In July 2008, Partners for Development (PFD) won the Counseling, Care and Antiretroviral Mentoring Project (CAMP) in Nigeria. The goal of CAMP is to provide a comprehensive package of care for People Living with HIV/AIDS (PLHIV) including Adult and Pediatric Care and Treatment, Antiretroviral Treatment (ART), Care for Orphans and Vulnerable Children (OVC), Prevention of Mother to Child Transmission (PMTCT), and HIV Testing and Counseling (HTC). A year after implementing CAMP in Niger Delta states of Akwa Ibom and Delta, CDC approved PFDs expantion to satellite sites for PMTCT, HTC and OVC in Bauchi and Benue states. In these states, PFD works through local community organizations and Primary Health Care (PHC) facilities. Delta and Akwa Ibom states each have a comprehensive care site: Assumption Clinic, in Warri, Delta state, and St. Josephs Center, in Ukana Iba, Akwa Ibom state. Both comprehensive sites provide outreach support to PHC facilities, particularly in for HCT and PMTCT. The comprehensive sites provide lab services, ART, and care and support to HIV positive clients. In the two Delta region comprehensive sites, a combined PFD and Daughters of Charity (DoC) team work to mobilize community support and volunteers to carry out home-based care, prevention and OVC services. In the Benue and Bauchi sites, PFD works with community-based womens organizations (Women in Nigeria, WIN and Women Empowerment Initiative of Nigeria, WEIN, respectively) to support HCT and PMTCT provision through PHCs. The same womens organizations mobilize and train volunteers to provide OVC and prevention services. The project will continue to build the economic capacity of caregivers to provide for the needs of their children and working with local govt & community for child protectio

PFD will provide a package of quality, facility and home/community-based sustainable HBC services, including clinical, psychological, spiritual, social, and prevention reaching 1,453 PLHIVs/PABAs while building the capacity of partners to ensure quality treatment and care. The capacity of facility/community-health staff will be built to ensure provision of a minimum HBC package of services to PLHIV and PABA, including BCKs. In-service training for clinical staff will focus on ART using the national guideline for standard package of care and management of OIs (cotrim provision) and STIs. HTC will be expanded, particularly for family members of PMTCT clients. Client satisfaction surveys will be introduced for QI. Provision of BCKs, nutrition supplements and transport reimbursement will encourage PLHIV enrollment and retention in care and treatment sites.

In summary, the strategy to identify HIV-infected persons early, refer for pre-ART, and retain them for quality continuum of care all the way through end-of-life involves:Improving awareness of the need for quality care and support through PE community outreach, PLWHA visits, and other prevention messaging, particularly as part of PwP.Expanding facility/community-based HCT to screen and enroll HIV positive persons for pre-ART preparation, including couples and families of HIV positive persons.Building capacity of health care workers is improved through appropriate training and support in facility, community as well as home-based care settings in accordance with task shifting strategies for volunteers.Improved referral linkages between facility, community (PHC to hospitals and back), and HBC programs to reinforce quality of care and support as well as integration of services with broader health services, including cervical cancer screening. Also, refer for non-HIV specific services such as IGA, FP/RH and PLHIV support groups.Reliable supplies of critical commodities such as BCKs are available at facilities and through community health workers.EID to catch infants early and follow through using a mother/child tracking system for defaulters, same day appointments, home visits to minimize LTFU and maximize adherence.

PFD will during the FY 12, mobilize and train CBOs, caregivers and volunteers to provide direct services to 2,002 OVC through priority family strengthening approaches that reinforce families long-term caring capacities as the basis of a sustainable response to children affected by HIV/AIDS. The aim is to boost household economic and food security, improve access to health care and schooling as well as encourage healthy parent-child relationship through key child protection interventions revolving around early childhood development, prevention for OVC, economic strengthening, and exit strategies for OVCs turning 18 and establishing linkages/networks. 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. PFD will empower CBOs as direct OVC service providers while exploring public-private partnerships. CBOs will mobilize community response through child protection committees at LGAs using household/community-focused, evidence-based, needs-driven and age/gender sensitive approach. Best practices will be shared with these committees/communities to ensure compliance with the FMWASD National Guidelines. CBOs will be trained to improve their organizational and technical capacity to engage and support social service systems established by GoN to create vital safety net for OVC. Community leaders and GoN will be engaged in negotiations involving EBG support to schools where OVC are enrolled.

Besides using Sesame Workshop model and materials for Kids Club activities, CAMP will explore use of Save the Children model for protection services and Christian Aid model for facilitation of Life Skills development. To create buy-in and support for OVC, CAMP will invite community leaders to meetings organized for CBOs, caregivers and volunteers. In addition to business skills training and linkage of caregivers and older OVC to microfinance services, PFD will consolidate community-led savings and loans activities for provision of credit to interested caregivers and volunteers. CBOs will be trained/mentored on data collection and reporting on OVC activities using National OVC M&E Data Collection and Reporting Tools. Monthly reports of activities will be sent to Department of Child Development and FMWASD. PFD maintains membership with AONN in respective states.

During FY 12, PFD will build capacity of state TB Control Program to integrate/provide quality TB/HIV co-infection services to 150 clients and establish a referral network between DOTS supervisors in the state DOTS centers so that HCT screening and linking clients for TB/HIV co-infection management services can be extended. Given the close interaction between HIV and TB, PFD will scale-up TB control programs in high burden and prevalence states of Delta and AKS to strengthen TB/HIV services in accordance with national strategy. In Delta state, PFD will work to improve services at government owned Eku TB Referral Hospital by scaling HCT and ART services for TB suspects and patients. In AKS, PFD will work with the State TBL Manager at the Comprehensive Treatment Centre where TB screening and diagnosis in PLHIVs will be intensified. The centre will recruit a TB microscopist who will take over the functions currently being undertaken by a TB DOTS Supervisor who visits the centre only to administer the drugs to eligible patients. MoUs have been signed to formalize collaboration between the State TB Control Program and PFD covering expansion of services to public facilities.

Key activities include: Capacity building for TB microscopist, strengthening lab services for accreditation, training on HCT for 5 DOTS supervisors in the LGA and strengthening referral networks between state DOTS Centers and SJRC as well as ensuring effective mentoring from the State TBL Manager. CAMP will provide logistic support for the quarterly TB/HIV review meetings at the centre to help generate quality data using the national TB and HIV M&E framework and tools to track progress towards stated targets.The STBLCP supplies TB DOTS drugs (CPT/IPT) to the patients with co-infection. Patients on DOTS will be closely followed, for both clinical management of the co-infection, and for early detection of multi-resistant TB (MDR) and referred through community health workers. PFDs work will improve infrastructure for TB diagnosis, renovate TB facility, install necessary equipment for diagnosing and treating TB, train facility staff on TB treatment protocols, provide treatment services and train DOTS supervisors as HCT Counselors.

In FY 12, a package of care and support will be provided to 71 HIV exposed infants/children at facilities, homes as well as communities through facility and community-based staff as well as caregivers and PLHIV support groups to ensure adherence to drug regimens, preventive prophylaxis, palliative care, immunization, nutritional as well as growth and developmental support. The aim is to optimize quality of life for HIV exposed clients and their families. In the case of adolescents with HIV, services will include youth-friendly counseling on PwP, enrollment with support groups, and assistance with transitioning into adult HIV services. Routine pediatric care will be integrated with MNCH, prevention and treatment of OIs and other HIV-related complications, including malaria and TB treatment, diarrhea control through access to cotramoxazole, safe water, pain relief and nutritional assessment and support. EID will be scaled in conjunction with existing testing services such as PMTCT, family members of those on adult pre-ART or ART care and treatment, GOPD or other child-centered integrated services.

HIV positive children will receive care and support at both facility and home/community, using leaders of PLHIV support groups, health care workers, volunteers or caregivers. Each of these cadres will be trained and mentored to deliver appropriate clinical care and support services to children. Children enrolled for care will be followed up and monitored closely by these service providers. BCKs and clinical care and two or more other supportive services will be provided. To maintain higher retainer-ship by those involved in care and support services for HIV positive children, CAMP will provide economic empowerment that will enhance the nutrition, logistics. PFD program officers and adherence counselors will work with community volunteers to improve retention in care using defaulter tracking system. Caregivers will be tasked with monitoring patients in their homes regularly, including supervision to ensure improved quality of care. CHW will conduct monthly rounds to visit children with HIV/AIDS and offer support to their caregivers. This will be tracked and reported on with patients disaggregated by gender.

In FY 12, PFD will ensure continued delivery of quality lab services at all sites in compliance with national/international standards, including purchase of equipment and commodities, and provision of quality assurance, staff training and other technical assistance. To ensure continuous delivery of quality lab services and compliance to national/international accreditation standards. PFD will work with CDC/Nigeria Lab Lead and collaborate with other PEPFAR IPs to provide refresher training to lab personnel at Assumption Clinic and Maternity, and Saint Josephs Rehabilitation Center in Delta and Akwa-Ibom and satellite sites. The refresher training will focus on routine diagnosis and monitoring of clients, and QA, particularly on improving the proficiency levels in HIV Serology, automated CD4+ estimation and blood chemistry analysis; application of safety measures, use of PPE, proper waste disposal; proper documentation, including use of worksheets, logbooks, temperature charts and corrective action forms; pipetting skills, blood collection techniques, sample transportation, reception, storage Inventory management of stock and lab reagents and procedures for OI testing (STI).

A system will be instituted for quick blood sample collection from satellite sites and easily transported to hub labs for analysis. PFDs Lab Scientist will organize quarterly review meeting for lab personnel in CAMP supported comprehensive and satellite sites and use this forum for information exchange and ensuring compliance to national standards. PFD will maintain on-going service and maintenance contracts with laboratory equipment and reagents suppliers to ensure functional equipment and quality reagent supply which are critical. PFD has engaged SLAMTA to conduct an assessment and upgrade labs in the two sites in preparation for national accreditation. One more additional laboratory is being proposed for preparation, making a total of 3 laboratories accreditation preparedness and presentation for national accreditation/ international accreditation.

PFD will generate quality data and information by introducing robust monitoring and evaluation system which will facilitate ease of data collection, storage, retrieval, analysis and utilization at each service delivery point in harmony with PEPFAR and GoN national indicators.

Further, CAMP will continue data generation and information sharing with sub partners, SACA, NASCP and other stakeholders through the USG monthly and quarterly DCT reporting. To maintain quality and sustainability at quality data collection at new sites, relevant program guidelines, registers, forms and report formats will be introduced for easy and accurate data generation. CAMPs M&E team lead will also provide training on New Generation and National Indicators (NGI) and on use of the new DCT spreadsheet to M&E personnel at each service delivery point. This will help roll-out and harmonize consistency and accuracy of data collection and use. PFD will continue to support efforts aimed at joint data verification and quality assurance with GON and work in line with GON policies and guidance to support Partnership Framework Implementation Plan (PFIP). This will mean phased transition of reporting on the paper-based excel format into the National reporting DHIS Platform. First, PFD will adopt the use of DHIS software at its Abuja country office before training and introducing the same at the service delivery points. This more integrated and robust monitoring and evaluation system will facilitate ease of collection, storage, retrieval, analysis and utilization of real time data and information for HIV/AIDS service delivery. This will enhance national capacity to undertake the same activities on their own when the project ends.

PFD will deliver comprehensive prevention interventions targeting 6,341 beneficiaries through trained volunteer PEs as well as CBOs using combination of evidence-based approaches that integrate behavioral, biomedical and structural interventions to address HIV drivers. The minimum prevention package interventions use PEs to conduct activities in accordance with National HIV/AIDS Prevention Plan 2010 2012 targeting in-and-out-of school youths, particularly young adult men and women ages 18-30 who engage in concurrent partnerships to promote abstinence, delay of sexual debut, fidelity, reducing multiple partners in Bauchi, Benue, Akwa-Ibom and Delta States. With supportive supervision, prevention activities will be delivered though innovative community outreach, population awareness, school-based, and vulnerability issues-based interventions.

PFDs prevention team will organize periodic community outreaches at cluster sites for sexual prevention messaging, including HTC; train 30 PEs to reach peer groups using PE Plus model training manuals, focusing on gender dynamics -- women PEs to reach girls/women vulnerable to sexual abuse, violence and coercion; conduct PE sessions in schools and MARP communities at least thrice a month via groups of 10-25 persons reached with evidence-based 3 minimum interventions; organize influence groups to facilitate quarterly meetings that create enabling environment for behavior change and maintenance; form and strengthen HIV/AIDS Clubs as safety nets for behavior change maintenance and link to biomedical services such as HTC, condom messaging and distribution; carry out weekly program supportive supervision and quarterly M&E meetings with specific target groups to assess program approach, both in partners offices and at intervention sites and use Prevention Intervention Tracking Tools (PITT v6.1.3) for QI - Comprehensive Prevention Intervention Data Entry sheet to track persons reached, strategies used and method to generate results based on 3 minimum intervention which addresses AB and COP.8) Promote sustainability via integration/transition of resources to GoN at all levels.

PFD will expand integrated HTC and other prevention services to reach 21,479 clients through PITC or client initiated approaches in a range of facility and community-based settings. The selection of HTC sites will be guided by knowledge of prevalence of HIV. Adopting the test-to-treat strategy, PFD will scale-up PITC for all patients accessing health services (ANC, TB clinics, out-patients) at all points of services. Mobile HTC for high HIV prevalence communities and sub-populations and home-based HTC for partners of families of PLHIV or TB will be conducted following the index patient model. CAMP will also generate demand for HCT through community outreach using sentinel surveys showing higher HIV prevalence rates among subpopulations/MARPs, including uniformed men and women, female sex workers, truck drivers/okada riders, and MSM. PFD will coordinate with SMoH for RTKs and consumables.

Private medical facilities will be supplied with RTK for routine screening on patients reporting for consultation. Clients will receive results the same day with appropriate counseling for those who test negative, positive or are in window period. Those tested positive in out-reach or facilities will be referred to treatment sites for enrollment into care and support services with encouragement on partner notification and CT. Discordant couples will receive prevention education on minimizing risk of infecting partner using condoms. Capacity of health workers, including lab personnel will be improved to cope with increased workload and to ensure testing meets minimum standards. Forty counselors and testers will be trained on HTC/CHCT using national training manual. The latest guidelines on rapid testing algorithm, retesting, and QA/QC protocols will be emphasized. Proficiency testing will be conducted for testers to evaluate performance using approved tools/techniques. M&E tools, including data collection and analysis, will be introduced to monitor progress incorporating couples HTC and other new PEPFAR recommended indicators. Pre-printed logbooks and registers will be used to record test results and lot numbers.

PFD will apply evidence-based interventions to avert new infections reaching 3,852 MARPs and general population in FY 12 with integrated HTC and condom services as well as refer to increase access to prevention as part of care and treatment, blood screening, infection control, PEP, and STI management in clinics for maximum impact on HIV incidence. MARPs, including alcohol users, at risk youth, mobile/migrant workers, truck drivers, the military and sex workers will be reached through trained PEs and CBOs with prioritized integrated behavioral, biomedical and structural interventions to address HIV drivers in accordance with National HIV/AIDS Prevention Plan. A sustainable BC strategy utilizing appropriate mix of interventions will be used to increase knowledge leading to adoption of safer sexual and RH practices among MARPs and general populations. Messages will be tailored towards BC based on needs and values of the groups. MARPs and general populations will be provided with opt-out HTC services and condoms at designated outlets.

CAMP will integrate prevention as part of care and treatment in facility and community-based settings in line with GHI principle; and promote positive health dignity and prevention. In clinics, 100% of transfusion-bound blood samples will be screened. In communities, COP program officers will utilize activities from at least three intervention prongs to reach individuals/groups using behaviors considered as drivers of HIV infections. These approaches include periodic community outreach, awareness campaigns, PE targeting MARPs, workplace interventions, referrals for STI management, and vulnerability issues interventions.For QI, the program will continue using PITT v 6.1.3 tools - Comprehensive Prevention Intervention Data Entry sheet to track persons reached, strategies used and results based on three minimum interventions addressing AB and COP. M & E tools include attendance sheets, activity reports, and IEC/condom distribution forms. The Make We Talk participatory M&E templates will be adopted to assess level of KAP of specific targets to help assess the level of BC, ensure QI, and alert on emerging issues.

PFD will expand/improve the quality of PMTCT services by building capacity of facilities to decentralize, integrate, scale-up, link as well as coordinate with GoN to reach 8,613 pregnant women and their eligible infants with sustainable PMTCT services. The strategy will include the activation of 16 new public/private PHC facilities and building staff capacity to integrate PMTCT into ANC services to maximize enrollment in line with GoN policy and knowledge of HIV prevalence; Linking new facilities and treatment sites to enroll and manage exposed infants via referrals; Supporting EID at facilities via PICT (out-out) for children, couples and families; Ensuring training manuals, guidelines, SOPs and M&E tools are shared and used; Strengthen links/referrals between ANC and comprehensive sites to increase HTC - send samples for CD4 count tests; Refreshing ANC staff on PMTCT, infant feeding/counseling, FP couseling, prophylaxis for mothers and newborns and EID; Adopting best practices in integration of MNCH/PMTCT interventions at PHCs covering a range of prevention, care and treatment services. These include clinical staging, treatment of acute OIs, using more effective ARV regimens, access to CD4 testing, enhanced prevention messages, retention and adherence of mother-infant pair, and palliative care and Intensifying HTC using PITC/opt-out model at the facilities while mobilizing the community to create demand, improve male involvement and couple TC.

PFDs approach will also facilitate coordination between State/LGAs for co-supervision, mentoring, and sharing work-plans; integration with MNCH, FP counseling, malaria diagnosis and treatment, TB co-infection management as well as other illnesses, particularly for HIV positive mothers and infants; support for logistics to ensure and provide test kits to avoid stakeouts of consumables; accurate data generation, reporting and feedback through M&E tools and materials to monitor progress and building mechanisms into PMTCT program to encourage long term retention, minimize LTFU and improve adherence via information systems strengthening at community-outreach/referral and facility levels.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.

PFD will ensure continued supply and access to HIV commodities by creating a functional as well as effective pooled supply chain management system whereby resources from major stakeholders (GF, GoN, PEPFAR, UNITAID/CHAI) are leveraged to ensure a continuous availability of the needed commodities. With the current treatment guidelines, the cut off level to commence treatment for adult/adolescent is a CD4 count of 350 or less. This has increased the number of those who need ARV drugs. It is therefore expected that with PHLWA education, strengthened support groups, expansion of access to PMTCT and EID program, the demand for ARV and OI drugs will increase. ARV and OI medicine supplies to the two sites shall be closely monitored through the monthly reporting tools, which PFDs Logistics officer reviews regularly and gives feedback to the site pharmacists. Drug and commodity wastage will be kept to a minimum through inter-site and inter IP commodity exchange. CAMP has also established relationship with SACA of respective states to benefit from ARV, RTK and OI drug distributions, exchanges and trainings. PFDs adult first line ARV supply will continue to be through SCMS; adult second line and pediatric ARV is being leveraged from the Clinton Foundation; while OI drugs will be procured directly by PFD and distributed to sites but also leveraged from NASCP or SASCP of respective states whenever available.

PFD supports GoN in planning and procurement by participating in national quantification exercises. This year, PFD experienced one stock out for Niverapine suspension due to change in the national ART guidelines which increased consumption of the drug. To ensure no stock outs in FY 12, PFD will participate in the forthcoming PEPFAR Nigeria COP 12 ARV and cotrimoxazole quantification process. PFD will also closely monitor its stock and place timely orders using the Supply Chain Manager Pipeline and Quantized Software. Lastly, PFD will make sure pharmacists/logistics officers in all supported sites are trained to efficiently order for commodities based on need estimates.

PFD will scale-up treatment activities focusing on access and quality in line with GoNs decentralization plan reaching 866 clients with integrated ART that improves treatment outcomes as well as enrollment in community care and support services. Interventions will target high burden/prevalence communities (MARPs), unmet needs, and early detection and treatment, particularly of children and women.

An experienced Clinical Advisor (CA) will ensure provision of in-service, harmonized training to facility clinicians, particularly at the newly decentralized PHCs. The CA will make periodic onsite supervision as well as record review to ensure quality of treatment services. Each facility will use recording/tracking tools to evaluate clinical outcomes which will be reviewed by the CA on a monthly basis to improve quality of clinical outcomes. Patients on treatment will be linked to community/home-based services and referral systems through CHEWs to help monitor adherence to drug regimens, pharmacovigilence as well as retention in program. Patients will be tracked through these same cost-effective mechanisms for provision of comprehensive care and treatment package, including cotrimoxazole prophylaxis, PwP, viral load monitoring and TB screening. A pooled procurement system will be used for drugs and commodities.Finally, PFDs strategy is to support GoN to implement relevant packages of priority, integrated adult treatment interventions and ensure adequate staffing at PHCs; coordinate with GoN-managed facilities to expand ART, PMTCT, HTC, HIV/TB and EID services to rural and MARP communities in accordance with GoN and international guidelines and SOPs; work with GoN and all other stakeholders to ensure the availability of drug supplies and lab commodities at PHCs; support GoN in training and monitoring of PHC staff to institutionalize QA and M&E at PHCs thereby ensuring consistent/accurate data collection using GoN tools and materials (registers, cards, and forms), data of which should feed into national reporting system and hold monthly meeting with State/LGA and facility health authorities for better coordination and address challenges pertaining to decentralization.

In FY 12, PFD will build the capacity of ART clinicians in facilities on pediatric ART management using GoN guidelines thereby establishing and strengthening linkages between hubs/satellites and treatment sites to reach 70 children with quality and sustainable EID interventions as well as link them to other OVC services.Through facilities, every exposed child will be offered DNA PCR test from 6 weeks to determine their HIV status. This is the entry point. HIV positive infants/children will be enrolled in care and monitored until they are qualified for ARV. Other children seen during routine clinic outlets with high index of suspicion will also be screened for HIV. ARV and cotrimoxizole prophylaxis will be provided as necessary for pre-ART enrolled positive infants and children.

PFDs strategies will entail working with facilities to integrate pediatric HIV services by setting specific targets and resources to finance and train those engaged in service delivery; maximize opportunities for identification of exposed/infected infants/children at multiple entry points, including HTC via PITC of sick children in facilities and communities, MCH/ANC units, PMTCT, HBC/OVC programs on a referral basis;conduct joint training of health care workers with state health authorities in pediatric HIV/AIDS care and treatment and utilize CHEWs for follow-up of exposed infants after home delivery linking them for virologic HIV testing at 6 weeks and early antibody testing between 9-12 months of age; shift towards family-centered approach in PMTCT and EID service provision. An integrated approach will not only help prevent HIV infection in the infant, but also increase survival of the mother through treatment and improve overall family health. PMTCT will be the entry point into comprehensive family-focused services for women, their exposed infants and HIV infected family and household members and keep records of children for proper follow-up on clinic appointments and for HBC. CHEWs will be trained on adherence counseling which is reinforced at every clinic visit to mothers or caregivers of children. Caregivers, volunteers and PLHIV will be trained to carry out follow-up, care and support services.