ACTION Plus Up will build on ACTION Plus network of over 200 mainly GON facilities at primary, secondary and tertiary levels of care in 23 States and the FCT.

HCT will continue to serve as the entry point to care, treatment and support with counseling and testing services provided to 989,899 clients via outreaches to hard to reach communities, couples counseling, moonlight HCT with community hot spot mapping, evening service delivery and home testing of family and friends of index PLHIV. Combination prevention (behavioral, biomedical and structural interventions) will be employed in preventing new cases of HIV by collaborating with implementing agencies who provide direct community level based prevention intervention services (peer education, peer education plus, ABC approach to prevention, HCT/mobile HCT, syndromic management of STIs, condom messaging and distribution and community awareness campaigns) that are evidence- based to MARPS and In- school youths utilizing the Minimum Prevention Package.

The Nigerian FMOH ART treatment guidelines adapted from the 2010 WHO ART treatment guidelines including the new recommendations for ART in pregnant women will be fully implemented at all sites, integrating OI, STI, TB prevention and treatment services and PEP. Focus will be on maintaining and expanding high quality services for care, treatment and prevention for existing clients in these states through continuous clinical improvement activities. Emphasis will also be placed on early identification of treatment failure through the empowerment of the ART Switch Committees. Patients suspected of ART treatment failure will access viral load testing through one of IHVNs supported 11 PCR laboratories and viral genotyping (for those failing second-line ART).

To address gap

IHVN/ACTION Plus Up will provide a minimum of one clinical/Palliative care service to PLWHA and persons affected by AIDS at over 200 ACTION Plus Up supported sites.

Some available services include:

Pain/symptom assessment and management using the C&S assessment and intervention tools

laboratory services for CD4, hematology, blood chemistry, LFT, OI and pregnancy testing and targeted HIV viral load testing

OI prophylaxis, diagnosis and management

access to appropriate TB diagnostics and linkages with DOTS programs

Screening for hepatitis B, malaria, diarrhea, cryptococcal infection and urinalysis for all HIV+ persons if indicated

Nutritional assessment, counseling and support (NACS)

Preventive services - Basic care kits plus at least two other services in the domains of HBC, psychosocial, spiritual, partner/couple HTC, risk reduction and support and STI assessment, diagnosis and management using syndromic management

Structured treatment preparation to support ART adherence

Home based nursing/visits/tracking provides care to the bedridden & tracks clients back to boost retention in care.

Home based HTC for family members and friends (PABA)

Specific and targeted services for PABA including Health Education talks, preventive, psychosocial and IGA through outreaches and seminars.

Community outreaches/seminars for stakeholders (Religious, traditional, general population, men etc) to promote behavior change towards HIV related issues

Reproductive health/Family planning needs of PLWHAs will be identified and appropriate referrals and linkages made to RH/FP clinics and FBO/NGO. Support Groups and Positive Health Dignity and Prevention (PHDP) will be championed by Peer Educators/TSS/ PLWHA. Singles (youths & unmarried) and Association of women living with HIV/AIDS (ASHWAN) support groups will be facilitated at community and facility level. IHVN will collaborate with FIDA and Legal AID Council for the provision of legal support and fundamental human rights for women and children.

Appointment system using registers, patient hand cards and appropriate use of PEPFAR ID, SMS reminders, and closed user group (CUG) and effective completion of ART and Pre-ART registers will be strengthened to reduce LTFU. Registers, referral tools and Community resource directories for appropriate documentation, transfers and linkages for wrap around services to CBO/FBO/NGO will be developed.

Catchment area mapping of ALL ACTION Plus Up supported sites will continue to create and maintain a data base of geographical areas and client load to be served at each facility/community.

Emphasis areas include: human capacity building for sustainability; local organization/CBO capacity building and partnership; TB-related wraparound programs; decentralization of care and treatment services to satellite.

In COP13, ACTIONPlus up will focus on consolidation of comprehensive high quality community-based VC services to 85,729 HIV infected and affected children including adolescents.

The focus of this VC scale up will be to expand community-based VC programming with emphasis on the most vulnerable children living without adequate adult support, living outside of family care, or living in a situation where they are marginalized, stigmatized, or discriminated against. The minimum package of VC services based on the National Guidelines and Standards of practice, appropriate for age shall be offered to 0 - 5, 6 -12, 13 17 years. All children who require VC services will be identified through household surveys, self and community referrals.

ACTIONPlus up will continue its collaboration with the States Ministry of Women Affairs VC units and the Local Government Council Social Welfare departments in facilitative supervision of VC services in each state.

ACTIONPlus up will build the capacity of LGA Social Welfare Officers in Coordination and Supervision for sustainability and ownership of the VC program in their LGAs and Communities. Community Based and Faith Based organizations will also be empowered to identify and care for VC within the Networks. These Faith Based Centers will create a sustainable mechanism for community care where there are no orphanages and so become a vehicle for transition of street based children into family care.

ACTION Plus Up is supporting the global as well as national strategy of strengthening the focus on three strategies for reducing the burden of TB in HIV-infected individuals (the 3 Is); intensified case finding (ICF), isoniazid preventive therapy (IPT) and infection control (IC).

Intensive case finding is the primary focus area whereby every HIV client IS to be screened for TB at every clinic visit with four questions (current cough, fever, night sweats and weight loss) recommended by the national TB/HIV guideline and WHO. Chest x-ray is supported for sputum smear negative clients with persistent symptoms. With the expansion of distribution of geneXpert machines in most parts of Nigeria, they will also be used for the diagnosis of difficult sputum smear negative cases in our HIV positive clients. Task shifting and sharing will follow. Integrated HIV/TB services is another primary area of focus in COP13. This is to ensure that all HIV/TB co-infected clients receive care on the same day, if possible at one clinic(one stop shop) reducing the number of visits to the clinic.

Isoniazid preventive therapy (IPT); clients found negative after TB screening with the above four questions will be provided with IPT through the HIV clinic along with pyridoxine. All HIV/TB clients will also receive co-trimoxazole, irrespective of their CD4 counts.

ACTION has piloted use of mini X-ray for active TB case finding. In COP13 ACTION Plus Up/ IHVN will scale up the mini X-ray facilities to support hospitals that don't have functioning X-ray on a caseload basis. The TB clinics will be supported to provide holistic patient care according to national guidelines, in addition to support for TB infection control (the third component of 3 Is) using established modified tools created through collaboration with other implementing partners (IPs), Government of Nigeria (GoN) and various partners.

Strengthening linkages between HIV and TB services is one of the main focus areas of IHVN. Other areas include increased strength of diagnostic capacity of HIV, TB & DR-TB, and intensified case finding for TB, community mobilization for the counseling and testing of HIV, increased uptake of IPT and pediatric TB/HIV.

IHVN will continue to maintain its membership in the National TB/HIV working group and the MDR-TB committee and will continue to be actively involved in national TB/HIV planning, implementation, monitoring and supervision.

Pediatric care and support (C/S) targets HIV-exposed and -infected children 0-15 years of age.

All services will be delivered using family centered and MCH integrated approaches.

Some of the services to be provided include:

Growth monitoring using supplied growth charts with nutritional assessment and counselling, as well as supply of multivitamins, mineral supplements and Plumpy nut.

Provision of basic health care package (BCP) to all HIV-infected children as well as HIV-exposed infants receiving services

Laboratory monitoring for all HIV exposed and-infected children - CD4 counts, haematology, and chemistry. For TB/HIV co-infected/suspect children, baseline and diagnostic chest x-rays. Paediatric infectious disease experts will equip clinicians with skills to effectively clinically diagnose TB in children, since TB diagnostics are often unrevealing in children. EID will be supported and available at all PMTCT points of service to improve the identification of HIV+ children for linkage into care and treatment services.

INH prophylaxis will be provided for HIV-infected children at the National TB Program DOTS centres. Supervision will be carried out by Home-Based Care/Community teams.

Home-Based care (HBC) for children is linked to HBC for adults and provided in all network areas.CSS teams support parents with ART adherence for children in the home through education, addressing adherence barriers, and supporting transition to FDCs. They also link family members to PMTCT, community immunization and family planning services. ACTION Plus Up will continue to strengthen psychosocial support for children by improving the quality of counselling available for vulnerable children.

Site-based adolescent clinics staffed by both adult and paediatric personnel will be established, to take care of their special needs and help transition them fully into adult care. Each clinic will ideally be staffed by adherence counsellors. Specifically under OVC activities, community-based Adolescent Clubs/Support will be formed

Pediatric Care and Support will be integrated with routine paediatric care, nutrition services, and maternal health services. Efforts will be made to have maternal and pediatric HIV services including OVC and Nutrition/Infant Feeding Counselling geographically proximal to immunization and, PMTCT/ANC clinics, and other points of routine paediatric and maternal care. Through renewed paediatric PITC efforts, HIV testing for all children with unknown status will be offered at all points of routine and HIV care services. Quality monitoring will be undertaken through regular site mentoring and supportive supervision using existing assessment tools, DCT and routine monitoring and evaluation indicators.

IHVN will support ARV Services, Basic Care and Support (BC&S), OVC, TB/HIV, PMTCT, and HCT programs by improving on lab infrastructure and training staff to accurately diagnose, stage and monitor patients, according to national and international standards. Using an integrated, tiered referral laboratory network model, IHVN will provide laboratory services at a minimum of 120 testing facilities with 234 HIV testing points (HCT, PMTCT, Blood safety, and TB clinic). All laboratory activities and methods will be based on standard operating procedures (SOPs) and manuals of operations (MOPs) developed, including policies and procedures for logistics. All sites will continue to participate in IHVN Quality Assurance program and Digital Proficiency Testing (AFRIQUAL Lab).

IHVN will partner with facilities Managements, Medical Laboratory Science Council of Nigeria and USG PEPFAR LTWG in enhancing the process of national/international accreditation of a minimum of 40 laboratories.

Thirteen functional PCR laboratories supported by IHVN will provide EID, Viral Load (VL) and HIV genotyping services to sites (IHVN, GON, GF and other IPs) geographically proximate to them and will roll-out VL testing for all ART patients in care to have a minimum of two tests per year. PLASVIREC (IHVN training and reference Centre) will continue to provide QA for the national EID and coordinate CDC external DBS proficiency testing for all EID labs in Nigeria.

IHVN will utilize mobile laboratories as part of standard of care and develop validation protocols for laboratory testing procedures and rapid point of care (CD4 & Gene Xpert) diagnostics platforms in high incidence/prevalence Local Government Areas (LGAs).

IHVN will activate 130 high TB burden sites and implement enhanced and cost-effective TB diagnostics services (e.g LED fluorescence microscopy, molecular assays, and genotyping) participate in national MDR surveillance, provide technical assistance to national TB program.

IHVN will organize biomedical engineering workshop for 30 laboratory scientists and biomedical engineers to improve on equipment maintenance and usage at sites.

IHVN will conduct monthly comprehensive laboratory data analyses, share scientific data and findings to support/guide prevention and treatment programs.

The SI department will implement electronic medical records system- Open MRS and DHIS for patient level and aggregate data reporting at all secondary and tertiary supported sites to improve patient management and monitoring and at the same time provide high quality data for reporting. The HMIS team of the department will continue to provide technical support to the sites on EMR. The SI department will conduct a patient audit at all supported sites to account for all patients provided with service during the COP year and continue to maintain the database generated during the exercise.

To ensure high quality in data generated and reported there will be routine data quality assessment exercises at all supported sites; ensuring feedback of DQA exercises are communicated and followed up. The department will be conducting focused supportive supervision and mentoring at supported sites to ensure quality in monitoring and evaluation processes at sites. The SI department will continue to work with the clinical team in ensuring continuous quality improvement activities at supported sites.

Routine data collection, analysis and reporting will be ongoing; there will be site expansions and the SI team will form part of the site assessment and activation teams. We will continue to ensure compliance to national tools, reporting lines and platforms.

We will continue to collaborate with the Government of Nigeria to strengthen the health system and improve the response; we will participate and provide technical assistance in the annual joint DQA and data validation exercises.

IHVN is the Lead IP in Delta, Ekiti, FCT, Katsina, Nasarawa, Ogun,Ondo and Osun and the co-Lead IP in Kano and Benue States Concept of lead IPs

PEPFAR-supported implementing partner with key and lead role in facilitating support to enhance the capacity of sub-national levels of government towards improving the coverage and quality of HIV/AIDS services:

Takes a lead role as USG State Liaisons in facilitating support to enhance the capacity of sub-national levels of government.

Lead partner becomes accountable for service delivery and health system strengthening in the assigned state.

Engage government at the State as well as LGA level to secure support for HIV/AIDS services and saturation Prevent, Care, and Treat

Provide government (State and LGA) with platform for coordination donor support and HIV/AIDS response within the State

Support SMoH (SASCP and SACA) to lead in planning, implementing, managing, monitoring, reporting and evaluation HIV/AIDS services

Build the capacity of states in managing partnership involving health programs to ensure sustainability (when the benefits of a project continue)

Provide technical, programmatic and other support to establish sustainability mechanisms (to continue the benefits of a project)

Strengthen HMIS and coordinate the harmonization of HIV/AIDS data reporting systems

Build capacity of State and LGAs to manage health commodities and drug logistics including ARVs, HIV test kits etc.

Lead IP Expected outcomes

Increase state capacity to coordinate donor activities

Increase government responsiveness and ownership of health programs

Improve capacity of states to develop plans, implement activities, monitor and evaluate health programs.

Improved health systems

Ensure statewide coverage to meet the HIV/AIDS unmet needs.

Development of fundable activities, State Strategic and Costed Plans for appropriate resource mobilization including State Government funding

States ownership through planning, coordination and gap analysis for basis of scale up of HIV/AIDS services

To support the centrally coordinated blood transfusion services 50 IHVN site laboratory Blood Banks will be supported to fully implement the National Guidelines for blood transfusion in Nigeria and linked to zonal National Blood Transfusion Service (NBTS) for blood exchange/supply through the NBTS-Hospital linkage program. All collected units of blood will be screened for the four transfusion transmissible infections (TTIs) (HIV, Hepatitis B virus, Hepatitis C virus and syphilis) using ELISA techniques. Tertiary facility Blood Bank laboratories with ELISA equipment will in collaboration with NBTS be supported to screen all their collected family replacement donor units for the four TTIs using ELISA in their facilities under the Hospital Linkage Program (HLP). Also under the Hospital linkage program, all facility Blood Bank laboratories without ELISA capability will be linked to proximate tertiary sites with ELISA capability or proximate zonal NBTS centers for ELISA screening of collected family replacement units and for blood exchange/supply. Blood donation drives will be conducted in collaboration with NBTS at supported facilities and surrounding communities. Blood donation counseling will be included as part of post-test counseling for HIV negative clients.

The main goal of Injection Safety Program in FY13is to reduce exposure to blood borne pathogens particularly HIV, and the incidence of medical transmission of these pathogens. Health care workers targeted for this activity include physicians, nurses, community health extension workers (CHEWs), laboratory workers and waste handlers.

ACTION Plus Up will collaborate with GoN/JSI/MMIS to provide Safe Injection programming to 204 supported sites in 23 states annually.

ACTION Plus up will strengthen and or facilitate the establishment of Infection Control Committees in all sites to supervise biomedical prevention services.

All exposed individuals to needle sticks and other sharps in facilities will be linked to the Post Exposure Prophylaxis (PEP) services. ACTION Plus Up staff in collaboration with supported facilities will incorporate PEP services into the Community Support Services (CSS). Advocacy visits and community mobilization to gatekeepers and the Police Force will be carried out to report real time cases of rape and link such individuals for free PEP services at the network of facilities providing HIV/AIDS care and treatment

ACTION Plus Up in collaboration with CCCRN will support follow-up and step down site level Basic trainings on Infection Prevention control in the context of Injection Safety and Universal Precaution to physicians and nurses from the inpatient wards, clinics, labor and delivery rooms, and the surgical theaters. In addition, HCT counselors performing rapid tests, laboratory scientists, blood bank staff, and waste handlers will also be trained. A follow-up of trainees and on-site retraining based on performance evaluation at sites will be paramount.

The oversight of this program area will be provided by a dedicated ACTION Plus Up Program Officer with the support of regionally based medical and nursing Program Officers.

ACTION Plus Up will procure and continue to provide personal protective commodities including gloves, eye shields, boots, and aprons. and will take on the new role of logistic supplier of seed stock for injection safety commodities and recurrent stock of Universal Precaution materials for all sites. ACTION Plus Up will supply seed stock color coded bin liners and waste bins for effective waste segregation. Commodities will be provided to sites based upon a pull system using a site level inventory control system linked to the Institute of Human Virology Nigeria (IHVN) warehouse logistics management information system.

ACTION Plus Up staff will implement ongoing quality assessment of implementation by direct observation and by training a local staff member to monitor compliance in harmony with hospital policies to be developed to promote sustainability.

To achieve /monitor the effectiveness of the program, an appraising monitoring tool developed will be used to evaluate the program

ACTION Plus Up will build on the successes of ACTION Plus in targeting young girls of 10 -17 years of age in Faith Based Organizations especially Girls brigade and NASFAT to continue providing prevention services employing the Minimum Prevention Package (MPP) strategies of: - Community Awareness campaigns, Peer education, Drama and Focus Group Discussions to other targeted youths/young adults 15 24 years considered to be the highest prevalence age. The overall goal of AB activities is to provide a comprehensive package of prevention messages at selected states with high HIV prevalence which seeks to empower youths in Tertiary Institutions, Islamic Schools, Girls Brigade and other youth Organizations to make an informed decision to practice primary or secondary abstinence or mutual fidelity.

Teachers, guidance counselors and peer educators will be trained to provide effective prevention interventions inclusive of AB messaging; the Family Life Health Education (FLHE) will also be adopted in addition for the training by the collaborating FBOs. In FY13, ACTION Plus Up will strengthen the linkages between appropriately balanced ABC services, condoms and other prevention activities. AB activities will be linked to and contribute to the general overall goal of HTC activities by providing testing to youths during program implementation. All those testing HIV positive will be linked to care and treatment. Scale up plans will include working with the Boys Brigade and YMCA

Baseline surveys will be conducted in each intervention community after which a quarterly monitoring system will be put in place to determine the progress of the intervention in terms of knowledge gained and behavior change. ACTION Plus Up will equally provide service at the community level through established youth organizations to complement the school based approach. Anti- AIDS clubs will be established in the institutions with the office of the HIV desk Officer being the Patron while the parent religious organizations (Churches and Mosques) will be advocated to for program ownership to foster sustainability.

HTC will continue to serve as an entry point to treatment, care and support programs. HIV Testing and counseling teams will utilize various models viz integrated, stand alone and mobile/outreach to achieve set targets.

Several strategies to be employed to reach a wide range of targeted populations include scaling up testing and counseling to multiple points of services in facilities for easy access, stepping up couple testing and counseling, engagement of well-trained community based outreach counselors to provide services to hard to reach communities and amongst MARPs, provision of services at odd hours during the night moonlight testing and counseling to cater for mobile or non resident sex workers and their partners. Mapping out hot spots in communities and reaching out to the population. Home testing and counseling services are also to be provided by the Community Home Based Care team to family and friends of the index PLHIV patients. Continuous proficiency testing will be provided to sites and outreach teams to check and assure quality of services.

C & OP activities will continue to play a significant role in preventing new incidences of HIV infections amongst MARPs groups namely Female Sex Workers and their Clients, Long Distance Truck Drivers, MSM, Out of School Youths, Drug Users and those who engage in Alcohol and Substance Abuse. These services will be provided in line with the Minimum Prevention Package (MPP) strategies of: - Peer education, STI Syndromic management, Condom education & distribution and HTC as enshrined in the National Prevention Plan. ACTION Plus Up will build on its collaboration with local NGOs in states with high HIV prevalence to scale up Community Level Based Prevention Intervention service provision including the establishment of condom outlets in these MARPs communities for free condom distribution. Part of the scale-up plan for FY13 will involve placing locally made wooden condom dispensers in each outlet to make male and female condoms available while assigning trained peer educators as the custodians of these boxes for accountability purpose.The distribution method will be based on a pull system where the NGOs will be responsible for making condoms available to the targeted MARPs communities.

Also in FY13 Community HTC services will be re-inforced and scaled up to include provision of house to house testing in these intervention communities. Those testing positive to HIV will be linked to care and treatment. ACTION Plus Up will also target out of school youths through community centers and organized activities supported through Vulnerable Children programming. C & OP programming will be balanced with AB intervention messages for youths in these settings. Baseline surveys will be conducted in each intervention community. A quarterly monitoring system will be put in place to determine the progress of the intervention in terms of knowledge gained and behavior change.

For program sustainability; the capacities of the collaborating NGOs will be built while Community Advisory Boards (CAB) will be established to promote the program and serve as the link with the communities. Trained peer educators in each target group will form small CBOs for program ownership and ACTION PlusUp will brand all the intervention communities with HIV prevention messages to complement other activities.

144 PMTCT sites from COP12, located in 24 states of Akwa Ibom, Anambra, Bauchi, Benue, Cross Rivers, Delta, Edo, FCT, Gombe, Imo, Jigawa, Kaduna, Kano, Katsina, Kogi, Kwara, Lagos, Nasarawa, Niger, Ogun, Osun, Plateau, Sokoto and Rivers will be maintained and expanded on. PMTCT care centres are linked to secondary and tertiary hub sites that provide more complex lab services in a network model. In this network, PMTCT stand alone points are linked to adult and pediatric ARV care through utilization of a PMTCT focal person in each hub, network referral standard operating procedures (SOPs), monthly PMTCT network meetings, training and incorporation of team approaches to care in all training and site monitoring. In COP13, 315,715 pregnant women will receive PMTCT counselling & testing and receive their results using provider-initiated opt-out testing with same day results. Same approach will be adopted for mobile PMTCT services to women in hard to reach communities.

HIV-positive pregnant women who require HAART will be linked to an ART point of service. This program will work closely with the care and support team to engage community based PMTCT model of care and ARV linkages to reduce loss of clients along the PMTCT cascade. In addition, each HIV-positive pregnant woman will be referred to OVC services in order to facilitate care for all of her affected children.

An anticipated 9,307 HIV-positive pregnant mother child pair will be identified and provided with a complete course of ARV prophylaxis on-site or by referral in line with the national guidelines, including CD4 counts without charge. Cotrimoxazole suspension will be provided to all exposed infants pending a negative virologic diagnosis. All HIV-positive women will be counselled pre- and post-natally regarding infant feeding practices in line with the National policy and linked to support groups (Mentor mothers) to increase access and retention in care. ACTION-Plus Up will provide safe nutritional supplements for HIV exposed infants.

ACTION-Plus Up will train and re-train HCWs including community-based health workers, TBAs and mentor mothers in the provision of PMTCT services using the national curriculum.

Program linkages will be operationalized at the site and program level, including linkages to adult and paediatric ART, OVC, Basic care and support services. ACTION-Plus Up will continue to provide Technical Support to Federal, State and Local Government for ownership and sustainability. Quality monitoring will be undertaken in line with national policy. In addition to routine monitoring and evaluation activities, ACTION Plus Up will continue to provide TA for the National PMTCT MIS and contribute to a multi-country PHE that will evaluate and document best program models to increase access to ART.

In COP13 ARV drugs will be procured so that ARV treatment can be provided to 142,656 adults and 15,582 children (77,675 new) at over 200 clinical sites in 23 states in Nigeria through a pooled prcurement system. The first component of this activity includes forecasting and procurement of ARV drugs. As part of the COP13 budgeting process, a forecast will be jointly carried out by ACTION Plus Up and SCMS and utilized to project COP13 ARV requirements. It is estimated that 90% of patients begun on EP-provided ARVs will be adults and the remaining 10% will be children. Patients on ARVs include those started on ARVs in prior years, patients in care who roll over into treatment, and newly diagnosed patients needing ART. Overall, it is assumed that 5% of both adults and children begun on ARVs during prior years will ultimately require second line treatment under COP13. Forecasting and pipeline is reviewed and adjusted if necessary monthly based upon site level consumption data provided by GHLIL/SCMS.

ACTION Plus Up will follow the National Treatment Guidelines in the provision of ARV regimens for adults and children. The regimen mix has been forecasted based on current utilization and balancing best clinical evidence with scalability. The present preferred first line adult regimen is zidovudine/lamivudine/NNRTI with the alternative regimen tenofovir/emtricitabine/NNRTI with stavudine rarely employed. PEPFAR and FDA-approved generic formulations will be utilized whenever available, and we anticipate 99% of the budget will be utilized to purchase generics. For all regimens, a four-month buffer stock is maintained to minimize the likelihood of problems with drug supplies. ACTION Plus Up staff develop ARV projections, and plan procurements accordingly. In COP13 all purchases of First line drugs and possibly Co-Trimoxazole will be purchased via PEPFAR (SCMS) pooled procurement mechanism, in line with current guidance.

The second component of this activity includes expediting commodities through the port of entry, followed by storage, distribution, and management of the commodities. This includes site assessment of pharmacies and storage facilities with corrective recommendations and actions. Needed site renovations for proper security and storage conditions in pharmacy stores will be undertaken by ACTION Plus Up.

Storage and distribution of ARVs, maintenance of a site level commodities management system, and instruction to site staff regarding the system, have been subcontracted to the GHLIL. GHLIL collects drug utilization data and documents proper storage conditions at the central warehouse, regional warehouses, and site level

ACTION Plus Up will pilot the involvement of Community pharmacies as patient drug counseling and pick up sites in the mobile care strategy network in COP 13 to strengthen the GON ART decentralization policy.

Quality control involves routine monitoring visits by ACTION staff from the central Abuja office or from regional offices to all sites every six months to review the implementation of SOPs and to compare reported usage based on monitoring and evaluation data with local manifests and pharmacy logs. The ACTION Plus Up training department analyzes data for patterns of deficiencies as well as individual site deficiencies in order to improve training and target weaknesses to address through retraining.

For COP 13, ACTIONPLUS UP will build on ACTIONs national network of over 200 mainly GON facilities at primary, secondary, and tertiary levels of health care in 23 states and the FCT through continued provision of comprehensive care, treatment, and wrap around services to over 115,372 HIV-positive adults. The Nigerian FMOH ART treatment guidelines adapted from the 2010 WHO ART treatment guidelines including the new recommendations for ART in pregnant women will be fully implemented at all sites, integrating OI, STI, TB prevention and treatment services and PEP. Focus will be on maintaining and expanding high quality services for care, treatment and prevention for existing clients in these states through continuous clinical improvement activities. Emphasis will also be placed on early identification of treatment failure through the empowerment of the ART Switch Committees. Patients suspected of ART treatment failure will access viral load testing through one of IHVNs supported 11 PCR laboratories and viral genotyping (for those failing second-line ART).

To address gaps in retention in care, and loss to follow up, ACTIONPLUS UP deploys an interlocking cadre of facilityand community-based client advocates. Network Coordinator (tertiary site and Hub-based); the Case Manager/Mother Mentor (PHC-based) and Community Health Extension Workers (CHEWs)/Adherence Partner (community-based) work in concert to link clients across the health systems managed by the federal, state and local governments and support down- and up-referrals with active feedback to ensure quality services are rendered and data captured. Linked to reliable client level data is ACTIONQual, a quality improvement framework based on the GON HIVQual and enhanced by IHVN which serves as a uniform tool for empowering site-based QI Committees to objectively evaluate performance and develop corrective interventions.

In line with the National Strategic Framework and the NPHCDAs National Decentralization of HIV/AIDS Services Plan, overcrowding at hub sites as a barrier to quality ART treatment access and retention is reduced through monitored down-referral of stable clients to PHCs where capacity for safe and high quality task-shifting will be built. CBO-based clinics for most-at-risk-populations (MARPS) staffed by a full multidisciplinary mobile team will bring user friendly ART treatment services to these marginalized populations.

ACTIONPLUS will build treatment and treatment support capacity of doctors, nurses, ancillary workers and volunteer cadres utilizing three tiers of in-service training: Basic HIV Training, Supplemental Program Area Training, and Advanced Training where content is both didactic and experiential (including mentorship and preceptor activities). Additionally, Assessment Guided Training addresses gaps identified through quality of care assessments. All trainings utilize and build on GON curriculum; utilize a network of Nigerian expert trainers and consultants to step-down and sustain local capacity.

In FY 13, ACTION Plus-Up aims to provide comprehensive care, support and lab monitoring to 8,241 HIV infected children; 1,593 of these children will be started and maintained on ART.

Provider Initiated Testing and Counselling (PITC) will be expanded to PHCs, TB DOTS centres, OVC service points and family planning services. Lab staff will however provide oversight and quality assurance for PITC.

Early Infant Diagnosis (EID) is an important entry point for Pediatric ART. EID services will be strengthened by increasing oversight at the site and regional level, to ensure that all positive children are tracked and enrolled into care within 2 weeks of result delivery.

At PHCs, positive children may be formally referred to the hub site for more comprehensive ART care. Health care for HIV infected children will be integrated at all sites, and include access to free lab monitoring, TB diagnostics and appropriate formulation drugs via GON-sponsored DOTS programs, provision of cotrimoxazole prophylaxis, diagnosis and treatment of malaria and treatment of common OIs. The home-based care (HBC) team will address the need for palliative care, tracking of LTFU clients, and in-home adherence counselling for parents.

A coordinated approach to linkage will be operationalized at site and program levels including linkages between PMTCT and pediatric ART, OVC services, pediatric care and support, and nutrition. Linkages will be forged with child protection committees in the OVC program to create community awareness for paediatric testing and be used to mobilize families and the community to access available services and support the program.

To improve adherence to ARVs among children and promote retention in care, ACTION Plus-Up will provide targeted adherence mentorship for pediatric providers to build their capacity in adherence counselling skills. Mentorship will cover child development, pediatric counselling, diagnosis disclosure, grief and loss and adherence to medications, employing the use of a national paediatric disclosure and counselling tool developed by IHVN.

In collaboration with USG and Federal Ministry of Health, we will continue to build the capacity of sites and states to collect, analyse and use EID and pediatric HIV data to evaluate program performance. We will continue to provide regular on site and electronic correspondence with program and site data-collecting staff to ensure generation of quality and timely data from all sites.