MSH ProACT project is designed to develop the leadership and management capacity of health managers and facility teams to improve organizational management and operational systems and to strengthen the capacity of health workers, state institutions and organizations to manage integrated HIV/AIDS programs and deliver quality HIV/AIDS care and support services in communities. Since 2007 the MSH ProACT project has rapidly and systematically scaled up the availability and accessibility of HIV/AIDS services in 25 sites across six states (Kogi, Niger, Kebbi, Taraba, Adamawa, Kwara) in Nigeria through a process of partnership and capacity building with indigenous public institutions providing health services at primary and secondary health facilities. In COP12 MSH will continue to support a minimum of 25 sites in six states to provide the full spectrum of HIV prevention, care and treatment services and will continue to work to strengthen the capacity of state and local governments to carry out evidence-based strategic and operational planning/budgeting, and advocate for resources needed to sustain their programs. MSH will also continue to support the establishment of TWGs, state supervisory teams for M&E, quality assurance and will assist the state and local governments to use M&E and other strategic information to develop plans that will guide the buy in by Implementing Partners and other donor agencies. Through fixed small grants, MSH will continue to develop the capacity of partner CSOs to deliver community-based TB/HIV services linked with health facilities. The project will continue to build the economic capacity of caregivers to provide for the needs of their children, and working with local governments and community to establish child welfare and protection systems.

ProACT implements the following care and support services which may be facility or community based: prevention and treatment of OIs and complications, nutrition assessment, counseling and support; adherence support, provision of commodities such as OI drugs and laboratory reagents, ITNs and water guard. Psychosocial care is provided during individual or group counseling and linking clients to facility or community-based support groups, and income generation activities Services are delivered in 25 Comprehensive Care and Treatment sites and communities in Adamawa, Taraba, Kwara, Kogi, Niger and Kebbi states.

In COP11 MSH ProACT built the capacity of facility multidisciplinary teams, CBOs and volunteers to provide comprehensive adult HIV care and support integrated with other health services through a family centered approach. It leveraged resources from local and state government to provide additional support like medication, laboratory reagents and consumables.

In the next 2 years it intends to scale up services to new sites and communities in high prevalence areas in the presently supported states. People living with AIDS will be empowered in a cell support group structure and linked to savings and loan associations for economic empowerment. Community institutions will be strengthened to own and provide sustainable care to PLA

To attain optimal client retention, the project will strengthen adherence to care and treatment for ART and Pre ART clients across supported facilities through capacity building for health workers and community volunteers, strengthened intra-facility linkages and empowerment of CBOS to facilitate community-facility linkages with appropriate feedback, and facilitate default tracking of clients. It will continue to empower clients to be responsible for their health by supporting them to build self-esteem via appropriate deployment of patient education materials and linking them to IGA.

The project will increase its Inter-Implementing partners networking and collaboration with community members to leverage other essential wrap-around services.

Data for monitoring PEPFAR specific indicators will come from ProACT internal monthly reporting system and data collected at the facility level using FMOH standard tools.

MSH ProACTs OVC program is aimed at improving the quality of lives of OVC and in COP12, will work to ensure continued access to basic education, broader health care services, targeted food and nutrition support, child protection and legal aid, economic strengthening and training of caregivers. To enhance household economic status in COP11, ProACT facilitated the formation of 10 Savings and Loan Associations (SLA) through PLHIV support groups in two focus states and also supported the initiation of community driven food bank as a strategy to improve food security for OVC and their caregivers. In COP12 ProACT will scale up SLA and food bank activities to additional sites and will strengthen existing partnerships and linkages with the Federal and State Ministries of Women affairs and Social development, Millennium Development Goal programs, National Program for Food Security, FADAMA II/World Bank Projects, National Population Commission and community based organizations to ensure comprehensive care for the OVC and their care givers. 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. ProACT will continue to strengthen existing kids club activities and for OVC who attain the age of 18years, ProACT will leverage on the HIV prevention peer education program to strengthen their life skills and link them to youth friendly reproductive health services, economic empowerment programs such as National Directorate of Employment-Graduate Assistance Program, Unilever Women Empowerment program.

To contribute to the national and state OVC response efforts, ProACT will work to develop leadership and management skills of the OVC Coordinating unit in the State Ministry of Womens Affairs. This support will include strengthening organizational and program management capacity to efficiently and effectively address OVC issues in a manner that ensures sustainability. ProACT will also work through partner CBOs to strengthen LGA child protection committees and will continue to build the capacity of CBOs/community volunteers to provide OVC services using the Orphans and Vulnerable tool (OVI) to determine level of vulnerability and Child Status Index (CSI) to assess OVC needs and provide or refer to necessary services appropriate to HIV status and age.

MSH PROACT TB HIV activity is implemented through 3 broad strategies-Strengthening capacity of people to better lead and manage TB/HIV programs (MSH LDP),Strengthening capacity for integrated TB/HIV service-delivery and building a trusted partnership with state governments and other TB partners for an effective and coordinated response.

In COP11 the project supported 25 CCT sites in strengthening TB HIV collaboration; health workers were trained in TB/HIV collaboration, TB DOTS, PITC and TB DOTs operators participated in the MSH PEPFAR Health Fellowship Program. It task shifted clinical screening of PLWHAs for TB and set up functional PITC points at all DOTS units and these resulted in increased TB HIV case detection and treatment. TB infection control was piloted in 4 out of 25 supported facilities.

In COP12 it will support 4 additional high burden sites to strengthen TBHIV service delivery. There will be, ongoing TA to the state TB programme to strengthen TB commodity SCMS, Training and refresher training for health care workers on TB/HIV, HCT and TB microscopy, capacity building of CTBC teams for increased case detection and adherence in the community. TA will also seek to address gender disparities in access to services. It will roll out site specific TB infection control in the remaining sites, Strengthen collaboration with NTBLCP on the management of MDR TB and ensure implementation and pilot implementation of IPT in 2 supported sites and subsequently roll out to other sites.

In COP11 it supported training of 12 microscopist in TB microscopy and 3 TB EQA focal persons and performed excellently in the TB proficiency testing with 97% in Q1.It will train additional microscopist and Set up 4 model TB labs at high volume sites with deployment of fluorescence microscopy and other equipments in COP12.

TB HIV TWG was reactivated in 5 out of 6 supported states and it participated actively in state led joint supervisory visits. In COP12, the TB/HIV coordination platforms will continue to be strengthened across all supported states; using the MSH LDP, will build the capacity of key stakeholders in the State in leadership, strategic planning and coordination of TB HIV activities.

In COP 11, Pro-ACT supported pediatric care and support in 25 facilities linked to the other feeder sites. The program witnessed increasing knowledge and awareness of the need to provide services to children evidenced by the data available. Efforts bordered around developing the EID grid for supported facilities using the hub and spoke model. In partnership with the sites alternative means were instituted to improve turnaround time for DBS samples from the reference labs.The HIV exposed infant services and HIV positive support services have been emphasized during mentoring visits. Pediatric focal persons were identified to strengthen care. The mother baby pair appointment system has also helped to keep adherence and reduce cost of accessing care by the clients.

In COP 12, increase access to pediatric enrollment will be given priority using innovative approaches that are sustainable. ProACT will also strengthen Integration of care into existing points of service such as immunization clinics child welfare clinics and Family Planning Units. The package of care will be expanded to ensure that all children receive cotrimoxazole preventive therapy, immunization, documented growth monitoring, infant feeding counselling and nutritional support. Pro-ACT will build capacity of health care worker and CBOS to use local resources like Kwash pap to improve nutritional needs of infants. Referral services will also be available to link mothers to food banks in the community. Pro-ACT will partner with the SMOH and HMB to provide growth monitoring charts for paediatric clinics that currently do not have.

System for Retaining clients in care will be strengthened by retraining data clerks and volunteers in the documentation and use of tracer cards and client defaulter tracking registers. Community support groups will also be strengthened to help identify and track defaulters back to care.

To improve case detection turnaround time for EID sample will be reduced by installing SMS in more facilities and improving on systems for repeat EID.

Paediatric Quality assessment tools will be updated and will form part of the facilitys continuous quality improvement (CQI) process using trained facility staff.

In COP11, LMS focused on strengthening Quality Management Systems, and instituting contracts for equipment maintenance services. In support of Kogi State government effort to expand access to quality diagnostic services, ProACT embarked on infrastructure improvement in 3 secondary health facilities while the SMoH provided 3 sets of lab diagnostic equipment for ART monitoring. In COP 12, ProACT will maintain all existing service contracts with equipment vendors and embark on evaluation of cost-effective lab technologies to replace those that have attained their salvage values. ProACT will work with the SMoH in 3 States to identify secondary health facilities in underserved populations for Laboratory infrastructure development to shore up her treatment targets.

In COP 11, ProACT supported the SMoH to constitute the State Laboratory Quality Management Task team with overall responsibility to institute Quality management systems and lab accreditation preparedness. In COP 12, ProACT will build on this effort to encourage and support registration and accreditation of public laboratories by SMoH through MLSCN in 3 States. ProACT will scale up quality management systems in other states not included in its pilots scheme in COP11 and expand its current external quality assessment scheme to other laboratory networks.

ProACT will in COP 12 support FMoH to constitute a technical advisory team to drive the strategic development of laboratory. FMoH will be supported to conduct population based reference ranges lab parameters in Nigeria. Integration of HIV Lab services will be piloted with consideration for both physical and management integration. Capacity of Laboratory Scientists will be built using the Leadership Development Program (LDP). Trained Lab managers will be supported to access grants directly from donors to scale up services and increase ownership and sustainability.

Strategic engagement with the private sector working with the Association of Medical Laboratory Scientists of Nigeria (AMLSN) and the Guild of Private Medical Laboratory Directors to identify private Medical Laboratory outfit for support to expand the delivery of quality laboratory services and increase ownership .

In COP12 MSH ProACT will sustain efforts aimed at transitioning the reporting of output and achievements of program level results from 56 existing secondary and primary sites in six focus states to the state government. Continued joint program monitoring visits will allow for tracking of results; analysis of scale up; improved program management; and feedback to service providers which will enhance service delivery. In COP11 MSH ProACT worked to integrate vertical HIV M&E systems with mainstream HMIS systems at 15 health facilities in Kogi and Niger states. In COP 12, MSH will work to ensure that all 25 comprehensive Care and Treatment (CCT) sites have fully integrated medical records units. MSH also worked to strengthen the capacity of facility records unit to generate and analyze service statistics data which guided decisions to improve quality of patient care. In COP12 MSH ProACT will strengthen the capacity of the SMOH, SACA and facilities to have functional data management systems (MIS, NNRIMS and DHIS 2.0 systems) that will generate timely and accurate data to inform decision-making at all levels. Through this activity the state governments will be able to utilize data to mobilize resources and coordinate wider stakeholder involvement in monitoring and evaluating HIV/AIDS and TB control efforts-critical elements in the initial steps towards government ownership and sustainability. Technical assistance provided to facilities and the state partners will be coordinated with national and other SI programs and aligned with the national and USG data quality assessment/improvement (DQA/I) and capacity building plan. Capacity building in this area will be achieved through a combination of approaches, including workshop training (training content will include M&E skills building, surveillance topics, and HMIS concepts), on the job training, and facilitative supervision. MSH will also continue to actively participate at national and state level M&E TWG meetings and will utilize evidence from the program to guide and influence the national M&E agenda.

The LMS/ProACT Prevention program was initiated in COP 09. It includes Abstinence/Be Faithful (HVAB) and Other Sexual Prevention (HVOP) programs. In COP 12, the LMS/ProACT project will continue to engage community and faith based organizations (CBOs and FBOs) through small grants to build upon COP 11 activities and expand to additional sites within the States. The HVAB program fulcrum strategy is peer education, leveraging on the GON Family Life and Health Education (FLHE) curriculum. Supported CBOs/FBOs will carry out behavior maintenance activities in intervention communities.

In COP 12, 65,454 persons will be reached with Sexual Prevention-Abstinence/Be faithful interventions which promote low risk behaviors, abstinence, delay of sexual debut or secondary abstinence for adolescents boys and girls, fidelity amongst married young people, reduce multiple and concurrent partners especially amongst out-of-school youth and young adults (age 18 -30). The HVAB program will pay special attention to the girl-child by empowering them with strategies which enable girls to develop self-esteem, critical thinking, assertiveness, and gain access to increased opportunities. Boys and young men will also be empowered to challenge negative masculine stereotypes and support norms and values of respect and equality between the sexes.

Trained peer educators in schools will continue to use the minimum prevention package interventions (MPPI) standard to carry out their activities. Strategies for MPPI will include the Peer Education Model using peer educators sessions and interactions and HIV/Health club meetings etc.; Community Awareness Campaigns such as small group discussions and IPC; the School Based Approach will leverage on the existing Family Life and Health Education (FLHE) curriculum in schools to increase knowledge and skills on adolescent reproductive health, HIV/AIDS and life building. Learning will be reinforced through the integration of FLHE into school curriculum. The Peer Education Plus model strategy would also be adopted.

ProACT will build the capacity of the State Ministries of Education to supervise, monitor and ensure quality of FLHE/MPPI through joint supervisory visits to schools.

ProACT will provide HCT services to MARPs, couples, pregnant women, children and clients seeking health care services at supported health facilities/communities in Kogi, Niger, Taraba, Adamawa, Kebbi and Kwara States using PITC and community outreach strategies. In COP 11 ProACT provided HCT services to 115,177 persons and will provide HCT services to 161,248 people in COP 12. ProACT will train 75 counselor testers to support service scale-up and also retrain 150 counselors to strengthen and update their skills. ProACT will continue to build upon the counseling and testing interventions initiated in COP11 by providing quality HCT services across supported sites; increasing access to HCT services for pregnant women in high prevalence communities through scaling up HCT services to 16 additional primary health facilities in the supported States.

ProACT will identify and partner with local CBOs in high prevalence communities surrounding the supported health facilities to mobilize and generate demand by working with existing social structures in targeted communities. Community HCT services will focus on male involvement, women and other vulnerable groups. These CBOs will also play a crucial role in promoting facility/community referrals and linkages. Intra-facility escort services and contact tracing will be intensified and supported by trained volunteers to ensure 100% enrollment and increase retention in care.

HIV testing at all sites will be conducted using the current national serial algorithm and ProACT will provide, through its quality control laboratory staff, routine monitoring and mentoring to site staff. Personnel involved in HIV testing will undergo quarterly proficiency testing, while testing accuracy will be routinely re-checked using limited retesting of patient samples. As part of quality control measures instituted at all HCT sites, the quality control staff will ensure that standard procedures are strictly followed in the safe handling and disposal of medical and other laboratory waste materials. Training for PEP will be provided to all staff involved in HCT services.

ProACT will scale up partner testing and couples counseling across supported sites.

The Other Sexual Prevention (HVOP) program is linked to activities in Adult Care and Support, TB/HIV, HCT, PMTCT and OVC. Since COP 09, ProACT has supported provision of HVOP in 53 health facilities and 24 communities in Kogi, Niger, Adamawa, Taraba, Kebbi and Kwara States. In COP 12, ProACT will continue to engage CBOs and FBOs through small grants to saturate the communities and expand to additional sites. The program fulcrum strategy is peer education, using the Minimum Prevention Package Intervention (MPPI) that addresses behavior change with a combination of intervention models. Supported CBOs/FBOs will carry out behavior maintenance activities in intervention communities.

In COP 12, ProACT will continue to target most at risk populations (MARPS) such as Men Having Sex with Men (MSM), injection drug users (IDU), female sex workers , married women, un-married young girls, transport workers, and uniformed service men. The MPPI for these groups will be Specific Population Awareness Campaigns (small group discussions or IPC); Community Outreach activities (HCT, condom messaging and distribution, balanced ABC messaging, etc); Peer Education Models using social peers (for DU, MSM and FSW populations); Job-related peers; Workplace Programs; Greater Involvement of People AIDS (GIPA), and condom service outlets. MARPs (MSM/IDU) requiring health services will be offered user-friendly services at ProACT supported facilities. Trained MARPS peer educators will saturate communities with prevention messages focusing on partner reduction, inter-generational sex, mutual fidelity, stigma reduction, etc. Quarterly behavior maintenance activities will be carried out by peer educators and CBOs through regular community outreach programs which focus on motivating sustained behavior change Low risk behavior will be promoted amongst MARPS through increased access to condoms from established condom service outlets. Peer educators will facilitate changes in attitudes and behaviors which put women at risk of HIV by promoting female access to male condoms through women-only safe spaces.

In COP 11, ProACT provided the minimum package for PMTCT supported sites in 41 health facilities across 6 states. Drug intervention was provided for all positive clients using the 2010 WHO option A and B depending on the facilitys capacity. All positive pregnant women were linked to CD4 within 1 week of diagnosis. HIVexposed infants received EID services and were adequately linked to treatment or OVC care depending on their status. In addition to receiving PMTCT services, each mother-baby pair were linked through referral to community HIV/AIDS services such as food bank, peer support groups and IGA activities for ongoing support.

In COP 12 ProACT will continue to use available national data to select high prevalence communities to scale up PMTCT services in the six focus states. ProACT will also continue to support quarterly community outreach targeting pregnant women and providing linkage for prophylaxis/treatment and CD4. Pro-ACT will continue to ensure that the quality of PMTCT services across its supported sites is maintained by conducting training and retraining of facility staff using the current National guidelines. Lay counselors will be trained and facilitated to carry out PMTCT counseling and support newly recruited PMTCT parents to adhere to prophylaxis and infant feeding practices. Emphasis will be laid on the quality of post test counseling given while the already instituted PITC at the labour ward will be extended to spouses who come to visit post delivery. Food and nutritional supplements will be leveraged from non-PEPFAR implementing partners for malnourished pregnant and lactating positive women. In addition Pro-ACT will collaborate with other partners to further integrate Family Planning into maternal and child health care to improve FP uptake and maternal and child health outcomes.

Pro-ACT will continue to encourage quarterly joint GON/USG/Pro-ACT supportive supervision. Updated National registers would be used with feedback provided to the facilities. The quality of service will be assured through supervision, QA/QI analysis, M and E, and QA checks using standardized national tools. Pro-ACT will disseminate information through regular reporting to the USG and GoN

In COP11 MSH ProACT project participated actively in the quantification of ARVs and OIs nationally and facilitated the initiation of a Logistics Management Task team in Niger State which is providing direction on joint warehousing and distribution of HIV commodities to reduce duplications in procurement between IPs and government. In COP12 ProACT will continue to participate in the national forecasting exercise and procurement planning meetings facilitated by the government of Nigeria, USG partners and SCMS project.

In COP11 all adult patients on Stavudine backbone were successfully migrated to Truvada based regimen. In COP12 the following assumptions were used in the forecasting for ARVs: Pediatric clients would be maintained on their current regimen. Children will be maintained on Stavudine only in cases where suitable alternatives are not available. New adult clients would be enrolled based on the following regimen distribution; AZT/3TC/NVP-35%, AZT/3TC/NVP-15%, TDF/FTC/NVP-35%, TDF/FTC/EFV-15%

All purchases of ARVs will be via SCMS pooled procurement mechanism in line with OGACs recommendation. Generic formulations will be used preferentially. ProACT partner Axios Foundation has developed a functional logistics system to ensure consistent availability of secure and high quality ARVs and related commodities plus accountability for the deliveries/usage. In COP12 Axios will continue to integrate its distribution and warehousing with State government network to deliver health commodities to patients.

In COP 11 none of the ProACT supported facilities reported stock out of ARVs. In COP12 ProACT will continue to ensure uninterrupted availability of ARVs to all facilities through leveraging of resources with Government of Nigeria (GON), USAID and other stakeholders and will build the capacity of state partners in the forecasting, procurement and distribution of ARVs and HIV commodities. This concerted effort will efficiently promote a sustainable supply of ARVs and other HIV related products to all health facilities covered by the project. The project will leverage second line pediatric ARVs from the CHAI. In addition, ProACT would leverage PMTCT commodities from CHAI/UNITAID

In COP 12, MSH ProACT will build on its achievements in providing support to SMOH to provide comprehensive care and treatment services. Additional 4175 patients will be provided with ART with projected cumulative active client load of 11,675

In COP 11 MSH supported the Kogi State Government in the activation of 3 state owned CCTs in underserved population. Supervisory teams were constituted and trained to provide technical assistance and participate in mentoring visits. In COP12 ProACT will strengthen this partnership with SMOH and institute a state training faculty. This will also be replicated in 2 other states to further scale up ART services.

ProACTs integrated service delivery model enhanced by Management level integration of project management teams and hospital management committees resulted in improved program ownership and coordination with improvement at service delivery units. In COP12 these processes will be strengthened and scaled up to new health facilities.

To improve access to quality ART care, ProACT is supporting the FMOH in the development of a national strategy to decentralize ART services to PHCs and built capacity of state and LGAs in Taraba state. State supervisory team was constituted, In COP 12, capacity of this team will be built to continue the implementation process. The process will also be replicated in states with high client burden.

Capacity of clinicians to evaluate patients in long term care for treatment failure and initiate second line therapy.35 physicians will be trained in advanced ART management. MSH ProACT will provide access for viral load monitoring in treatment experienced patients by building networks with existing PCR laboratories.

In addition facility driven continuous quality improvement (CQI) systems piloted at 6 selected facilities in COP 11 will be scaled up and mainstreamed into all 28 CCTs in COP 12.Capacity of facility based MDTs to perform monitoring and quality improvement checks .Capacity of state supervisory teams will also be built to conduct periodic site performance evaluations and use relevant data to make strategic decisions.

Pro-ACT in COP 11 focused on building the capacity of facility health and SMOH staff through organized trainings, extended CMEs and support for National TOT. PITC was institutionalized at the pediatric wards and at support group meetings with linkages to the pediatric treatment clinics. Pro-ACT worked with the state partners at the facility and State ministry levels to increase access to DBS by decentralizing collection, developing a hub and spoke model along with innovative ways of transporting the sample to the reference labs. Pediatric adherence was improved by using pediatric fixed dose ARV formulations and strengthening the mother baby pair appointment system.

In COP 12, Pro-ACT will scale up pediatric uptake by the institutionalization of genealogy forms into the record unit and further train data clerks and triage nurses on its use linkage to the community volunteers for tracking.

Quality indicators will be introduced into the PITC points at the ward and POPD to ensure maximum uptake. Priority attention will be given to parents at the adult ART clinic for accompanying children so as to create demand for pediatric HCT. PITC points will also placed at MCH clinics with active referral to pediatric ART clinics. All PITC points will include DBS collection for children less than 18 months who test sero positive.

In order to increase client retention, Pro-ACT will establishing children psychosocial groups in some facilities leveraging from partners like Sesame Street and UNICEF. Pro-ACT will provide a sustainable reward system by leveraging from organizations already into children education. They will provide full/part scholarship, school materials and admission for school age children who have demonstrated good adherence. Pro-ACT will also look into supporting the state partners and supported facilities to establish adolescent reproductive health clinics and give it youth friendly environment to encourage uptake.

Capacity building for task shifting to address Human resource gap will be done. Pro ACT will incorporate few modules from IMCI, and safe motherhood training curriculum into pediatric ART training curriculum to further sensitize and equip Health workers for integration.