In FY2013 CCFNs Sustainable HIV Care and Treatment Action in Nigeria (SUSTAIN) will provide comprehensive HIV care, treatment and prevention services in twenty five (25) Partner Treatment Facilities, five (5) standalone PMTCT sites and three (3) Community Based Organizations in 12 states of Adamawa, Benue, Delta, Edo, FCT, Kaduna, Kogi, Nassarawa, Ondo, Oyo, Plateau, and Taraba. The focus in FY2013 is to maintain and expand to additional PTFs and satellite sites, with further emphasis on decentralization to community and home levels. Through primary and secondary faith-based facilities SUSTAIN will extend ART care and treatment services to underserved rural communities to reach 504 (new) and 1067 (current) children and 5,216 (new) and 39,278 (current) on ART by the end of the fiscal year. In setting and achieving these targets, consideration has been given to modulating SUSTAINs rapid scale-up plans in order to concomitantly work towards continuous quality improvement. All PTFs will be strengthened in their capacity to provide comprehensive quality ART care and treatment services through a variety of models of care delivery. This includes quality management of OIs and ART, a safe, reliable and secure pharmaceutical supply chain, technologically appropriate lab diagnostics, treatment preparation for patients, their families and supporters and community based support for adherence. This technical and programmatic assistance utilizes on-site mentoring and preceptorship. A key component for successful ART is adherence to therapy and capacity building to improve the quality of services. SUSTAIN will strengthen Continuous Quality Improvement (CQI) to improve and institutionalize quality interventions.

In FY2013 SUSTAIN will provide adult treatment, care and support services in 25 Partner Treatment Facilities (PTFs) and 10 satellite sites across the 12 states of Adamawa, Benue, Edo, FCT, Kaduna, Kogi, Nassarawa, Ondo, and Taraba. Through primary and secondary faith-based facilities AR in COP09 will continue to extend ART services to underserved rural communities to reach 4,770 new patients for a total of 30,150 active adult patients by the end of the year. Comprehensive package of care and support services will be provided to a cumulative 50,589 PLHIV and 101,178 PABAs in the same period. In setting and achieving COP09 targets, consideration has been given to consolidating on ARs rapid COP08 scale-up efforts in order to concomitantly work towards continuous quality improvement.

The package of care services provided to each PLHIV includes a minimum of clinical service with basic care kit and two supportive services in the domain of psychological, spiritual, and PHDP delivered at the facility, community, and household (home based care) levels in accordance with the PEPFAR and Government of Nigeria (GON) national care and support policies and guidelines. The basic care package for PLHIVs in SUSTAINs partner sites include Basic Care Kit (ORS, LLITN, water guard, water vessel, gloves, soap and IEC materials,); Home-Based Care (client and caregiver training and education in self-care and other HBC services); Clinical Care (basic nursing care, pain management, OI and STIs prophylaxis and treatment, nutritional assessment- weight, height, BMI, micronutrient counseling and supplementation and referrals, Laboratory Services (which will include baseline tests - CD4 counts, hematology, chemistry, malarial parasite, OI and STI diagnostics when indicated); Psychological Care (adherence counseling, bereavement counseling, depression assessment and counseling with referral to appropriate services); Spiritual Care (access to spiritual care); Social Care (support groups facilitation, referrals, and transportation) and Prevention Care (Prevention with Positives). All PLHIVs nutritional status will be assessed at contact and on follow-up visits, micronutrients will be provided as necessary, and those diagnosed as severely malnourished will be placed on a therapeutic feeding program. This will be done through wraparound services as well as direct funding. SUSTAIN will procure basic care kits through a central mechanism and OI drugs will be procured through mechanisms that ensure only NAFDAC approved drugs are utilized.

In FY2013 SUSTAIN will ensure prioritized and focused interventions that address childrens most critical care needs through family strengthening approaches. SUSTAINs OVC primary strategy for achieving this will be strengthening parents and caregivers so they can provide for their childrens basic needs. SUSTAIN will engage community based organizations with proven track records in OVC program implementation to support this strategy. SUSTAINs OVC programming has several key elements: proactively seeking children at risk through a multi-pronged approach for increasing access to care and HCT and ensuring a holistic child focused and family-centered approach to care. Priority areas include education, psychosocial care and support, household economic strengthening, social protection, health and nutrition, child protection, legal protection and capacity building. SUSTAIN will place significant emphasis on strengthening services to OVC beginning with building skills in partner CBOs and community care providers to identify children who are vulnerable and provide them with appropriate services. SUSTAIN will adopt use of the Child Status Index to assess vulnerability and determine needs of the children. Households will also receive a preventive care package containing ITN, water guard, water vessel, soap, ORS sachets, and IEC materials on self-care and prevention of common infections according to GoN guidelines. These services will be underpinned by providing good supportive counseling for children and adolescents. AR will intensify collaboration with GON and other stakeholders to ensure prompt diagnosis of TB in children and facilitate provision of pediatric TB formulations.

SUSTAIN will strengthen existing structures to build children support groups in saturation communities and expand their activities to include periodic social/recreational and educational activities with the involvement of uninfected children to address issues of stigma and discrimination. Nutritional services will include nutritional assessment, nutritional counseling and education and therapeutic feeding. SUSTAIN will expand its central OVC team to include a nutritionist who will assist in building capacity of HCW in nutritional assessment, establishing nutritional corners in all LPTFs for culture and region sensitive counseling rehabilitation.

CCFN SUSTAIN strategy for TB/HIV is to ensure that all HIV positive clients in Partner Treatment Facilities (PTFs) are routinely screened for TB while TB patients have access to HIV counseling and testing (HCT). Dually infected clients are offered appropriate care within and outside the PTF. SUSTAIN will support TB DOTS centers at PTFs and HCT services in stand-alone TB DOTS centers in focal states. SUSTAIN will continue to implement HCT in existing TB DOTS centers to provide HCT to all TB patients and suspects and will also ensure facility co-location of TB DOTS centers in all supported PTFs. TB DOT Centers will be supported to expand services to include care and support and follow up services. Referral mechanisms will ensure TB/HIV co-infected clients access supported HIV care and treatment services. SUSTAIN will implement the global 3 Is program of TB/HIV management strategy. Over 40,000 HIV positive patients in care at all supported sites will be rescreened for signs of TB clinically with symptom driven follow up laboratory screening. Isonizide Preventive Therapy (IPT) will be strengthened across all sites. The TB/HIV program will be in collaboration with State and National Tuberculosis and Leprosy control programs (STBLCP and NTBLCP). All clients offered HIV counseling and testing services from the TB DOTS centers will receive their results. Laboratory infrastructure will be upgraded and human capacity developed to ensure adequate TB diagnosis for HIV positive patients. SUSTAIN will continue to strengthen the pharmacy services at supported TB DOTS sites to improve forecasting and avoid stock outs, working with sites and State Government to recognize and eliminate stock outs due to facility level or government level TB logistic weaknesses, as an aspect of health systems capacity strengthening.

Through basic care and support services all TB/HIV patients will be put on co-trimoxazole prophylaxis therapy (CPT) according to the national guidelines. Community health care providers will trace family members of PLHIV accessing TB/HIV services and facilitate their TB screening and appropriate care. SUSTAIN will ensure proper patient triage, specimen collection & processing, waste disposal, proper ventilation and administrative control activities such as active identification of those with TB symptoms and patient segregation. TB infection prevention and control will be accomplished using these workplace practices, administrative and environmental measures. Patient and staff education will be routinely conducted to ensure program success. SUSTAIN will continue to use the developed joint adherence strategies for patients on ARVs and TB DOTS and strengthen the facilities capacity to meet special needs of PLHIV on both ART and anti-TB treatment. Nosocomial transmission of TB to HIV+ patients as well as facility staff will be prevented through measures and principles such as basic hygiene, proper sputum disposal, and good cross ventilation at clinics. The national guidelines on TB infection control on co-located sites will be implemented in all SUSTAIN supported sites. Patients screened and treated for TB and TB/HIV will be entered into the updated reporting tool provided by the NTBLCP with appropriate linkages of medical records between TB and HIV points of service. In support of the NTBLCP and STBLCP, AR will provide TB consumables, reporting & recording tools, ACSM materials in places where these are not available

SUSTAIN will support strategies to increase pediatric enrollment into care and treatment by strengthening linkages and referral at all service levels, reinforce and expand community based care for children, promote family centered care and treatment and provider initiated testing and counseling (PITC )for all children. ART clinics will be supported to initiate family days to provide opportunities to increase testing for children and provide comprehensive care. All exposed infants delivered in the PTF or identified through the family centered approach will be linked to the ART HIV Comprehensive Care clinic for enrollment into care and treatment. Aggressive community based activities will be put in place to identify exposed infants including those lost to follow up from the PMTCT program. The basic care package for HIV positive child/care givers in supported sites include Basic Care Kit (ORS, LLITN, water guard, water vessel, soap, IEC materials, and gloves); Home-Based Care (client and caregiver training and education in self-care and other HBC services); Clinical Care (basic nursing care, pain management, OI and STIs prophylaxis and treatment, nutritional assessment- weight, height, BMI, micronutrient counseling and supplementation and referrals, Laboratory Services (which will include baseline tests - CD4 counts, hematology, chemistry, malarial parasite, OI and STI diagnostics when indicated); Psychological Care (adherence counseling, bereavement counseling, depression assessment and counseling with referral to appropriate services); Spiritual Care (access to spiritual care); Social Care (support groups facilitation, referrals, and transportation) and Prevention Care (Prevention with Positives).

All HIV positive childrens nutritional status will be assessed at contact and on follow-up visits, micronutrients will be provided as necessary, and those diagnosed as severely malnourished will be placed on a therapeutic feeding program. SUSTAIN will provide DBS/DNA PCR technology for early infant diagnosis in addition to the logistic support for transportation of blood samples to designated laboratories in collaboration with other Implementing Partners. All infected children will be evaluated for ART using CD4 or CD4%. All SUSTAIN supported sites will have the capacity to determine CD4% for evaluation of immunological status of children less than 6 years. Based on available evidence on child survival and morbidities in relation to immunological staging, SUSTAIN will provide ARVs for all infected infants (less than 1 year) in addition to other revised ART guidelines tin accordance with revised National pediatric ART guidelines so as to prevent mortality and brain damage in rapid progressors. Appropriate first and second line regimens that preserve future options with minimal toxicity profiles will be adopted for all PTF. SUSTAIN will intensify collaboration with GON and other stakeholders to ensure prompt diagnosis of TB in children and facilitate provision of pediatric TB formulations. All children on ARV will have at least monthly home visits to ensure adherence and assess need for intervention. Specific efforts and training will be made to develop adolescent friendly services for infected and affected children including linkages to reproductive health.

This activity ensures that appropriate Lab support is provided for lab diagnosis, clinical monitoring and HIV testing. Linkages with HVSI will ensure tracking of lab infrastructure indicators. SUSTAIN will support Laboratory (Lab) infrastructure in all support partner treatment facilities (LPTFs). SUSTAIN will provide on-site capacity to testing for HIV, laboratory monitoring of disease progression and response to treatment, opportunistic infections (OIs) diagnosis and monitoring of antiretroviral drug (ARVs) toxicity. SUSTAIN will support the improved diagnosis of TB, PCP, cryptococcal infection, syphilis, hepatitis B (HBV), protozoal and bacterial infections. SUSTAIN does not routinely do Viral load (VL) testing but ensure that VL testing is done to make difficult therapy switch decisions as well as for program evaluation on a random 10% subset of our clients from each PTF who have been on therapy for a period of 6 -9 months annually by collaborating with other PEPFAR IPs with viral load capacity and at 1 of our PTFs with VL capacity. In addition, 2-3% of AR clients on ART would require VL testing based on clinical indications. SUSTAIN will also support expansion of early infant diagnosis (EID) at PMTCT supported facilities in accordance with the national EID scale up plan. SUSTAIN will participate in the USG-GON coordinated Laboratory Technical Working Group (LTWG) to ensure harmonization with other IP and GoN supported laboratory program. SUSTAIN will support the development of a common Lab equipment platform appropriate for each lab level.

In FY2013 SUSTAIN will provide support to 35 sites in a total of 12 states, all of these partner sites are secondary level and of these facilities have PCR capacity: 1) St Vincent's DOC (DREAM model) has bDNA VL testing supported by CRS private funding. SUSTAIN will provide automated CD4 testing equipment with capacity for processing large patient loads, cytosphere reagents using binocular microscopes that are easy to use and appropriate for secondary care centers for manual CD4 testing as backup in place of automated CD4, hematology analyzers and chemistry machines. All labs will be supported to test for syphilis, PCP, TB, HBV, hematology, chemistry, cryptococcosis and CD4. SUSTAIN will provide an additional 5 LPTFs with fluorescent microscopes for enhanced TB and malaria diagnosis, and support necessary training and reagent procurement for these equipment at all 15 labs. A SUSTAIN Lab Specialist will be dedicated with the overall responsibility for equipment installation and maintenance. All SUSTAIN Lab Specialists have received training and will continue to receive updated trainings from CD4 manufacturers and other lab equipment manufacturers as maintenance engineers to support the servicing of CD4 and other machines. SUSTAIN will use its reagent forecasting tools at all levels to determine consumption and predict need, to forestall stock outs. Working with SCMS and CHAN Medi-Pharm, SUSTAIN will centrally procure lab reagents from manufacturers locally and abroad and distribute to PTFs. HIV Test kits will be provided directly by the USG through the SCMS mechanism. SUSTAIN will work with locally certified QA experts to implement the Lab EQA program

SUSTAINs SI activity incorporates program level reporting and implementation of both paper-based and computerized Health Management Information Systems (HMIS) in PTFs. This activity is supported by Futures Group. Using in-country networks and available technology, SUSTAIN will continue to strengthen PTFs Patient Management Monitoring (PMM) systems with added emphasis on harmonization with the Government of Nigerias (GON). As part of capacity building and contribution to program sustainability SUSTAIN will continue to provide logistical support for automated PMM to local partner facilities by providing them with computers and other logistical support systems and will continue to expansion of these services in FY2013. SUSTAIN will support the process of harmonizing its existing IQCare PMM system with the LHPMIP with a view to actualizing efficient PMM-PME integration. SUSTAIN will continue to strengthen its program for Continuous Quality Improvement (CQI) in order to improve and institutionalize quality interventions. This has included standardizing patient medical records to ensure proper record keeping and continuity of care at all PTFs.

SUSTAIN will provide TA to PTFs and personnel to adapt and harmonize existing tools to meet the standards of the GON having conducted proper roll-out of GONs revised M&E tools thus ensuring that monitoring and evaluation of the SUSTAIN program is consistent with the national plan for patient monitoring. SUSTAINs SI team will work with CQI specialists to conduct site visits at least quarterly during which evaluations of the utilization of National tools and guidelines, proper medical record keeping, efficiency of clinic services and referral coordination were conducted. Data flow including data collection, management and reporting was assessed and recommendations for improvement given. Supportive supervision and mentoring has been provided to all on-site staff that collect and utilize data (e.g., clinicians, pharmacists, data entry personnel, administrators). All of these activities will continue to be supported in COP09 with more frequent on-site TA and follow-up monitoring visits to address any weaknesses identified during routine monitoring visits. State M&E officers shall be informed of, and involved in the monitoring processes and the training programs in order to instill a sense of ownership and ensure sustainability of these efforts. Data Demand and Information Use (DDIU) trainings will be expanded to include respective SACAs and LACAs. SUSTAIN will conduct quarterly Date Quality Assessment in all sites.

SUSTAIN will support the linkage of supported Partner Treatment Facilities (PTF) and their satellite sites to the National Blood Transfusion Service (NBTS) zonal centers across the country. In FY2013 SUSTAIN will support 25 PTFs and 1o satellite sites in 10 states (Adamawa, Benue, Delta, Edo, FCT, Kaduna, Kogi, Nassarawa, Ondo, Plateau, Taraba and Oyo). Blood transfusions occur at all 25 PTFs. SUSTAIN will work closely with the National Blood Transfusion Service (NBTS) and Safe Blood for Africa Foundation (SBFA) in all aspects of its blood safety program. SUSTAIN will support the NBTS in implementing its primary objective of migrating fragmented hospital-based blood services to centralized NBTS-based blood services nationwide. A key feature of this program is the development of a nationwide voluntary donor recruitment system. NBTS, through linkages its zonal centers will develop with SUSTAIN and its supported facilities, will provide TA for blood donation drives held by these SUSTAIN-supported hospital facilities. In addition, SBFA will train nurses and medical laboratory scientists in these facilities to recruit repeat voluntary blood donors from the ranks of current family replacement donors. SUSTAIN will work with the PTFs to ensure management buy-in for the NBTS blood services program, to create support of blood donor organizers, and to strengthen health facility and community focused blood drive activities. CCFN will draw upon its unique position in working with mainly faith-based facilities to facilitate blood donation activities within parishioner communities. SUSTAIN will support the distribution of IEC/BCC materials obtained from NBTS and SBFA to promote the need for voluntary non-remunerated blood donation. In addition, SUSTAIN will establish blood transfusion committees to oversee blood use based on national algorithms and standards in the health facilities.

This linkage will include regular delivery of donated units of blood to NBTS for screening in conjunction with a regular delivery of screened units of blood to the facility. NBTS will pick up unscreened blood units from the PTFs and will transport these units back to NBTS centers where they will be screened for the 4 transfusion transmissible infections (TTIs) of HIV I and II, hepatitis B, hepatitis C and syphilis using ELISA techniques. In addition to collecting unscreened units, NBTS will deliver to the PTFs their requested order of screened units for blood banking and use at the facilities. NBTS will also provide monthly feedback on rates of the 4 TTIs found by ELISA screening of blood units collected by each facility. All PTFs that do blood transfusions will ensure appropriate facility-level collection of blood. Directed and voluntary donors will be prescreened with the NBTS donor screening questionnaire and donors will be deferred as necessary based on their responses. Deferred donors will be offered HCT. At least 2,500 blood donors will be screened using the National HCT testing algorithm, thereby utilizing the blood donor setting as another point of service for HCT during pre-donation. A PEPFAR-supported evaluation of the current emergency-based transfusion system will provide insight into rates of TTIs, including HIV, that go undetected in emergency screened blood.

SUSTAIN Partner Treatment Facilities (PTFs) consist largely of primary and secondary healthcare institutions located within communities that are poor and underserved in all areas of social infrastructure including healthcare. A proportion of HIV infections are still transmitted within these healthcare facilities through unsafe injection practices. In FY2013, SUSTAIN will expand to support safe injection activities at all PTFs in the focal states. SUSTAIN injection safety activities encompass the training of infection control personnel from each supported facility on universal precautions and medical waste management. Healthcare workers trained in collaboration with John Snow Inc. /Making Medical Injections Safer (JSI/MMIS) will step down the training to ensure sustainability and behavioral change. It is expected that a total of 120 personnel will be trained. This step down training to other PTF staff, including nurses, doctors, laboratory staff, hospital cleaners, laundry workers and waste managers, will include topics such as proper techniques for giving injections, drawing blood, dispensing blood into laboratory bottles for laboratory testing, and disposal of used needles, sharps and other materials contaminated by blood and other biohazardous materials. SUSTAIN will obtain and use MMIS supplied manuals to conduct follow-up on-site training at AR-supported LPTFs. Behavioral change communication (BCC) activities will be carried out to reduce unnecessary use of injections. SUSTAIN will provide supportive supervision to all trained staff in supported facilities.

SUSTAIN will collaborate with JSI/MMIS to supply and distribute single-use needles, safety boxes and personal protective equipment to all supported PTFs. This activity will involve the provision of retractable needles and syringes, sharps containers and liquid hand washing soap in LPTF wards, clinic rooms, laboratory work stations and strategic areas to encourage their use. This activity will also provide personal protective equipment (PPE) for health workers and ancillary hospital staff who come into contact with sharps and contaminated materials. SUSTAIN will work with each PTF to improve access to water at each hand washing point. For sustainability purposes, AR will ensure that these activities are integrated within each facilitys overall infection prevention and control and workplace safety programs. SUSTAIN will also support post-HIV exposure prophylaxis (PEP) programs at all sites. Health care waste management will be supported in this activity. Incinerators will be repaired and fueled where they are available and constructed where there are no incinerators. SUSTAIN will strengthen its program for Continuous Quality Improvement (CQI) to improve and institutionalize quality interventions. CQI specialists and Laboratorians will conduct team site visits at least quarterly during which there will be evaluations of infection control practices, waste management procedures, proper record keeping, and use of standard operating procedures for injection safety.

All HIV programs supported by SUSTAIN promote abstinence until marriage, and mutual fidelity within marriage. SUSTAIN does not finance, promote or distribute condoms. In line with its HIV Policy, however, SUSTAIN does provide age-appropriate, complete and accurate information about condoms to its partners as part of its HIV activities. SUSTAIN will implement its AB programming activities in line with the overall PEPFAR Nigeria goal of providing prevention services to individuals reached through a balanced portfolio of prevention activities. SUSTAIN will provide full accurate information on prevention services. The program will support partner treatment facility (PTF) activities targeting HIV + clients, their families and communities who access care at these points of service. And community based organizations to target out school youths. Prevention priorities will include behavior change for risk reduction and risk avoidance, counseling and testing. All SUSTAIN supported PTFs will provide education and training to patients and community health volunteers on secondary prevention. There will be structured peer education that includes systematic training curricula, refresher training, and training on essential life skills. In addition, age appropriate abstinence only messaging and secondary abstinence messaging will be conveyed to adolescents and adolescents, especially orphans and vulnerable children receiving both facility and home based support. This service will also be extended to schools and National Youth Service Corps orientation camps. SUSTAIN will cover communities with AB messages conveyed through multiple media.

The program aims to cover communities targeted with messages conveyed through multiple fora. Utilizing such a methodology, a large number of people will be reached with messages via one method or another, but the counted group will be those individuals that would have received AB messaging: (1) on a regular basis and (2) via the three strategies (community awareness campaigns, peer education models and peer education plus activities). Fidelity in relationships will be promoted through information, education and communication (IEC) materials and enlisting the support of religious leaders in community-led peer education plus activities. A family-centered approach will provide opportunities to maximize prevention messaging to all family members. SUSTAIN will draw on culturally appropriate prevention messaging material for these activities. Training will be an integral part of this program and will be directed at facility staff, community level staff and religious leaders to be able to promote abstinence and being faithful messages to patients, their families and communities.

SUSTAIN will increase support for counseling and testing services in 25 Partner Treatment Facilities (PTFs), 10 satellite and three Community Based Organizations in FY2013. An emphasis will be placed on satellite decentralization clinics and family members of In-care clients. SUSTAIN will build the capacity at existing and new PTFs to enable them integrate HCT services within care and treatment systems and obtain resources from the GoN and other agencies to increase uptake of HCT services in all points of service in the facilities. All HCT service outlets will be branded with the Heart to Heart logo. SUSTAIN will support Provider Initiated Testing and Counseling (PITC), opt-out testing and point of service testing in all supported healthcare facilities. These approaches to HCT will be strengthened by technical and programmatic staff through onsite mentoring /preceptorship of providers and the engagement of leadership at supported facilities. SUSTAIN will scale-up couples counseling and testing in all supported sites through organized training, family centered testing and on site mentorship. Referrals to outlets that provide other prevention services not available at supported facilities will be provided and tracked. All HCT sites will provide same day results and will use the current National serial testing algorithm. For infants and children less than 18 months Early Infant Diagnosis (EID) will be available at PMTCT sites according to the national scale up plan. Rapid HIV test kits provided by the USG through SCMS will be distributed to PTFs by our warehousing and distribution agent based on utilization. Sites will be actively linked to Government of Nigeria and other donor agencies to access extra kits and supplies needed and supported to maintain their regular usage and feedback through the above mentioned strategies. Sites will be trained on forecasting and stock control using bin cards and will maintain a three month buffer. PTFs will report on inventory and forecasting to the central office on a bimonthly basis.

In FY2013 SUSTAIN will target the provision of HCT services mainly to PABAs - especially children, as well as to STI patients and TB DOT clients at the PTFs and satellite clinics. SUSTAIN will target women of reproductive age with combined HCT and STI screening and provide HCT services as a routine component of blood transfusion services. All HCT clients will be linked to prevention services, as well as treatment, care and support services where applicable. SUSTAIN will train and retrain PTF staff on counseling and testing using the GON HCT training curriculum. Counselor training will include couples counseling to strengthen this aspect of the program. This will ensure the availability of a pool of trained counselors to promote continuity. In addition, providers will be sensitized on the adoption of PITC, opt-out testing and point of service testing in their facilities. Non-laboratorians will be used at multiple points of service for facility based HCT where appropriate and when allowed by national policy. To expand HCT services within the network of faith based organizations and increase rural access to HCT, SUSTAIN will support community and family based HCT and advocate for greater use of trained non-laboratory staff to conduct testing in the community setting as well.

**Not Provided**

In FY2013 CCFN SUSTAIN will increase the PMTCT services to at least 5 additional facilities SUSTAIN with other IPs, will support the implementation of the PEPFAR-Nigeria Local Government Area (LGA) coverage strategy, ensuring the provision of PMTCT services in at least one health facility in every LGA. This is a critical step toward universal access to PMTCT services. Through its PMTCT services SUSTAIN will provide testing, counseling and results to 104,000 pregnant women. Antiretroviral (ARV) prophylaxis will be provided to 3,870 women. This activity will include, as a part of the standard package of care, routine provider initiated opt-out HIV counseling and testing (HCT) in antenatal clinics (ANC) for all presenting women and in labor and delivery wards (L&D) and the immediate post-delivery setting for women of unknown HIV status. Same day results will be provided to clients. SUSTAIN will use group health information, individual pre-test and post- test strategies and rapid testing based on the National testing algorithm. Partner testing and couple counseling will be offered as part of PMTCT services to enhance disclosure. SUSTAIN through community linkages, will utilize community and home based care services to promote partner testing. Clients will have access to free laboratory services including CD4 counts and STI screening. Free medications including those for OIs as needed and hematinics will also be provided. PMTCT regimen for mother and baby will be provided based the current national guidelines. AR will use its community linkages and mother-to-mother support groups to encourage HIV+ pregnant women to deliver in a health facility. For those HIV+ women who choose not to do so and deliver at home, the same community volunteers will follow-up and identify them for needed postpartum services.

SUSTAIN will engage traditional birth attendants (TBAs) in addition to the mother-to-mother support groups to reach HIV+ women who choose to deliver outside of the health facility. A focal person at each PTF will be responsible for tracing HIV+ mothers and their infants in the community and linking then back to care. The HIV+ mothers and their infants will be linked postpartum to ART care and support services which will utilize a family centered care model. AIDSRelief will offer HIV early infant diagnosis (EID) in line with the National Early Infant Diagnosis scale-up plan from 6 weeks of age using DBS. Implementation of the EID scale-up will be done under the guidance of the GON and in conjunction with other IPs who will be conducting the laboratory testing. SUSTAIN will collaborate with GoN as appropriate for commodities and logistics support of the EID program. Exposed infants will be actively linked to pediatric care and treatment, while their families will be referred to age-appropriate OVC services. SUSTAIN will strengthen mother and baby follow up strategies to reduce loss.

In FY2013, SUSTAIN utilize first and second line ARV drugs to treat over 35,000 patients including children in 25 PTFs and 10 satellite clinics in 12 states of Nigeria. An estimated 25% of PLHIV already enrolled in care will qualify for and be placed on ART during the year. An estimated 5% of ART clients will require 2nd line treatment. In setting and achieving FY2013 targets, consideration has been given to modulating SUSTAIN scale up activities in order to concomitantly work towards continuous quality improvement. SUSTAINs supply chain management system will ensure that the necessary infrastructure, systems and skills are in place for efficient forecasting, distribution, storage, and distribution of quality and efficacious ARVs to supported PTFs with effective monitoring and evaluation. Assessment of new sites will follow the SUSTAIN Information Gathering Tool and the Pharmacy Support and Assessment Standards Checklist. Pharmacies will be refitted to improve commodity security. Technical support to PTFs to institutionalize standard operating procedures (SOPs) for drug management will be supported and we will train and retrain 30 pharmacists and 30 other health workers including pharmacy technicians or assistants in the use of developed SOPs which are in line with national guidelines. These SOPs include drug requests, receipts, recording, dispensing, discrepancy reporting, temperature control and disposal of expired drugs. In-depth training of the PTF staff in the utilization of SOPs, forecasting and quantification for ARVs and general drug management issues will be conducted.

All ARVs received from the Supply Chain Management Systems are warehoused and distributed transported under air-conditioned environments and have in-transit insurance coverage. Procurement procedures for other commodities will follow USG and NAFDAC regulations and are consistent with National Treatment Guidelines. SUSTAIN will have service contracts with CHAN Medi-Pharm for warehousing and distribution. The Pharmaceutical Management Team manages country operations with a Therapeutic Drug Committee (TDC) comprising of clinicians, pharmacists, palliative care specialists, strategic information advisors and program managers. The TDC reviews drug utilization patterns across all PTFs, assesses scale-up progress and develops required technical support plans. SUSTAIN will support the strengthening or establishment of Therapeutics Drug Committees (TDC) at all Partner Treatment Facility. The TDC will have the key responsibility of developing policies for managing medicines use and administration, evaluating the clinical use of drugs and managing a formulary system. The TDC will promote rational use of medicines (RUM) through the medication use reviews, provision of drug information to patients, monitoring medication errors, development, and implementation of Pharmacovigilance plan (data gathering activities relating to detection, assessment and understanding of adverse drug events / reactions i.e. ADEs or ADRs and treatment failure). The SUSTAIN technical team will provide technical assistance through training and on site mentorship for these committees

All PTFs will consolidate on their capacity to provide comprehensive quality ART services through evidence based models of care delivery. This includes quality management of OIs and ART, a safe, reliable and secure pharmaceutical supply chain, technologically appropriate lab diagnostics, treatment preparation for patients, their families and supporters and community based support for adherence. This technical and programmatic assistance utilizes on-site mentoring and preceptorship. It also supports the development of site specific work plans and ensures that systems are in place for financial accountability. AR will adhere to the Nigerian National ART service delivery guidelines including recommended first and second line ART regimens. In addition, SUSTAIN will partner with the Government of Nigeria and Global Fund as appropriate to leverage resources for providing antiretroviral drugs to patients. SUSTAIN will continue to strengthen institutional and health worker capacity through the training, retraining and mentoring of health service providers to provide care and treatment services at the facility and community levels. Doctors, pharmacists, nurses, counselors, and community health extension workers will receive training and onsite mentoring that will allow them to provide comprehensive care. Training will maximize use of all available human resources including a focus on community nursing and community adherence. Care and Treatment trainings will be based on the national curricula. SUSTAIN will collaborate with the GoN and other stakeholders to develop task shifting strategies to enable nurses and community health officers to provide ART.

SUSTAIN will conduct 2 week intensive didactic and practical trainings preceding site activation followed by regular onsite mentoring. SUSTAIN will also train community volunteers including PLHIV and religious leaders to provide peer education counseling, psychosocial and spiritual counseling, respectively. SUSTAIN will use GON/USG recommended standardized training curriculums, manuals and training aides for all trainings. Information, education and communication materials will be provided to enhance these trainings. SUSTAIN will work closely with the USG and GoN team to monitor quality improvement at all sites and across the program. Over 90 Health care workers will benefit from these trainings referred to above in HIV Care, Treatment and Support. A key component for successful ART is adherence to therapy at the household and community levels. PLHIV on treatment are encouraged to have a treatment support person such as a family member to whom he/she had disclosed HIV status to improve support in the home and increase adherence. SUSTAIN will continue to build and strengthen the community components by using nurses and counselors to link health institutions to communities. Each PTF will appoint a staff member to coordinate the linkages of patients to all services. This will also build the capacity of PTFs for better patient tracking, referral coordination, and linkages to appropriate services. These activities will be monitored by the SUSTAIN technical and program management regional teams.

SUSTAIN will provide broad based access to HCT for all children through a multi-pronged approach; family centered approach to care and treatment, PITC (provider initiated testing and counseling for all children) and community mobilization. All exposed infants delivered in the PTF or identified through the family centered approach will be linked to the ART clinic for enrollment into care and treatment. Intensive community based activities will be put in place to identify exposed infants including those lost to follow up from the PMTCT program. SUSTAIN will provide DBS/DNA PCR technology for early infant diagnosis in addition to the logistic support for transportation of blood samples to designated laboratories. All infected children will be evaluated for ART using CD4 or CD4% as all sites will be equipped with capacity to determine CD4% for evaluation of immunological status of children less than 6years. Based on available evidence on child survival and morbidities in relation to immunological staging, AR will provide ARVs for all infected infants (less than 1 year) to prevent mortality and brain damage in rapid progressors. Appropriate first and second line regimens that preserve future options with minimal toxicity profiles will be adopted for all PTF. SUSTAIN will ensure adequate adherence at the home level with enhanced home visits proceeded by intensive treatment preparation for identified caregivers. All children on ARV will have at least monthly home visits to ensure adherence and assess need for intervention. SUSTAIN will build the capacity of CCFN technical staff and at the PTFs to establish adolescent programs for infected and affected children including linkages to reproductive health.

Non ART eligible children will be enrolled into care for periodic follow-up, including laboratory analysis at least every 6 months, to identify changes in ART eligibility status. All enrolled children will be linked to the OVC program to access an array of services including nutritional support, preventive care package (water sanitation/treatment education, ITN) and psychosocial support. All PTFs will be empowered with training and tools to ensure nutritional assessment. ART sites at PTFs are co-located in facilities with TB DOTS centers to facilitate TB/HIV service linkages. SUSTAIN will collaborate with GON and other stakeholders to ensure prompt diagnosis of TB in children and facilitate provision of Paediatric TB formulations. A key component for successful ART is adherence to therapy at the household and community levels. SUSTAIN will ensure intensive treatment preparation directed at an identified caregiver to ensure strict adherence and will continue to build and strengthen the community components by using nurses and counselors to link health institutions to communities. Focal staff in PTFs will be trained using national curriculums to ensure quality care and treatment. Training topics include paediatric ART clinical care; treatment adherence and laboratory monitoring based on available evidence based best practices. Emphasis will be placed on early identification and treatment of lymphoid interstitial Pneumonitis, HIV encephalopathy and other diseases peculiar to infected children. Training will maximize use of all available human resources including a focus on community nursing and community adherence to ensure care is decentralized to the home level.