficiency testing for CD4 count and TB microscopy, advocate directly with the SMOH to hire and post more laboratory scientists/technologists to the laboratories, and work with the management of the respective hospitals and the chief laboratory scientists/technologist to ensure the laboratory space meets minimum requirements. Trained laboratory scientists, working with the HACCI-supported laboratories, will continue to receive on-site training and mentoring to ensure they acquire the required confidence and independence to continue services in the absence of HACCI project staff at the end of the project. The project will reinforce the supervisory capacity of chief laboratory scientists to take over the mentorship of lab staff. Regular evaluation of lab technicians on their technical skills and achievement of minimum standard knowledge necessary to perform analysis using the provided equipment platform will help chief laboratory scientists to determine training needs. The project will also analyze and strengthen the system of sending blood samples from stand alone PMTCT sites and PHCs providing ARV refills to be analyzed in the comprehensive sites and then promptly sent back to the facilities to ensure sustainability of the system.

In FY 12, HACCI will continue its efforts to increase facility-level reporting through the national system. Specifically, the project will support health care workers to better document the services they render using national data tools. HACCI subscribes to the three ones principle and is using the GONs M&E platform: the District Health Management Information System (DHIS). Furthermore, HACCI will continue to place the GONs National HIV Strategic Plan at the centre of its SI efforts. HACCI will also work with the MOH in Enugu and Ebonyi states to strengthen the reporting system from the health facilities to the LGAs and then to the state MOH in line with the national HMIS system. The Enugu MOH has been using the national platform and the DHIS since 2006 through the support of the DFID-funded PATHS project. HACCI bought into the existing system and is working with the MOH to strengthen it. HACCI recognizes the need to maintain an accurate database of patients receiving HIV care and treatment services in Nigeria and will support the implementation of a web-based national data system that will uniquely identify clients by category of services provided. HACCI will actively participate in the planning and implementation of this database. All patients receiving care in HACCI-supported facilites will be given unique ID numbers, and their information will be fed into the national database. Over the past 4 years, HACCI organized bimonthly M&E meetings, to which health facility staff, MOH officials, the state AIDS control agency and other partners were invited. The meetings were used to collate data, review results, discuss achievements, challenges, etc. In the final year of project, HACCI will continue to support the SI lead implementing partner to organize these meetings as another step toward eventually transitioning responsibility for organizing and coordinating meetings to the MOH. HACCI technical staff will continue to collaborate with state and national officials to conduct at a minimum quarterly DQA or field monitoring visits. These visits will serve to improve data quality, improve staff capacity and further prepare government to lead SI efforts by the end of the project.

In FY12, HACCI will provide HCT in Enugu and Ebonyi states, which will target most at-risk individuals, couples, pregnant women and the general population in line with GON goals and aspirations. This will be done through provider-initiated testing and counseling that will be geared towards normalizing HIV testing. Provider testing and counseling will be carried out in supported health facilities in HCT sites and DOTs centers. It will target inpatient and other sick clients seeking non-HIV related services who often yield higher positivity rates. Outreach/mobile HCT will target high-risk populations including brothel and non-brothel based commercial sex workers, long distance drivers and MSMs while the family-centered approach will target the family members of HIV-positive clients. In addition, we will continue to promote client-initiated HCT through intensive community mobilization including participation in community gatherings such as womens and mens associations and cultural festivals. We will leverage GON resources to integrate HCT into routine health care services by working with government facilities to implement strategies to provide HCT to all their clients as a routine service. As HACCI plans for transfer of responsibilities to the GON, we will work with the MOH and LGAs to supervise and support referral focal persons in sites and other HCT service delivery points to correctly refer, track, and follow up with clients to ensure they enroll in care or treatment services. Referrals will be documented in the referral register to facilitate monitoring of the effectiveness of the system. Finally, we will work with government counterparts to ensure they are prepared to provide quality HCT services through regular supportive supervision and monitoring of the quality of counseling to ensure services are provided in accordance with national guidelines and SOPs. Quality control measures include tracking records on available test kits, batch numbers and expiry dates; periodic inclusion of previously characterized samples or dry tube specimen (DTS); and use of proficiency testing using Panels for HIV proficiency from South Africa.

In FY12, HACCI will continue to utilize the hub and spoke model of service delivery in all seven health districts in Enugu state and southern zone of Ebonyi state. The comprehensive sites, which provide adult and pediatric care and treatment as well as laboratory monitoring services, form the hubs and the primary cares sites form the spokes. Each hub will serve 3-5 spokes, thus allowing for better access to PMTCT services for pregnant women in rural areas. This effort will be expanded in FY12 to achieve better coverage and to improve access to PMTCT services for rural communities. We will intensify our community mobilization efforts to ensure that communities know about PMTCT, appreciate its importance and utilize PMTCT services. HACCI-trained and supported community volunteers will mobilize the population for PMTCT uptake, promote couples counseling and male involvement in PMTCT. We will work with community leaders and organizations so that every pregnant woman and her spouse know their HIV status and access appropriate services before delivery. We will collaborate with TBAs in targeted communities to facilitate access to PMTCT services for their clients. We will continue to train and mentor health care workers at secondary and primary health care facilities to provide PMTCT services according to their level of care and in line with the national task shifting and decentralization agendas, including supporting adequately staffed PHCs to provide ARV refills. We will do this in close collaboration with responsible officers in the MOH and the LGA Health Departments to promote transfer of skills and responsibilities in the areas of supervision, routine data collection, and monitoring service quality.

HACCI will continue to promote the integration and strengthening of PMTCT with MCH and RH services, which will serve as an entry point to other HIV services for women, their children, and increasingly, for male partners. HACCI also recognizes that minimizing unintended pregnancies is crucial to effectively eliminate new pediatric infections and will expand its effort to support the availability of FP services. We will work with the MOH and health facility management to co-locate or link PMTCT and FP services.As part of our strategy to increase the uptake of HTC at antenatal clinics in supported PMTCT facilities, we shall defray/absorb antenatal booking/registration fees for all pregnant women. In addition, we shall ensure that communities served by the health facilities are adequately informed of this benefit/privilege through local media outlets and strategically placed IEC materials.

In FY 12, URC will to serve adults and children with antiretroviral (ARV) drugs including those with advanced HIV infection, HIV infected pregnant women for PMTCT and rape victims. In line with the national ART guidelines and the national goal of streamlining the number of regimens, HACCI will procure AZT/3TC/NVP and TDF/FTC/NVP both as fixed dose combinations and as single drugs for use as first line drugs. Patients that fail will be switched to the second line of either TDF/3TC+LPV/r for clients on Zidovudine-based first line and AZT/3TC/LPV/r for clients that had tenofovir-based first line. We will also purchase TDF/3TC/EFV, TDF/FTC/EFV as well as ABC for PMTCT. These drugs will be purchased through the pooled procurement from SCMS. HACCI has participated in pooled procurement through SCMS since the beginning of the project, which has helped ensure regular availability of antiretroviral drugs. We will also continue to leverage adult second line and pediatric first and second line drugs from the Clinton Health Access Initiative (CHAI). The project will further support the national ARV program in procurement strategic planning by participating actively in national quantification exercises. We will share our lessons with the national program to help guide decisions in changes to ART guidelines. Finally, HACCI will reinforce its work with the MOH and LGAs to raise the performance levels of health care workers and deliver sustainable improvements in the management and technical skills of procurement practitioners and managers in Nigeria. At the site level, URC will work with clinicians, nurses, pharmacists and pharmacy technicians to document adverse drug reactions and report instances to the NAFDAC. We will monitor this data with the national program, which will also aide decision making related to changes in the ART guidelines.

In FY12, working closely with the MOH, HACCI will continue to work in 7 health facilities located in the underserved areas of Enugu and Ebonyi states to consolidate the progress made in the provision of comprehensive HIV services. HACCI will further strengthen the referral systems to promote access to TB treatment and other needed services. The project will continue to build the capacity of health care workers employed in supported health facilities in the correct use of ARVs in line with current national guidelines. Health care workers previously trained will be mentored and closely supervised to ensure they deliver high-quality services and improve their skills. Health care workers in selected PHCs will continue to be mentored to provide ARV refills, adherence counseling, management of minor side effects and OIs. To improve retention on ART and quality of care, HACCI will engage MOH counterparts to utilize the gap analysis framework which uses performance measurement data to identify and address deficiencies in program quality. The project also employs the chronic care model to increase and maintain high-level adherence and retention to reduce the risk of resistance and improve well being. Patients will be encouraged to use family and trusted relatives to improve adherence and the patient support base. HACCI will continue to use support group members and expert patients to strengthen adherence counseling in both facilities and communities. Adherence counseling is closely linked to treatment initiation and maintenance with initial, one month and six month counseling sessions. Close links will also be formed with HBC providers to maintain adherence within the home setting. We will maintain the mentoring of health workers and MOH counterparts to perform clinical audits and use clinical notes from patients visits and pharmacy records to measure performance and clinical outcomes. The gap analysis framework will then be used to improve coverage, retention in care and clinical outcomes. To promote sustainability and ownership, HACCI will carry out quarterly joint supervisory visits of ART services with the state ministries of health.

In FY12, HACCI will continue the provision of ART services in 7 comprehensive health facilities in Enugu and Ebonyi states to children with advanced HIV infection. HACCI along with government counterparts will continue to closely mentor health facility staff to ensure that quality services are provided for children. We will work with the MOH and LGAs to ensure that all supported sites increase early identification of children living with HIV/AIDS and improve referrals within and between health facilities to help prevent loss to follow-up. We will work to link PLHIV diagnosed in standalone HCT, PMTCT, TB/HIV service delivery points and under 5 clinics to care and treatment services. We will strengthen referral linkages between PMTCT sites and ART clinics to ensure that HIV positive infants identified through EID are enrolled early on treatment. We will also ensure that all supported sites are linked to the national EID network. To increase pediatric enrollment and scale up ART services coverage, new and existing PLHIV in adult care and treatment as well as support group members will be encouraged to bring their children to HCT sites for counseling and testing. Positive children identified from this effort will also be linked to care and treatment. Baseline investigations including CD4%, chemistry and hematology tests will be performed on all enrolled HIV-infected children before commencement of ART. To improve the quality of treatment, HACCI will utilize the gap analysis framework to reveal and address gaps in program quality and the chronic care model to increase and sustain progress in adherence and retention. HACCI will work with facility-based referral focal persons and other health care workers providing HCT to ensure identified HIV positive children are enrolled and receive care and treatment services. Referral linkages will also be strengthened between HBC providers, OVC programs, other GON and community child welfare services and the health facilities to ensure that clients receive all necessary wraparound services. Lastly, we will work with health facility staff and the MOH to promote integration of pediatric ART with MCH services.