Catholic Medical Mission Board (CMMB) is implementing the ANISA project in Western Equatoria State to strengthen clinical and public health services in order to prevent and reduce the impact of HIV in South Sudan. Western Equatoria States (WES) HIV prevalence rate of 7.2% (2009 ANC Surveillance Survey) is the highest in South Sudan; the countrys average is 3.0%. The ANISA project is being implemented in the four most western counties of WES Yambio, Nzara, Ezo and Ibba; which are also thought to have the highest burden of HIV in WES. The ANISA project supports the Ministry of Health by working within and strengthening the existing government health care system. The ANISA project trains and mentors government staff at the facilities as well as conducts policy and related workshops for county level health officials. Project training is extended to and conducted with local health workers in all ten counties in WES. CMMB abides by the approved South Sudan guidelines and policies.

CMMB is working together with World Vision Incorporated (WVI) to implement the primary prevention as well as care and support components of the program. The size of the target population in the four counties is over 120,000 annually. Given the prevalence level and population size, all sexually active adults are considered at-risk and are targeted in order to detect those with HIV infection. A specific focus is also made on the refugee population from neighbouring countries. Project ANISA has expanded the availability and quality of HIV testing and counseling (HTC) services, PMTCT, palliative care and support, and primary prevention programs for youth and at-risk adults. All activities have set targets that are monitored and reported with the help of an M&E Officer.

PEPFAR South Sudan is focusing on providing the PEPFAR South Sudan Basic Care Package to all persons who test for HIV and to ensure compliance by patients with treatment and follow up to ensure referrals are completed. This Basic Care Package provided at clinic settings consists of cotrimoxazole prophylaxis, screening for active TB, distribution and education on the use of condoms, linkage to local PLHIV support services and CD4 staging.

A home based care kit is provided to those infected with HIV; this kit is provided by CMMBs sub-partner World Vision International. The home based care kit includes: insecticide-treated bed nets to prevent malaria, a safe water vessel, water purification tablets, condoms, filter cloth and information, education and communication materials.

World vision will continue to update and train more care givers and procurement and distribute home based care (HBC) kits. To ensure care and support services get closer to PLHIV, ANISA will continue sub-granting CBOs that have always been in the communities and played a great role in supporting PLHIV. The CBOs have a set of experienced care givers and understand the communities and needs of PLHIV well.

Currently there are 171 trained and supervised care givers. Training of 200+ care givers is of utmost importance. Care givers take care of bed-ridden individuals living with their families and visit friends and neighbors living with HIV and AIDS. Care givers also take care of bed ridden individuals who are abandoned by relatives. The need for training of health providers is more than ever before because of the high number of HIV patients in Western Equatoria. This is one sure way of stigma reduction among health providers against PLHIV.

ANISA also sub-contracts with local CBOs who are trained and monitored to deliver care and support to PLHIV. The project will sub-contract to 5 CBOs this year.

In year three, there will be training of 15 Health Workers for standard management of opportunistic illnesses will also be of focus.

Information, Education and Communication (IEC) materials are small sized posters with HIV prevention and or care and support sensitization messages. One thousand five hundred posters will be printed and put up around the community to raise awareness in year three. Production of this kind of material will continue in next two years.

During the war years, which most recently ended in 2005, the laboratory personnel in WES primarily received various non-standardized institutional training such as from NGOs focused on one disease area or on emergency medical responses. A recent assessment made by CMMB revealed a serious lag in laboratory skills amongst the 12 laboratory staff in the health facilities in the four counties where ANISA delivers programs in WES. In order to address this skills gap and ensure laboratory results used for decision making are accurate, an annual up-date training with mentoring have been instituted. In consultation with the CDC laboratory focal person, a laboratory training will be conducted focusing on basic laboratory skills and developing internal SOPs, record keeping, biosafety, universal precautions, inventory management and equipment maintenance and will build on the training conducted in the previous year.

The ANISA program will continue to provide some basic laboratory consumables to the four Primary Health Care Centers (PHCC) laboratories that service the areas of ANISA implementation. This will ensure that the facilities are able to perform necessary laboratory tests to all clients.

CMMB employs a Monitoring and Evaluation specialist who works together with the M&E officer on the ground to carry out continual monitoring of the project activities as well as actively participate in capacity building of the County Health Departments. In year three and next two years this support will be one of the key activities to ensure the counties take charge of collecting, analyzing and dissemination of HIV data to stakeholders to guide planning and implementation.

Support is provided to the County Health Department for necessary supplies to enable the surveillance officer to be trained and supported in strategic information. Ensuring a steady supply of stationary and printer cartridges is a supplement to this to enable them to collect data from throughout the respective counties and share it with relevant stakeholders.

South Sudan only recently came out of a more than two decades civil war. The new Government of South Sudan has established a decentralized government system with each state having semi-autonomous decision making power. The overall level of general knowledge and understanding of HIV and AIDS in South Sudan is very low and this is reflected in the leaders. They often do not understand HIV/AIDS well. They can contribute to, or even be a source of, HIV misinformation that can circulate quickly in the local communities. In addition health and especially HIV is not given priority by the state decision makers whose support can provide a positive influence at all levels of program implementation and garnering community support. The major outcome of this component of the ANISA program is to ensure that leaders from all levels (local, county, and state) understand the disease and actively participate in leveraging resources for HIV as well as actively supporting interventions geared towards stopping the spread of HIV in WES.

CMMB will train 60 policy makers and implementers from the local, county and state level on policy issues affecting health; this will be a continuation of trainings conducted in the current year. Top State government officials have been trained in FY2011 in HIV trends with a focus on the trends in WES as well as their roles as decision makers in leveraging resources for responding to HIV in their state. The next set of decision- makers will be members of Legislative Assembly, County executive secretaries as well as Payam Chiefs from WES. These decision makers/community gate keepers are chosen from the four counties of Yambio, Nzara, Ezo and Ibba where ANISA implementation is focused.

CMMB is developing a standard training manual for the training of both policy makers and health workers. The training objectives include: informing key state decision makers about HIV; increasing participants knowledge of the effect of HIV on economic growth; and helping participants to recognize their role in controlling HIV and other diseases in the State. Key topics to cover are:

HIV/AIDS facts and fiction

History and dynamics of HIV/AIDS

HIV: who is affected & who is not affected; Stigma

Key WES Indicators (HIV prevalence, MMR, etc)

Primary Prevention of HIV and its challenges in WES

Secondary Prevention of HIV (HTC, PMTCT, etc.)

Treatment Care and Support

Key determinants of Health in WES

The 5 control knobs of Health service delivery

Role of politics/politicians in health service delivery

Impact of HIV on economy/future of a State

Identifying a common voice for advocating for more resources to support health service delivery/HIV in the State

A second training program addresses improving the level of knowledge and skills of clinical officers. There are not many in-service opportunities to improve skills related to HIV/AIDS and this activity provides needed in-service training to clinical officers in the 4 counties where ANISA is being implemented. Using adopted training manuals from MOH and WHO, 16 Clinicians will be trained in the management of opportunistic infections, including diagnosis, treatment, as well as managing side effects of ARVs and drugs used to treat opportunistic infections. The clinicians will also be given training so as to reduce stigma against HIV patients by health workers, which is quite common in WES.

PEPFAR South Sudan has prioritized activities to detect as many persons with HIV as possible. In the next two years, Sexual prevention activities under AB will target about 80,000 relatively more at risk population along the busy trade routes of: Ibba-Yambio, Yambio- Nzara, Nzara- Ezo via Diabio. HTC data from the last two years have shown that there are more positive adults in town areas and along these corridors compared to rural areas. Young adult men and women aged 18-30 who engage in concurrent partnerships will be targeted with designed messages on HIV transmission, faithfulness and benefits of taking an HIV test. The AB is linked to other services through the messaging. The target groups and convinced to know their HIV status to better inform their choice of A or B risk reduction. The target groups are also linked to health facilities to seek help for any health need arising including access to condoms as part of OP programming should they fail to maintain the A or B option. ANISA project has been able to package messages to unlock community and cultural social norms and practices as well and myths that. These messages are uniform throughout the program to ensure that quality assurance (QA) is promoted. AB, OP, HTC as well as PMTCT are all linked; a combined team carries out combined sensitization twice a month on the local FM station, key markets and churches.

ANISA project has established fixed static and outreach HTC centres along the Ibba-Yambio-Nzara-Ezo corridor which are easy to reach points of taking a HIV test. A focus will be made to test the partners and families of those who test HIV positive; discordant couples will be targeted to reduce transmission of HIV from one partner to the other partner.

Gender inequalities among families and communities tend to put individuals into circumstances that increase HIV risk behaviors. Activities to reduce gender inequalities will also be prioritized.

Relationships involving multiple and concurrent partners are common in WES. In a geographic area with high HIV prevalence like WES, activities aimed at reducing multiple and concurrent partners to eventually one partner and being faithful to that one partner will also be focused on.

Currently the project has 396 trained community peer educators in target counties. Nearly a half of these are quite active. They are the frontline persons who spread the messages and actively participate in organized community visits. Organized visits occur targeting high risk groups like those in markets, truck drivers stops, public transport stations (including taxi motorcycles -boda boda) and church functions.

In the next two years, more 160 peer educators will be trained altogether. The peer education trainings used a standard curriculum which is used uniformly in all the trainings to ensure the graduated peer educators deliver the intervention uniformly across the program and thus promoting QA. An estimated 80,000 youth and adult male and females will be directly reached with AB messages.

The M&E specialist and the more experienced peer educators are used to monitor the progress of the program after orientation of the needed supervisory work. All visits to target groups are scheduled and peer educators show up to pass on the prescribed messages. The M&E team visits these service delivery points at random to monitor and provide needed support to the educators.

The ANISA project is targeting to test 40,000 adults men and women in the four counties where the project is being implemented. In year two about 11% of the 17,312 persons tested at stand-alone HTC sites were found to be positive.

ANISA has primarily used client-initiated approaches in the past; the four static sites at the PHCCs have stand-alone VCT sites. In year one and two, 37 HTC outreach sites have been active in the counties of Ibba, Yambio, Nzara and Ezo. Increase in cost of fuel made the number of fixed outreach sites to be reduced to 16. ANISA is assessing how to transition to PITC in the next project year. ANCs use PITC approaches. ANISA supports the annual National HCT Campaign around World AIDS Day.

ANISA is conducting refresher training for sixteen of the HTC counselors in year three. TB screening using a checklist will form part of the training, to ensure they pick up this important bit as soon as they are trained. Otherwise the refresher training focuses on ensuring the protocol is clearly followed. As PITC will be rolled out, ANISA project will also be training clinicians and laboratory staffs of the health facilities in the protocol of HTC/PITC. Those who have been trained will have to begin PITC, and then eventually rolled on to all health facilities in the next two years. HTC activities related to PWPs are arranged in that a counselor accompanies care and support team visiting PLWHA. Family members during this visit are counseled and tested.

The national algorithm of serial testing has been used since January 2010 (Determine and Unigold). The tie breaker test Bioline has been suspended since January 2012 because some batches were found faulty.

Linkages to treatment and care services are provided through the referral system that has already been established with ART centers in the state. VCT supervisors follow-up with ART centers to pick up the referral slip. Ongoing counseling is through the post-test clubs that is formed at all static centers and meet regularly. In next two years, VCT counselors will undergo training to enable them provide basic HIV care where referrals have proven a challenge. This basic care will include TB Screening, provision of cotrimoxazole to initiated clients, and making appropriate referrals. Linkages to treatment and care are provided through counselors who follow-up on monthly referrals at area clinics. Patients are also offered post-test club entry after testing positive, and more are accepting their status within a post-test environment.

Clients that have tested positive as part of the post test counseling are referred for treatment as well as care and support services by use of referral cards. A monthly follow up and counting of the number of referral cards are done in all the ART centres to assess the proportion of those who reach the ART services. In the past two years, nearly 90% of positive clients have registered with the nearest Care and Support organizations. HTC activities are closely linked to AB and OP as well as PMTCT; the team carries out combined sensitization twice a month on the local FM station, key markets and churches.

ANISA project has a skilled team leader who does regular supervision of counselors. Counselor monthly meetings are conducted as a means of continual quality of services check. DBS has been drawn and processed for 10th client and sent to reference laboratory in Juba. DBS sample is also collected for discrepant results.

The high uptake for HTC in the 4 counties ANISA is implementing in is greatly attributed to the awareness campaign as part of other prevention activities. Activities in the next two years will continue to target locations with a growing HIV risk including the trade corridors and town centres and suburbs. There will be out reach into the main markets, where a music system blaring music is used to attract people and peer educators sit and chat with those selling items. Male peer educators talk with the men and female peer educators talk with the women. Questions and answers about some of the myths around HIV transmission and condom use are given in these sessions and communities are made aware of the places where counseling and testing services are provided. Churches have been another place where peer educators address the congregation and the pastor gives them a few minutes to respond to questions and fears of church goers. All these mentioned are captured as big groups according to new generation PEPFAR indicators. The small group comprised of between 1-25 persons met, talked to and the peer educator has been able to respond to their questions. Local FM radios have been used once a week to discuss live on air HIV prevention messages and often people called to ask questions and are responded to.

Promotion of condom use forms a big component of the OP campaign. Peer educators are given special topics on condoms and their role in controlling the spread of HIV. Their peer-educators use the same messages for communicating the message to their peers in the communities. ANISA adopted and designed condom promotion leaflets with pictures showing correct use of condoms and benefits. Condoms are regularly distributed to outlets in lodges, bars, saloons and trailer parks in Yambio, Nzara, Ezo and Ibba. Through their network peer educators have identified individual condom distributors who are regularly supplied with condoms. By the end of year two of ANISA, 14 condom distributors were known, 6 of whom were women. Use of condoms in WES, which is assessed by the rate and number of replacements at the condom access points, has substantially increased. The current average condom consumption has increased to 45,000 a month for male condoms and 5000 a month for female condoms. This is expected to increase in the next two years are more are reached with messages and supply of condoms remain fairly constant.

The HVOP activities are estimated to reach over 75,000 people directly through both small group and big group discussion in next two years. However multiplier effect and radio program ensures that over 500,000 people are reached. Over $196,306 is set aside for these activities and as well $10,000 to be spent on refresher training for 80 peer educators in year 3.

Implementation of PMTCT is part of the ANC program and the four PMTCT prongs are delivered directly or through appropriate referrals. The ANISA project adopted a comprehensive approach to integrating HIV testing and PMTCT to the ANCs in order to reduce infant and maternal death. At ANC sessions HIV testing has been integrated as part of the other diseases which increase infant mortality like malaria, syphilis, diabetes and hypertension.

The CMMB ANISA project will continue to conduct PMTCT activities in four established PMTCT clinics in Yambio, Nzara, Ezo and Ibba counties and 16 fixed outreach sites. With the PMTCT outreach services, 40% of the mothers were reached in Year Two of the project; ANISA also provided testing for 4,243 women, 201 of whom were found positive. In the next two years, about 10,000 mothers will be reached with ANC/PMTCT services. Based on the current project prevalence rate among pregnant women, about 1000 HIV positive mothers and babies will receive a comprehensive PMTCT package.

All HIV positive women receive ARV prophylaxis at the ANC except those in stage three and four who are referred to the nearest ART center for ART initiation. All HIV positive mothers are enrolled for ongoing care and support. A basic care package of condoms, cotrimoxazole, staging and referral for ART, TB screening, and linkages to persons living with HIV community support groups is offered to all HIV positive individuals at the sites. The static PMTCT centers supported have a nearby ART center. STI screening and treatment is offered to every woman at ANC clinics.

PITC is currently being used within the ANCs; however, it is expected that as PITC is introduced to the PHCUs and other sections of the PHCCs by ANISA, there will be an increase in the number of women accessing ANC/PMTCT. As ANISA assesses how PITC will be integrated at supported facilities, there may be changes in the PMTCT program.

ANISA supports in-service PMTCT refresher training for project and MOH health care workers in PMTCT for the 15 midwives and 9 counselors that work in project sites. With PEPFAR South Sudans focus on integration of services, all the PMTCT services will be part of the ANC services in the maternal and child health (MCH) of the governments health facilities.

To improve and strengthen retention and adherence of mother-infant pairs as well as strengthen care and support services for HIV positive mothers, ANISA uses a Mentor Mothers program. A Mentor Mother is an HIV positive mother who works within her community. The goal for Mentor Mothers is to ensure women adhere to taking their ARVs in order to prevent MTCT, mobilize pregnant women for testing, and follow up on babies to ensure exclusive breast feeding. The program also includes teaching mothers within their communities about HIV and how to live in a positive manner.

Traditional birth attendants (TBAs) remain an important cadre within the healthcare system in South Sudan. ANISA trains and uses TBAs to increase the number of pregnant women who attend ANC and are thus tested for HIV and to increase the proper use of prophylactic medicines to ensure babies are born HIV free. Each TBA is assigned a positive pregnant woman at ANC who resides close to her to monitor and refer for health center delivery, or to ensure the baby receives Nevirapine syrup in a timely manner for a home delivery. TBAs receive refresher training annually on safe delivery to prevent MTCT.