The Catholic Medical Mission Board (CMMB) is a partner in the FY09 COP; they are one of the partners that were selected under the FY09 Funding Opportunity Announcement that had been indentified in the FY09 COP as "TBD". Two partners were selected for this TBD. Although identified here as "new", CMMB (and this mechanism) are continuing from FY09; once the mechanism ID is established for the FY09 activities, that same mechanism ID should be used in FY2010 for CMMB.

The Catholic Medical Mission Board's ANISA Project (meaning "Together" in Zande) is located in Western Equatoria State (WEQ) and focused on reducing the incidence of new HIV infections through

primary and secondary prevention; improving care and support to people living with HIV/AIDS; and strengthening the local capacity in Western Equatoria State (WEQ) in strategic information, policy development, and implementation. Clinicians and community health volunteer cadres are trained and supervised in the provision of three kinds of service packages: 1) Primary Prevention, AB & Other Prevention (OP); 2) PMTCT; and 3) Care and support (palliative care, OI management and support to PLWHA).

The program includes layers of implementation and capacity-building beginning at community volunteer level (e.g. TBAs, HBC workers), a tier of 'peer champions', outlets for services delivery, and mobile 'outreach days' (for PMTCT and VCT). Reporting for each intervention cluster is designed to support unique messaging and linkages, but also, through the project staff design, support cross-cutting outcomes related to improving knowledge, access and use of services, and sustainability of quality services within existing PHC modalities.

The program is designed with a strong community-clinic linkage and team-oriented training and supervisory structures to support the gradual scale-up in knowledge and demand for services. ANISA will support four primary health Care Centers (PHCC) with counselling and testing services and four PHCCs with PMTCT. These sites will be located in Yambio, Ezo and Nzara. ANISA will have partnerships with the Star PLWHA group and the MACASO PLWHA group in Yambio and facilitate the formation of groups in Nzara and Ezo. Groups will be functionally linked to the World Vision Community-based Livelihoods Recovery Program. Peer educators will be used to provide prevention messages and support for condom outlets will continue. The focus of HIV/AIDS prevention programming will be other prevention, life skills education, and parent-youth communications in Yambio, Ezo, and Nzara counties.

ANISA will continue to work with partners to provide a holistic package of care and support to PLWHA and their families. The project focuses on providing a comprehensive and quality package of services for PLWHA and their families, building on clear linkages between facilities-based services (HCT, palliative care, PMTCT, etc.) and community-based prevention and care, through two way referrals, supervision networks and strategic information flows. Home-based caregivers (HBCGs) come from local CBOs, FBOs and PLWHA groups and have been trained to provide services to PLWHA that include: 1) distribution of and training in use of Basic Health Care Packages (BCP) 2) palliative care 3) referrals to treatment and care services, 4) support for adherence to treatment for OIs, HIV/AIDS, and TB (if appropriate) and 5) follow-up care (such as linking with PMTCT clients to refer newborns for testing at 18 months). Additionally, HBCGs will also be trained to provide nutritional counseling and referrals/linkages for food, livelihood, and spiritual support. To enable HBCGs to work safely and efficiently while maximizing coverage, ANISA provides HBCGs with bicycles and HBCG kits.

ANISA works with partner organizations that support PLWHA groups to build the capacity of such groups to provide and advocate for their own needs. This includes the 600+ member supported Star PLWHA group and the 150+ member MACASO PLWHA groups in Yambio. The program will include formation of PLWHA groups in Ezo and Nzara counties. World Vision will provide these groups with linkages and technical support through World Vision's existing food, agriculture and livelihoods programs in Western Equatoria State, such as providing agricultural technical support to PLWHA group-owned community vegetable gardens to maximize crop yield (for both meeting immediate nutritional needs, as well as for sustainable income generation). ANISA also supports existing partner organizations conducting vocational programs (such as YWCA) and looks for ways to expand these opportunities to PLWHAs. ANISA will facilitate linkages of PLWHA to state and national-level PLWHA groups through coordination with SSAC.

ANISA employs a HCT/PHC Integrated approach to counseling and testing complemented by outreach counseling-testing. Three approaches are used. The strategy allows the project to utilize existing

infrastructure and manpower and supplement gaps through mobile outreach.

Facilities-based HCT: ANISA will continue to ensure that staff are properly trained and equipped at four PHCCs to provide counseling through either client initiated (CICT) or provider initiated (PICT) counseling and testing. It is expected that the four sites will be renovated or otherwise upgraded during the first year to meet the minimum standards of infrastructure required. It is expected that each site will have two counselors and one lab technician who will be trained in outpatient consultation, CT functions, treatment of OI and STI, and consistent and correct use of condom.

Stand-alone VCT: ANISA will continue to provide VCT at two stand alone VCT sites in Western Equatroia State.

Mobile CT: The trained health workers from each of the four ANISA PHCCs will perform regular mobile VCT outreach to allow people in remote areas to access HCT services. Mobile teams will be composed of a counselor, a laboratory technician/assistant and driver and will travel to provide services as required in the community.

Yambio State Hospital will be the referral facility for clients requiring more specialized tests and clinical management. If indicated, samples and/or clients testing positive for HIV will be referred for CD4 count, renal and liver function tests, at the beginning and for follow up if the clients are on anti-retroviral treatment.

To coordinate and work with the PEPFAR SI Advisor and the in-country SI team to ensure that data

collected and anlyzed are consistent with PEPFAR standards.

The CMMB model is to build capacity beginning at the community volunteer level (e.g. mid-wives, HBC

workers) to include a tier of 'peer champions'.

ANISA will continue to work with GoSS, SSAC and local partners to support, strengthen and scale-up existing HIV/AIDS prevention programs in Yambio, Nzara and Ezo counties and to establish local capacity for conducting primary prevention programs in Ezo County.

ANISA will continue to use interpersonal communication approaches to complement the mass awareness-raising activities currently conducted by local partner organizations. The project will generate a core of sustainable knowledge and skills as well as a supportive enabling environment through introduction of life skills education, parent-youth communications tools, small peer dialogue groups and mixed community dialogue groups. Peer Educators and community networks will generate a core of sustainable knowledge on HIV prevention within the community to foster community ownership of the issue as well as to address the lack of health workers. Community members will use their knowledge of referral networks and linkages to encourage counseling and testing, care and support opportunities which ANISA will update through close collaboration with SAAC, MoH, and partner organizations. Culturally appropriate IEC materials in the local language will be produced to support BCC activities.

ANISA will continue to build on World Vision's existing psycho-social HIV/AIDS project (PSIA) to promote delay of first intercourse among youth 10 to 14 years-old, increase "secondary abstinence", and faithfulness to one partner among 15 to 24 year olds. Youth will also receive appropriate and accurate information on consistent and correct condom use. This will be done in partnership with the MoE, DoTY, ECS and YWCA through the training of teachers and PE to provide value-based life skills courses for in- school youth (public and private schools) and through the training of PE's to reach out-of-school youths, complemented by school-based, church-based and community parents groups focusing on parent-youth communications.

The project will also give emphasis on reaching high-risk groups to strengthen their ability to accurately personalize risk associated with high-risk behaviors; this will include civil servants with deployments away from home. ANISA will work with the WEQ Police Force, the Police Training Academy in Yambio and the Wild Life Department to target their workforce with comprehensive prevention and risk reduction skills including knowing ones' status (and disclosure), partner reduction, correct and consistent condom use, effects of alcohol abuse, and importance of STI treatment. ANISA will reach out to women's groups in markets and cooperatives and train peer educators among CSWs, motorcycle taxi (tuk-tuk) drivers and lodge owners along the prominent Yambio/WEQ trade route to promote behavior change and risk reduction skills such as condom use and negotiation, and link women to vocational and IGA opportunities to address root causes of transactional/commercial sex work.

ANISA will promote a network of community conversations that will involve people throughout the

population, including civic and faith leaders, traditional leaders, adults and youth to enhance their deep understanding of social vulnerability to HIV caused by gender norms, culturally sanctioned sexual behavior and harmful traditional practices. Trained facilitators from among the HBCGs, PLWHA groups, youth and parent-teacher associations will lead these community dialogues, with the purpose of creating community ownership and action planning for on-going prevention and care responses. The emphasis in these groups is on deeper levels of understanding about the risks of MCP and early sexual debut and creating new broad based social commitment to changing the underlying norms and practices that drive these behaviors, thus developing inherent HIV/AIDS competencies. This approach draws from World Vision's innovative "Common Ground Melting Pot" groups in the ARK project in Tanzania and Kenya, as well as the "community conversations" model currently implemented in Ethiopia and Tanzania. Members of PLWHA groups will be engaged to act as Hope Ambassadors in encouraging community awareness of HIV/AIDS and the importance of knowing ones' status. Trained facilitators from the community, as well as CHWs in ANISA's mobile outreach teams will lead discussions that help create accountability for safe sex, CT, prevention of HIV and support for PMTCT.

ANISA will continue to work with GoSS, SSAC and local partners to support, strengthen and scale-up existing HIV/AIDS prevention programs in Yambio, Nzara and Ezo counties and to establish local capacity for conducting primary prevention programs in Ezo County.

ANISA will continue to work with GoSS, SSAC and local partners to support, strengthen and scale-up existing HIV/AIDS prevention programs in Yambio, Nzara and Ezo counties and to establish local capacity for conducting primary prevention programs in Ezo County.

ANISA will continue to use interpersonal communication approaches to complement the mass awareness-raising activities currently conducted by local partner organizations. The project will generate a core of sustainable knowledge and skills as well as a supportive enabling environment through introduction of life skills education, parent-youth communications tools, small peer dialogue groups and mixed community dialogue groups. Peer Educators and community networks will generate a core of sustainable knowledge on HIV prevention within the community to foster community ownership of the issue as well as to address the lack of health workers. Community members will use their knowledge of referral networks and linkages to encourage counseling and testing, care and support opportunities which ANISA will update through close collaboration with SAAC, MoH, and partner organizations. Culturally appropriate IEC materials in the local language will be produced to support BCC activities.

ANISA will continue to build on World Vision's existing psycho-social HIV/AIDS project (PSIA) to promote delay of first intercourse among youth 10 to 14 years-old, increase "secondary abstinence", and faithfulness to one partner among 15 to 24 year olds. Youth will also receive appropriate and accurate information on consistent and correct condom use. This will be done in partnership with the MoE, DoTY, ECS and YWCA through the training of teachers and PE to provide value-based life skills courses for in- school youth (public and private schools) and through the training of PE's to reach out-of-school youths, complemented by school-based, church-based and community parents groups focusing on parent-youth communications.

The project will also give emphasis on reaching high-risk groups to strengthen their ability to accurately personalize risk associated with high-risk behaviors; this will include civil servants with deployments away from home. ANISA will work with the WEQ Police Force, the Police Training Academy in Yambio and the Wild Life Department to target their workforce with comprehensive prevention and risk reduction skills including knowing ones' status (and disclosure), partner reduction, correct and consistent condom use, effects of alcohol abuse, and importance of STI treatment. ANISA will reach out to women's groups in markets and cooperatives and train peer educators among CSWs, motorcycle taxi (tuk-tuk) drivers and lodge owners along the prominent Yambio/WEQ trade route to promote behavior change and risk reduction skills such as condom use and negotiation, and link women to vocational and IGA opportunities to address root causes of transactional/commercial sex work.

ANISA will promote a network of community conversations that will involve people throughout the population, including civic and faith leaders, traditional leaders, adults and youth to enhance their deep understanding of social vulnerability to HIV caused by gender norms, culturally sanctioned sexual behavior and harmful traditional practices. Trained facilitators from among the HBCGs, PLWHA groups, youth and parent-teacher associations will lead these community dialogues, with the purpose of creating community ownership and action planning for on-going prevention and care responses. The emphasis in these groups is on deeper levels of understanding about the risks of MCP and early sexual debut and creating new broad based social commitment to changing the underlying norms and practices that drive these behaviors, thus developing inherent HIV/AIDS competencies. This approach draws from World Vision's innovative "Common Ground Melting Pot" groups in the ARK project in Tanzania and Kenya, as well as the "community conversations" model currently implemented in Ethiopia and Tanzania. Members of PLWHA groups will be engaged to act as Hope Ambassadors in encouraging community awareness of HIV/AIDS and the importance of knowing ones' status. Trained facilitators from the community, as well as CHWs in ANISA's mobile outreach teams will lead discussions that help create accountability for safe sex, CT, prevention of HIV and support for PMTCT.

Support will continue in the four PMTCT service outlets established in Year 1, projected to be at the Nzara PHCC, Ezo PHCC, Yambio PHCC and the Makpändu PHCC. Routine MCH/ANC and PMTCT services are to be integrated into the Primary Health Care services. Staff will continue to be trained to counsel, test, and educate women on optimal feeding choices, prevention of mother-to-child transmission, and living positively with HIV/AIDS. Ongoing support and refresher trainings will be provided by the Team Leader and community 'champions' called 'mentor mothers'.

ANISA's PMTCT approach will be integrated into ANC, and aim to improve ANC attendance. ANISA will train health workers to provide a minimum package of PMTCT services in our target sites including ANC, couples-based HCT, delivery modification, ARV prophylaxis, nutritional counseling for mother and newborn, post-natal care, family planning and follow-up care.

Pregnant women will be identified in the community and encouraged to attend ANC at supported centers to access PICT. HIV-positive mothers will be supported through community peer counselors, through a mother mentor approach, whereby women will be educated on maternal-child transmission and the importance of receiving ARVs for prophylaxis. CMMB has adapted its PMTCT curricula to include Mothers2Mothers support program to improve follow-up of women, their exposed infants, and breastfeeding practices in line with MoH guidelines.

Health workers, Traditional Birth Attendants and other cadres (home based care providers, etc) will be trained in the PMTCT "key messages" to guide the clients throughout a continuum of care from PHCC to the home. In the PHCC, all eligible clients will be referred for ARVs according to GoSS guidelines launched in June 2008 and ANISA will ensure provision of pediatric prophylactic ARVs to children born to HIV positive mothers, e.g. preferred AZT from 28 weeks (7 days post-delivery for infant) with single dose- NVP to mother and child, or alternatively, single dose Nevirapine at delivery and to infant within 72 hours of birth.

ANISA will look at existing Breast Feeding practices and aim to increase uptake of exclusive breast feeding for 6 months and immediate cessation per GoSS guidelines. Messages will be crafted for mothers, fathers, and mothers-in-law to ensure women are supported in their choice of BF options. Clients requiring additional nutritional support will be referred to existing World Vision and other partners programs for complementary food and livelihood support. Family planning counseling will also be provided. Fathers/spouses will be encouraged to have HCT and advocacy will encourage men to take the lead in supporting their partners and infants in care services.

ANISA will ensure that the laboratory technicians at the supported sites receive adequate training to

conduct quality laboratory work. The training will be planned and coordinated with the PEPFAR Lab

Advisor.